Nutritional Anthropometric and Mortality Survey Final Report

NUTRITIONAL ANTHROPOMETRIC AND MORTALITY SURVEY FINAL REPORT

HABASWEIN AND WAJIR SOUTH DISTRICT

NORTH EASTERN PROVINCE, KENYA

16th - 26th January 2012

Acknowledgements

Save the Children takes this opportunity to express special thanks to; .  European Commission Humanitarian Aid (ECHO) for their financial support.  The Provincial administration, United Nations Children’s Fund (UNICEF), Arid Lands Resource management Project (ALRMP), Ministry of Agriculture (MoA), Ministry of Health (MOH) and District Development Office (DDO) through their respective district focal persons for the support provided during the entire survey period.  Survey team (coordinator, supervisors, team leaders, enumerators, and drivers) for their tireless efforts to ensure that the survey was conducted professionally and on time.  The Monitoring and Evaluation team who tirelessly ensured the survey data entry and analysis was done.  Community members who willingly participated in the survey and provided the information needed.

Rahab Kimani, Nutrition coordinator Save the Children

Table of Contents Acknowledgements ...... 2 Table of Contents ...... 3 List of Tables ...... 4 Table of figures ...... 4 Abbreviations...... 5 1.0 Executive summary ...... 6 2.0 Introduction ...... 11 3.0 Survey Methodology ...... 13 3.1 Sampling procedure and sample size for Anthropometric and mortality data ...... 14 3.1.1 Sample size calculation for anthropometry ...... 14 3.1.2 Sample size calculation for mortality ...... 14 3.2 Sampling procedure: selecting households and children ...... 14 3.3 Case definitions and inclusion criteria ...... 15 3.4 Questionnaire, training and supervision ...... 16 3.5 Data analysis ...... 17 3.6 Nutritional indices ...... 17 4.0 Results ...... 20 4.1 Survey sample description ...... 20 4.2 Anthropometric results (based on WHO standards 2006): ...... 20 4.3 Mortality results (retrospective over 3 months/days prior to interview) ...... 24 4.4 Children’s morbidity ...... 25 4.5 Water and sanitation ...... 27 5.0 Food Security and Utilization ...... 30 5.1 Infant and Young Child Feeding Practices ...... 30 5.2 Food diversity at household levels ...... 31 5.3 Main livelihoods activities ...... 32 6.0 Discussion ...... 33 6.1 Nutritional status ...... 33 6.2 Mortality ...... 34 6.3 Targeted Feeding Programme coverage ...... 34 6.4 Blanket feeding programme...... 35 6.5 Causes of malnutrition ...... 35 7.0 Conclusions ...... 36 8.0 Recommendations...... 36 9.0 References ...... 37 10.0 Appendices ...... 38

List of Tables Table 1 : Results summary for acute malnutrition ...... 7 Table 2: Results summary for Mortality ...... 8 Table 3: Results summary for children’s morbidity, immunization and supplementation ...... 8 Table 4: Results summary for water, hygiene and sanitation ...... 8 Table 5: Results Summary for food and income sources ...... 9 Table 6: Amount of rainfall received in the district during the last short rains ...... 11 Table 7: Food aid basket ...... 12 Table 8: Other relief programmes in the area ...... 13 Table 9: WFH indices ...... 17 Table 10: MUAC indices ...... 18 Table 11: Height for Age indices ...... 18 Table 12: Mortality Thresholds ...... 18 Table 13: Survey Sample Selection ...... 20 Table 14: Acute Malnutrition definitions: ...... 20 Table 15: Distribution of age and sex of sample ...... 20 Table 16:prevalence of malnutrition based on weight for height z-scores (and/oedema) and by sex ...... 21 Table 17: Prevalence of acute malnutrition by age, based on weight for height z-scores and/or oedema ...... 21 Table 18: Distribution of acute malnutrition and oedema based on weight-for-height z-scores ...... 22 Table 19: Prevalence of underweight based on weight-for-age z-scores by sex ...... 22 Table 20: Prevalence of underweight by age, based on weight-for-age z-scores ...... 23 Table 21: Prevalence of stunting based on height-for-age z-scores and by sex ...... 23 Table 22: Prevalence of stunting by age based on height-for-age z-scores ...... 23 Table 23: Mean z-scores, Design Effects and excluded subjects ...... 24 Table 24: Plausibility Checks for Anthropometric Data ...... 24 Table 25: Mortality rates ...... 24 Table 26: Prevalence of reported illnesses in children in the two weeks prior to interview (n=267) ...... 25 Table 27: Vaccination, deworming and Vitamin A coverage ...... 26 Table 28:Handwashing time ...... 29 Table 29: Dietary diversity amongst children 6-23 months ...... 31 Table 30: Minimum meal times -6-23 months ...... 31 Table 31:Comparison of acute malnutrition expressed by MUAC 2011 and 2012 ...... 34

Table of figures

Figure 1: Map of Wajir South ...... 12 Figure 2: Population age and sex pyramid ...... 21 Figure 3: Weight for height z-scores ...... 22 Figure 4: Symptoms breakdown in the children in the last two weeks prior to interview (n=267) ...... 25 Figure 5: Caretaker’s health seeking behaviour ...... 26 Figure 6: Vitamin supplementation coverage ...... 27 Figure 7: source of water ...... 27 Figure 8: Time taken on water collection ...... 28 Figure 9: Methods of water treatment ...... 28 Figure 10: Types of toilet facilities ...... 29 Figure 11: Initiation of breastfeeding ...... 30 Figure 12: Exclusive breastfeeding in the last 24 hours ...... 30 Figure 13: Food consumption 7 days and 24-hour recall...... 32 Figure 14: Main Livelihood activities ...... 33 Figure 15:Comparison of malnutrition rates based on WFH Z-scores in Wajir South (2009-2012) ...... 33 Figure 16: Comparison mortality rates 2009-2012 ...... 34

Abbreviations

ALRMP II - Arid Lands Resource Management Project II APHIA Plus Aids Population Health Integrated Assistance Project ASAL - Arid and Semi-Arid Lands CMR - Crude Mortality Rate CI - Confidence Interval CMR - Crude Mortality Rate CSB - Corn Soya Blend ECFF European Commission Food facility ECHO - European Commission Humanitarian Aid ENA - Emergency Nutrition Assessment EPI - Extended Programme of Immunization GAM - Global Acute Malnutrition GFD - General Food Distribution HAZ - Height-for-Age Z-score HNSP - Hunger Safety Net Project IYCF - Infant and Young Child Feeding Practices 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 RUSF - Ready to Use Supplementary Food RUTF - Ready to Use Therapeutic Food SAM - Severe Acute Malnutrition SC - Stabilization Centre SCiK - Save the Children in Kenya 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 WASDA - Wajir South Development Association 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

1.0 Executive summary

Wajir South is one of the districts that form Wajir County in North Eastern Province (NEP) and is gazetted as part of the Arid and Semi-Arid Lands of Kenya (ASAL). The district is located in the North West horn of Kenya bordered by Somalia republic to the east, Wajir West district to the West, Lagdera to the south and Wajir East district to the North. The district was in 2010 subdivided into Habaswein and Wajir South districts. The larger Wajir South district administratively consists of 5 divisions including Habaswein, Sabuli, Banane, Kulaaley and Diif. Within the five divisions there are a total of 14 government health facilities including Habaswein district hospital.

Rainfall in the district is unpredictable, erratic and inadequate amounting to 250-300 mm annually on average and the district experiences an annual evapo-transpiration of 2500mm apart from the last short rains which was adequate it is also characterized by long dry spells and short rainy seasons which are erratic, unreliable and poorly distributed. Temperatures are normally high ranging between 28-40°C. Soils are mainly sandy and sandy loams.

The districts are characterized by chronic food insecurity and high rates of malnutrition. The community is largely pastoralist and pre-dominantly Somali. Due to the drought experienced in 2011 in the Horn of Africa (HOA) which was declared by the Kenyan president as a national Disaster, many livestock died, dams dried up and there was an escalation in the rates of malnutrition. Thereafter, in the months of October to November, the district as in many parts of Kenya experienced torrential rains that resulted in massive flooding rendering many parts of the district inaccessible. Though there water and pasture availability improved, there was an increase in prevalence of diseases affecting both humans and livestock. Insecurity further affected the district since September 2011 with the main affected sites being Dagahaley, Gerilley, Dadajabulla, Sarif and Diff.

The district population is currently estimated at 137,9911 persons with a growth rate of 3.7%. About 60% -70% of the people depend largely 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 range lands hence pastoral activities are practiced all over the district. The prominent ethnic group is Somali-Muslim.

Survey objectives

The overall goal of this survey was to assess the current nutrition situation given the on-going nutrition emergency interventions. This assessment constituted a nutrition surveillance system as well as providing information for program future planning.

The specific objectives of the 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 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;

1 According to the projected population based on 2009 National population census 6

Area Covered The survey was conducted from 16th to 26th January 2012 in the five divisions of Wajir South namely Habaswein, Sabuli, Banane, Diif and Kulaaley.

Methodology A two stage cluster sampling using SMART (Standardised Monitoring of Assessment in Relief and Transition) methodology was employed with identification of clusters being proportional to the population size. The target population for the anthropometric survey was children aged 6-59 months and mothers with children aged between 0-59 months. A total number of 38 clusters were selected and 645 households were visited.

Data was collected on anthropometry, morbidity, vaccination and de-worming status, Vitamin A, zinc and iron folate supplementation, Infant and young child feeding practices, hygiene and sanitation practices and food security.

Retrospective information on mortality was collected using the current household census method, with a recall period of 90 days (from 20th October 2011-Kenyatta Day), from all households visited including those without children under the age of five. A total of 38 clusters and 645households were visited and 863 children from 6 to 59 months were assessed for anthropometry and other indicators. The final analysis was on 847 children after exclusion of 16 records.

Anthropometric and mortality data were analyzed using the ENA software version November 2011. Qualitative and quantitative data was analyzed using the Epi Info/ ENA software.

Key findings

Table 1 : Results summary for acute malnutrition INDEX INDICATOR RESULTS WHO(2006) Z- score Global Acute Malnutrition (196) 23 .1 % N=847 W/H< -2 z and/or oedema (19.5-27.3 CI) Severe Acute Malnutrition (39) 4.6 % W/H < -3 z and/or oedema (3.5-6.3 CI ) NCHS(1977) Z-score Global Acute Malnutrition (172) 20.3 % N=847 W/H< -2 z and/or oedema (16.9-24.1 C.I.) Severe Acute Malnutrition ( 17) 2.0% W/H < -3 z and/or oedema ( 1.2-3.3 C.I.) MUAC Global Acute Malnutrition (80) 9.4% ANALYSIS MUAC (<125 mm) ( CI) [N=847]

Severe Acute Malnutrition (13) 1.5% MUAC (<115 mm)

At risk of malnutrition MUAC (≥125 and (270) 31.9% <135mm)

Oedema present 0

Table 2: Results summary for Mortality

Child Mortality CMR (total deaths/10,000 people / day) 0.30 (0.13-0.68) U5MR (deaths in children under five/10,000 children under five/ day) 0.54 (0.19-1.52)

Table 3: Results summary for children’s morbidity, immunization and supplementation

Child Morbidity Total children sick 25.6% (267) Diarrhoea 60% (160) Fever, cough, difficult breathing 63%(168) Fever with chills like malaria 40% (108) Vomiting 34% (90) BCG SCAR Present 96.3% (817) Absent 3.7% (31) MEASLES 9-59 MONTHS By card 51.20% (434) According to caretaker 44.14% (374) OPV 1 By card 54.8% (468) According to caretaker 42.3% (359) OPV 3 By card 54.2% (460) According to caretaker 42.1% (357) De-worming Given Once 50.4% (427) Given twice 29.0% (246) Vitamin A supplementation (in Once 70% (61) the last 6 months)-6-11 Months Twice 20% (17) Vitamin A 12-59 Months Once 61% (466) Twice 34% (257)

Table 4: Results summary for water, hygiene and sanitation

Source of water  Borehole 46 (224)  Public water pan 27%(135)  Unprotected well 9% (41)  Water tankers 11% (51)  Protected well 5% (23) Water purification  Did nothing to water 88.7 %(424) Access to toilet facility  Yes 26% (123)  No 74% (345) Place of relief (defecation) for people with no access to toilet  Bush defecation 64% (207)  Open field defecation 6% (31) Hand Washing  Before eating food 36.4% (174)  After visiting toilet 15.7 % (75)  After cleaning children’s bottoms 6.1% (29)  Before preparing food 6.8%% (32)  Before feeding the child 6.3%(30)

Table 5: Results Summary for food and income sources Livelihood activity  Livestock herding 38.4%  Wage/casual 9.6%  Petty trade 10.2%  Firewood/charcoal 1.2% Source of food  Purchase 81.3%

Food consumption (7 day recall period)  Cereal 99.1%  Sweet sugar honey 91.2%  Milk and Milk products 90.2%  Oil/fats 89.8%  Dark green leafy vegetables 5.4%  Vitamin A rich foods 4.5% Source of income  Sale of livestock 43.9% (215)  Petty trade 12.4% (61)  Casual labour 15.5% (76)

Conclusions

The prevalence of acute malnutrition in wajir south district is considered “critical” with global acute malnutrition (GAM) of 23.1 (19.5-27.3 95% C.I.) and Severe Acute Malnutrition (SAM) rate of 4.6 % (3.5-6.2 95% C.I.). Compared with the survey undertaken in 2011 which indicated GAM of 28.5% (24.4-33.0 95% CI) and SAM of 4.5% (2.7-7.4), the acute malnutrition rates have reduced though not statistically significant due to overlapping confidence intervals. Other indicators like Vitamn A supplementation, deworming,have also improved compared to the previous survey.

RecommendationsImmediate • Continue supporting to the MOH with OJT ,supportive supervision and logistical support. • Scale up community mobilization activities through the empowerment of the community i.e. Traditional Births Attendants (TBAs), sheikhs and traditional healers in the detection and referral of acutely malnourished children <5 years, pregnant and lactating mothers. • Need for provision of water trucking and water storage equipment to areas affected by water stress as well as fuel subsidies and repairs. • Scale up Behaviour change communication (BCC) and formation of Community Mother to Mother support groups to improve Infant and Young Child nutrition status.

Medium term • MOH to develop a health workers retention strategy to reduce the high staffs turn over. • Continued health outreach in locations inaccessible to health facilities to offer basic primary health care package • Strengthen continuous nutrition surveillance through regular nutrition assessments and ongoing MUAC screening • Strengthening of hygiene practices to reduce the incidence of diarrhoeal disease including health and nutrition promotion to educate the community on basic WASH i.e. domestic treatment of drinking water and proper disposal of faecal waste.

Long term • Provision of toilet facilities through community participatory approaches coupled with awareness campaign on the importance of using such facilities i.e. Community Led Total Sanitation (CLTS) and Participatory Hygiene and Sanitation Transformation (PHAST) approaches • Disaster risk reduction strategy in programming .This includes but not limited to strategic re stocking, educating the community on management of disaster risk reduction , pasture growing and provision of fuel for irrigation, and encouraging the communities to establish pasture range reserve /reseeding to avoid mass losses of animals (livelihood) during drought . • Need for defined linkage of nutrition sector cluster with other sectors such as Water Sanitation and Hygiene (WASH) in the longer term. • Advocacy for recruitment and retention of health workers i.e. nurses , Clinical Officers (Cos) and nutritionists in North Eastern province • Government of Kenya (GOK) to strengthen community health strategy in the ASALS to foster empowerment of CHWs to participate in health and nutrition promotion and management of minor childhood ailments.

2.0 Introduction

Wajir South is one of the districts that form Wajir County in North Eastern Province (NEP) and is gazetted as part of the Arid and Semi-Arid Lands of Kenya (ASAL). The district is located in the North West horn of Kenya bordered by Somalia republic to the east, Wajir West district to the West, Lagdera to the south and Wajir East district to the North. The district was in 2010 subdivided into Habaswein and Wajir South districts. The larger Wajir South district administratively consists of 5 divisions including Habaswein, Sabuli, Banane, Kulaaley and Diif. Save the Children operates in all the Divisions of Wajir South districts. Within the five divisions there are a total of 14 government health facilities including Habaswein district hospital.

The districts are characterized by chronic food insecurity and high rates of malnutrition. The community is largely pastoralist and pre-dominantly Somali. Due to the drought experienced in 2011 in the horn of Africa (HOA) which was declared by the Kenyan president as a national Disaster, many livestock died, dams dried up and there was an escalation in the rates of malnutrition. Thereafter, in the months of October to November, the district as in many parts of Kenya experienced torrential rains that resulted in massive flooding rendering many parts impassable. Though there water and pasture availability improved there was an increase in prevalence of diseases affecting both humans and livestock.

Table 6: Amount of rainfall received in the district during the last short rains DIVISION Amount of rain receive in mm(Monthly) October 2011 November 2011 December 2011 Total Diff 205.1 300 0 505.1 Habaswein 114.1 144.8 0 258.9

Insecurity has further affected the district over the year with the main affected sites being Dagahaley, Gerilley, Dadajabulla, Sarif and Diff.

Rainfall is unpredictable, erratic and inadequate amounting to 250-300 mm annually on average and the district experiences an annual evapo-transpiration of 2500mm. It is also characterized by long dry spells and short rainy seasons which are erratic, unreliable and poorly distributed. Temperatures are normally high ranging between 28-40°C. Soils are mainly sandy and sandy loams.

The district population is currently estimated at 137,9912 persons with a growth rate of 3.7%. About 60% -70% of the people depend largely 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 range lands hence pastoral activities are practiced all over the district. The prominent ethnic group is Somali-Muslim.

The larger Wajir South district has a total population of 137,991. The population is predominantly Muslim and of Somali ethnicity, and is divided into clans, with community elders being in charge of daily affairs. Ogaden is the predominant clan and other clans include Masare, Garre, Degodia, Murule and Ajuran. Ogaden clan is further divided into four sub-clans namely-Garre (GK), Bah Gere, (BG) Muhamed Zuera (MZ) and Makabul (MK).

2 According to the projected population based on 2009 National population census 11

Figure 1: Map of Wajir South The District consists largely of a featureless plain. There are three swamps namely Boji, Lagbogol and Lorian all of which are found in Habaswein division. The area receives bi-modal rains with the onset of the long rains in April-May. 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 October to December. However in the past short rains have been more reliable than the long rains. The annual precipitation is about 280mm which varies in amount and distribution from year to year. The district’s climatic condition is characterized by recurrent droughts and unreliable rainfall that hinders crop production and growth of pasture for livestock keeping. These cyclic shocks have retarded development in the area since gains of a particular season are wiped out by drought and famine3.

Save the Children has been implementing programmes in Wajir South district since July 2009. Save the Children’s strategy for Wajir South aims at improvement of and access to health facilities, the protection and improvement of the nutritional status of beneficiaries and improved food security and livelihoods of beneficiaries through community management structures and social protection. Save the children integrated approach including health, Nutrition, Food security and Livelihoods Support program, Water Sanitation and Hygiene (WASH), child protection and Education programmes aims to address the immediate and underlying causes of malnutrition through enhancement of house hold food security and livelihoods in the medium term while at the same time linking this to long term livelihood support.

The World food programme (WFP) through its implementing partner Wajir South Development Association (WASDA), has been undertaking General food Distribution (GFD) in the area since 1994. In the Month of December 2011 WFP through the Kenya Food Security Steering Group (KFFSG) increased the GFD target beneficiaries to 308,700 persons against the total population of 606,000 persons in the entire Wajir County. All GFD are distributed are at a 75% ration scale of the daily per capita energy requirement4 as follows;

Table 7: Food aid basket Commodity Ration sizes Cereals 10.35kgs Pulses 1.80kgs CSB 1.20kgs Vegetable Oil 0.60kgs

The ministry of special programmes through the office of the president (OOP) has also been supplying relief food commodities to various communities and institutions as agreed by the District Steering Group (DSG).

3 Wajir South District Development plan 2008-2010(Final Draft) 4 Based on the UNHCR/UNICEF/WFP guidelines for food and nutrition in emergencies 12

Table 8: Other relief programmes in the area Organization Activities Horn Relief Cash relief and cash for work APHIA plus Health (HIV) , child protection World Vision Wajir South Sponsorship, Water and Sanitation, food aid, education and ADP Health VSF Suisse Improved Community Response to Drought (ICDR Project)

Save The Children in Integrated management of acute malnutrition, health, food Kenya(SCUK) security and livelihoods, WASH for health facilities, education and child protection Food Aid, Disaster Risk Reduction, school feeding WFP/ WASDA programme WARDA(Waaso Resource Health, Education and food aid Development Agency)

The specific objectives of the 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 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;

3.0 Survey Methodology The survey used the standardised monitoring and Assessment of relief and transitions (SMART 2006) sampling methodology. Emergency Nutrition Assessment (ENA) for SMART software was used to determine sample size for anthropometry and retrospective mortality. Children from 6 to 59 months of age were included in the sampling. Two stage cluster sampling was applied to assign clusters and to select the survey population. A local events calendar was used to aid mothers in accurate determination of the ages of their children. The principle of Probability Proportional to Population Size (PPS) was used in the identification of clusters using ENA for SMART software version 2011.

A total population of 137,991 was estimated for the survey area covering the five divisions. Information on population figures was obtained from the District Development Officer (DDO) in Wajir south based on projections from the 2009 National Census. The survey training took place from 16th to 19th January 2012 while data collection was conducted from 20th to 26th January 2012.

3.1 Sampling procedure and sample size for Anthropometric and mortality data

3.1.1 Sample size calculation for anthropometry

The sample size was calculated using the ENA for SMART software package. The number of children under 5 (U5) in the survey area was estimated at 20% of the total population (26,014 children). In addition to the under-five population data, the following basic assumptions were made:

1) The estimated prevalence of malnutrition is 28.5 %5) 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 1.36 4) The average number of persons per household is 6 and 1 mother per household. To calculate number of clusters to visit, the total sample for anthropometry and IYCF was used. Number of households (645) was divided by number of HH to be reached per day (17) resulting to 38 clusters.

3.1.2 Sample size calculation for mortality

The sample size for mortality was determined by using the following factors:  Total population of 137,991  The estimated Crude Mortality Rate (CMR) was 0.38 deaths/10,000 persons /day (Wajir south May 2011 nutrition survey).  Level of the desired precision was 0.3%  Design effect was 2  Recall period of 90 days  Average family size of 6

ENA/SMART software automatically calculated the sample size for mortality as 3924 persons using the above-mentioned data. Considering average household size of 6 persons, and expected non response rate of 3%, ENA further generated 578 households as the minimum sample size.

As the sample size for anthropometry (645 HHs) was larger than the sample size for mortality 578 HHs), it was decided to use the higher sample size higher precision for mortality results.

Given the operational circumstances and based on the fact that one cluster had to be completed in a day, 17 households were estimated to be visited in one day which yielded 38 clusters (645/17).

A recall period of 90 days was selected to enable the respondents recall the number of deaths without bias. The retrospective data was obtained within a period of 3 months specific dates being 20th October 2011(Kenyatta Day) to 20th January 2012- first day of the survey data collection.

3.2 Sampling procedure: selecting households and children

EPI7 method was utilized to select the households. A household was defined as a group of people who sleep under the same roof and eat from one cooking pot. Members of a household may not necessarily

5 GAM rates May 2011 Wajir South nutrition survey 6 From May 2011 Wajir South nutrition survey 7 SMART Methodology, 2011 14

be related to one another. If there were several structures within the same compound but each had their own cooking pot, then they were considered as separate households. Each survey team with the help of a village guide per cluster moved to the centre of the village where they spun a pen and walked to the direction the point of the pen faced to the edge of the village. While at the edge of the village, the team spun a pen again and walked along this second line counting each house on the way. Using random numbers list, the team selected the first house to be visited by randomly selecting a number between 1 and the total number of households counted. The randomly selected number became the first household to be visited and thereafter they moved in the right hand direction after every household. The respondent was the primary caregiver of the child/children. For the empty households the team confirmed from the neighbours if the owners were coming back the same day, they noted on the absentees form and went back later. In case the household members had migrated the teams noted and walked to main entrance where they selected the next household by moving to the right hand direction from that household.

In the event that the team reached the end of the cluster and had not attained the target households, a different direction was determined by randomly spinning a pen and the process repeated until the expected households per cluster was achieved. All children aged between 6 and 59 months of the same household were included in the survey for anthropometric measurements, while all children age between 0-23 months from the same household were included in the Infant and young child feeding practices(IYCF) survey . If the children were absent their names were noted in the absentees form and the teams returned back later to the same household to measure the children.

A retrospective mortality questionnaire using the current household census method was conducted for all the households sampled in each cluster, regardless of the presence of children under five years.

3.3 Case definitions and inclusion criteria

Age: All children aged 0-23 months in the households visited were included in the IYCF survey while all children 6-59 months in the households visited were included in the anthropometric survey. Caregivers were requested by the survey teams to produce the Child Welfare Clinic (CWC) cards or birth certificates at the beginning of the interviews to verify age and other information required i.e. Immunisation and Vitamin A supplementation status. In case the care givers did not have the CWCs cards or birth certificates, age was determined using a local events calendar which was developed during the survey teams training based on remarkable events that had taken place and could be recalled by most respondents in the community(see annex 4). Age for children 0-59 months was recorded in months. Weight: Children were measured using the electronic scale (UNISCALE8). All children were weighed with minimal clothing and no shoes. In case of children who could not stand on the scale, the caregivers were requested to stand on the weighing scale then after their weight was noted the scale was switched to read the weight of the child. Weight was read to the nearest 0.1kg Height: was measured using the height board to the nearest 0.1cm. Recumbent length was taken for children less than 87 cm or less than 2 years of age while those greater or equal to 87 cm or more than 2 years of age were measured standing up. All children were measured with no shoes, hijabs and caps. Height was taken by two measurers while the third staff recorded the readings. Bilateral oedema: Oedema was assessed by the application of normal thumb pressure for at least 3 seconds to both feet at the same time. The presence of a pit or depression(with supervisor’s verification) on both feet was recorded as oedema present and no pit or depression as oedema absent. MUAC: Mid Upper Circumference (MUAC) was measured at the midpoint of the left upper arm to the nearest 0.1cm using the standard MUAC tapes. Morbidity data: Information on two-week morbidity prevalence was collected by asking the mothers or caregivers if the child had been ill in the two weeks preceding the survey and including the day of the

8 Recommended as a valid weighing instruments in the guidelines for nutrition and Mortality assessments in Kenya 15

survey. Illness was determined based on respondent’s recall and was not verified by a health worker. Immunization status: For all children 6-59 months, information on Pentavalent 1 and OPV 1 and Pentavalent 3 and OPV 3 and measles vaccination was collected using Child Welfare Clinic cards and recall from caregivers. The vaccination coverage was calculated as the proportion of children immunized based on CWC records and recall. Further explanations were given to the caregivers to aid her in recalling i.e. the dosage whether injection or oral and the age of immunization. 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 “Sedax bilood aan sodhafney”. Samples of Deworming tablets were also shown to aid the caregivers in recall. Water and sanitation: information on access to clean drinking water and toilet facility and disposal of children faecal waste was collected in all households visited. Food security, livelihood and dietary status: Information on livelihoods activities, source of food, registration for general food distribution and coping strategies was collected in all the households visited. 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 90 days starting from 20th October 2011, Mashujaa day. Information was collected on the age and sex of the household members, the number of household members present within the recall period, the number of persons who joined or left within the recall period, and the number of births and deaths over the recall period. The presumed causes of death were recorded based on the following case definitions:

1= Diarrhoea (minimum of 3 watery stools/24hrs). 2= Bloody Diarrhoea; 3= Measles (fever with rash); 4= Fever; 5= Lower respiratory tract infection (fever, productive cough, chest pain, difficulty breathing) 6= Malnutrition; 7= Injury; 8= Other (Specify); 9= Unknown

3.4 Questionnaire, training and supervision

The overall survey was coordinated and supervised by Save the Children nutrition coordinator, 1 Ministry of Health DHMT member, I Save the Children nutrition officer and 1 UNICEF Nutrition Support Officer. For data collection, a total of 6 teams were recruited for the survey. The survey teams comprised 1 team leader and 3 enumerators/measurers. The 12 enumerators were selected through an interview process while team leaders were staffs from line ministries including 3 MOH staffs, 1 Ministry of Agriculture staff, 1 staffs from District Development Office and 1 staff from Arid Lands Resource Management Project II (ARLMP).

The survey was preceded by a 4 days thorough training by 3 Save the Children and 1 MOH staffs and covered the following topics;-  A brief introduction on Signs and symptoms of malnutrition, conceptual framework of malnutrition;  The objectives and purpose of the survey; 16

 Roles and responsibilities of the survey staffs  The survey design and methodology;  Sampling procedure;  Household selection, data collection procedures, accurate completion of questionnaires and interview skills;  How to take anthropometric measurements using standardized procedures. Standardization test for the measurements were conducted;  Development of a calendar of events ; and  Pre-testing of the questionnaires, translation into local language and the data collection procedure were undertaken before the actual survey. This was followed by the review of the questionnaires based on the feedback from pre-testing where no changes were made.

During training, a standardization test was also done whereby all survey team members (18) and the supervisors measured ten (10) same children each two times. Based on the results of the first test the precision and accuracy were not good and hence, the whole test was re-done after which the survey teams were formed based on individual team member’s strength. Based on the standardization report, team members with difficulty in taking measurements were retrained again until it was ascertained they could take accurate measurements. Teams were closely supervised by 3 supervisors (3 Save the Children staff and 1 Deputy District Public Health Nurse (D.DPHN) throughout the survey period. The supervisors were also trained on how to control the quality of work and collect qualitative data. Teams were trained to check anthropometric measurements twice before recording and ensured that all questions had been filled before leaving each household. At the end of every day during the de-briefing session, all the questionnaires were checked and any errors or omissions in data recording were verified and if information was missing the particular households were revisited.

3.5 Data analysis

Data entry was done by 4 data entry clerks who were supervised by Save the Children Monitoring and Evaluation Officer. The data entry clerks also participated in the four days initial training to be able to understand all the parameters in the questionnaire. Anthropometry data was entered on ENA for SMART 2011 version on a daily basis and the plausibility checks done. Any irregularity in the data was discussed with the team the following day in the morning before they set off to the field. Due to vastness of the district teams spent in the field but questionnaires were sent to the base on a daily basis. Anthropometric, mortality and quantitative data entry, cleaning, processing and analysis was conducted using EPI info version 3.5.1, ENA for SMART 2011 and SPSS version 16 software. The software flagged off any extreme, potentially incorrect or out of range values. Additional analysis for frequencies was conducted using windows SPSS and MS excel.

3.6 Nutritional indices

Acute malnutrition indices: Weight-for-height (WFH) index Acute malnutrition rates were estimated from the weight for height (WFH) index values and oedema. The values were derived from comparison of children in the survey to WHO 2006 references and are reflective of current nutritional conditions. WHI indices were expressed in Z-scores.

Table 9: WFH indices Weight for Height z-score Global Acute Malnutrition <-2 SD and/or oedema Moderate Acute Malnutrition <-2 SD and ≥ -3 SD Severe Acute Malnutrition <-3 SD and/or oedema Global acute malnutrition was therefore defined as ‘the proportion of children presenting with a weight for height index less than -2 Z scores. 17

MUAC

The guidelines used are as follows:

Table 10: MUAC indices MUAC <11.5 cm severe acute malnutrition and high risk of mortality MUAC ≥11.5 cm and <12.5cm moderate acute malnutrition MUAC≥12.5cm and <13.5cm at risk of moderate malnutrition MUAC≥13.5cm adequate nutritional status

Chronic Malnutrition Index: Height-for-Age (HFA) -Stunting

Chronic malnutrition rates were estimated from the height-for-age (HFA) index values. The HFA indices were compared with WHO standards and are reflective of long-term/ chronic malnutrition. HFA indices are expressed in Z-scores.

Table 11: Height for Age indices Height for Age z-score Global Chronic Malnutrition <-2 SD Moderate Chronic Malnutrition <-2 SD and ≥ -3 SD Severe Chronic Malnutrition <-3 SD

Global chronic malnutrition was therefore defined as ‘the proportion of children presenting with a weight for age index less than -2 Z scores.

Mortality Indices

The crude mortality rate (CMR) was determined for the entire population surveyed from the time of recall period to the time of survey. His was calculated using the SMART software.

The proportion of deaths among children under-five years of age (U5MR) is also calculated the same way using the under-five population data. The thresholds are defined as follows:

Table 12: 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

Survey Data Validation Process Close supervision of data entry was done on daily basis and data cleaned and validated at the end before actual analysis. Validation of the data was based on the following parameters:  Out of usual range values – flags  Age and sex distribution  Digit preference scores  The standard deviation  Skewness (This is a measure of the degree of asymmetry of the data around the mean)  Kurtosis (This shows the relative flatness of the data compared to a normal distribution).

During data analysis, the ENA for SMART software flagged any missing data, extremes or potentially 18

incorrect z-scores values. All flagged z-scores were excluded from the analysis. A triangulation of information was done to verify the findings of the quantitative data; information was collected through key informants, secondary data and observation.

The survey results were also presented to the Nutrition Information Technical Working Group (NITWG) under the Nutrition technical Forum (NTF) for validation during which the survey was validated.

4.0 Results

4.1 Survey sample description

Table 13: Survey Sample Selection Number of children 6-59 months surveyed 863 Number of children 6-59 months analyzed by WHO 847 Number of children 6-59 months analyzed by NCHS 847 Number of total population surveyed for mortality 3724 Number of children under five surveyed for mortality 1024 Number of HH covered in the mortality survey 663 Number of persons who joined the household during the recall period 93 Number of persons who left the household during the recall period 33 Number of under five children who joined the household during the recall period 17 Number of under five children who left the household during the recall period 17 Number of births during the recall 10 Average Number of persons per HH 7 Average Number of children per HH 2 % of children under five in the population 27.5%

Of all the households visited with children between 6-59 months, 10 children were absent. The children had either been taken to the grazing lands “baadia” following the livestock movements in order to access milk or to their grandmothers who took care of them when their mother gave birth to younger siblings.

4.2 Anthropometric results (based on WHO standards 2006):

Table 14: 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

Table 15: Distribution of age and sex of sample Boys Girls Total Ratio AGE (mo) no. % no. % no. % Boy: girl 6-17 96 53.6 83 46.4 179 21.1 1.2 18-29 102 47.9 111 52.1 213 25.1 0.9 30-41 117 53.2 103 46.8 220 26.0 1.1 42-53 91 54.5 76 45.5 167 19.7 1.2 54-59 34 50.0 34 50.0 68 8.0 1.0 Total 440 51.9 407 48.1 847 100.0 1.1 Of the children measured 51.9% were boys while 48.1% were girls. The overall sex ratio was 1.1 which is within the recommended range of 0.8-1.2

Figure 2: Population age and sex pyramid

There was a slight overrepresentation of boys aged 6-17, 30-41 and 42-53 months which may be attributed to age recall bias as age determination in the absence of birth certificate and child welfare cards was based on local events calendar. Compared to the previous surveys, this does not represent a typical pattern for those age groups.

Table 16: prevalence of malnutrition based on weight for height z-scores (and/oedema) and by sex All Boys Girls n = 847 n = 440 n = 407 Prevalence of global malnutrition (196) 23.1 % (113) 25.7 % (83) 20.4 % (<-2 z-score and/or oedema) (19.5 - 27.3 (21.4 - 30.4 (15.8 - 25.9 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate malnutrition (156) 18.4 % (86) 19.5 % (70) 17.2 % (<-2 z-score and >=-3 z-score, no (14.9 - 22.5 (15.6 - 24.2 (12.8 - 22.7 oedema) 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe malnutrition (40) 4.7 % (27) 6.1 % (13) 3.2 % (<-3 z-score and/or oedema) (3.5 - 6.4 95% (4.2 - 8.9 95% (1.9 - 5.3 95% C.I.) C.I.) C.I.) The prevalence of oedema is 0.0 %

Table 17: Prevalence of acute malnutrition by age, based on weight for height z-scores and/or oedema

Severe wasting Moderate Normal Oedema (<-3 z-score) wasting (> = -2 z score) (>= -3 and <-2 z- score ) Age Total No. % No. % No. % No. % (mo.) no. 6-17 179 9 5.0 33 18.4 137 76.5 0 0.0 18-29 213 6 2.8 29 13.6 178 83.6 0 0.0 30-41 220 6 2.7 41 18.6 173 78.6 0 0.0 42-53 167 12 7.2 35 21.0 120 71.9 0 0.0 54-59 68 7 10.3 18 26.5 43 63.2 0 0.0 Total 847 40 4.7 156 18.4 651 76.9 0 0.0

Table 18: Distribution of acute malnutrition and oedema based on weight-for-height z-scores

<-3 z-score >=-3 z-score Oedema present Marasmic kwashiorkor Kwashiorkor No. 0 No. 0 (0.0 %) (0.0 %) Oedema absent Marasmic Not severely malnourished No. 40 No. 807 (4.7 %) (95.3 %)

Figure 3: Weight for height z-scores

Table 19: Prevalence of underweight based on weight-for-age z-scores by sex

All Boys Girls n = 847 n = 440 n = 407 Prevalence of underweight (168) 19.8 % (96) 21.8 % (72) 17.7 % (<-2 z-score) (16.4 - 23.8 (17.3 - 27.2 (13.4 - 23.0 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate underweight (135) 15.9 % (79) 18.0 % (56) 13.8 % (<-2 z-score and >=-3 z-score) (13.0 - 19.4 (13.9 - 22.9 (10.4 - 17.9 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe underweight (33) 3.9 % (17) 3.9 % (16) 3.9 % (<-3 z-score) (2.3 - 6.4 95% (2.1 - 6.9 95% (2.1 - 7.2 95% C.I.) C.I.) C.I.)

The weight for Age (WFA) indices which measures underweight is a combination measure of both acute and chronic malnutrition (wasting and stunting) therefore it indicates a reflection of both current and past nutritional experience of the community. A Percent of underweight was seen in boys than girls from the community surveyed.

Table 20: Prevalence of underweight by age, based on weight-for-age z-scores

Severe Moderate Normal Oedema underweight underweight (> = -2 z score) (<-3 z-score) (>= -3 and <-2 z- score ) Age Total No. % No. % No. % No. % (mo.) no. 6-17 179 10 5.6 29 16.2 140 78.2 0 0.0 18-29 213 7 3.3 34 16.0 172 80.8 0 0.0 30-41 220 4 1.8 34 15.5 182 82.7 0 0.0 42-53 167 9 5.4 23 13.8 135 80.8 0 0.0 54-59 68 3 4.4 15 22.1 50 73.5 0 0.0 Total 847 33 3.9 135 15.9 679 80.2 0 0.0

Table 21: Prevalence of stunting based on height-for-age z-scores and by sex

All Boys Girls n = 847 n = 440 n = 407 Prevalence of stunting (164) 19.4 % (87) 19.8 % (77) 18.9 % (<-2 z-score) (16.0 - 23.3 (15.5 - 24.9 (14.6 - 24.1 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate stunting (126) 14.9 % (66) 15.0 % (60) 14.7 % (<-2 z-score and >=-3 z-score) (12.0 - 18.2 (11.6 - 19.1 (10.7 - 20.0 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe stunting (38) 4.5 % (21) 4.8 % (17) 4.2 % (<-3 z-score) (3.0 - 6.6 95% (2.7 - 8.3 95% (2.6 - 6.7 95% C.I.) C.I.) C.I.)

The height-for-age (HFA) indices assesses linear growth and hence it reflects the cumulative effects of chronic nutritional inadequacy and/or recurrent chronic illness which may result in a child having a low HFA (referred to as stunting) indicated by shortness when compared to his/her age cohorts. It is not affected by seasonality but is rather related to the effects of socio-economic development and long- standing food security situation in a community. The results (Table 21) indicate a global stunting rate of 19.4% (16.0-23.3 95% CI) and severe stunting rate of 4.5 %( 3.0-6.6 95%CI ). However this is higher than that of the last survey where the Global stunting was at 12.2% (9.5-15.4 CI) and Severe stunting at 2.3% (1.4-3.9 CI) 95% which may be indicative of a worsening situation. According to the results boys are more affected than girls though not significantly different

Table 22: Prevalence of stunting by age based on height-for-age z-scores

Severe stunting Moderate Normal (<-3 z-score) stunting (> = -2 z score) (>= -3 and <-2 z- score ) Age Total No. % No. % No. % (mo.) no. 6-17 179 9 5.0 25 14.0 145 81.0 18-29 213 19 8.9 39 18.3 155 72.8 30-41 220 6 2.7 33 15.0 181 82.3 42-53 167 3 1.8 20 12.0 144 86.2 54-59 68 1 1.5 9 13.2 58 85.3 Total 847 38 4.5 126 14.9 683 80.6 23

Mean Weight for height Z scores WHO Standards 2006

The mean weight-for-height Z scores was -1.20±01.14 with a design effect of 1.77 whereas the weight- for-age mean Z scores -1.25±0.94 with a design effect of 1.74 and the height-for-age was –0.79±1.30 with a design effect of 1.75. There were no Z scores that were not available nor out of range as shown in the table below.

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

Indicator n Mean z- Design Effect z-scores not z-scores out scores ± SD (z-score < -2) available* of range Weight-for-Height 847 -1.20±1.14 1.77 0 0 Weight-for-Age 847 -1.25±0.94 1.74 0 0 Height-for-Age 847 -0.79±1.30 1.75 0 0 * contains for WHZ and WAZ the children with oedema.

Table 24: Plausibility Checks for Anthropometric Data

Indicator Survey Overall sex ratio: p-value = 0.257 (boys and girls Digit preference weight 0 (5) equally represented) Overall age distribution: p-value = 0.002 (significant Digit preference height 2 (7) difference) WHZ (Standard deviation) 0 (1.07) Overall age distribution for boys: p-value = 0.074 (as WHZ (Skewness) 0 (0.20) expected) Overall age distribution for girls: p-value = 0.026 WHZ (Kurtosis) 0 (0.10) (significant difference) Percentage of flags 1.1% Overall sex/age distribution: p-value = 0.000 (significant difference) Age ration: ages 6-29: 30-59 1.04

4.3 Mortality results (retrospective over 3 months/days prior to interview)

Table 25: Mortality rates

CMR (total deaths/10,000 people / day): 0.30 (0.13-0.68) (95% CI) U5MR (deaths in children under five/10,000 children under five / day): 0.54 (0.19-1.52) (95% CI)

Information on mortality was collected. A total number of 3274 people were included in the mortality survey. Out of these, 1024 of them were children below 5years of age. Of all deaths reported during the survey 2 (20%) deaths occurred in children under five years while the other 8 (80%) deaths occurred in persons over five years. Both mortality rates were within the acceptable levels for emergency situations. The causes of deaths for the children under five years were due to diarrhoea. Moreover, causes of death for adults were lower respiratory tract infections (2), injury (1), others (ageing -1, suspected dengue fever -1) and unknown causes (3).

4.4 Children’s morbidity The prevalence of reported illness was determined based on a two-week recall period (this was inclusive of the day of the survey). As shown in the table below, more than a third (31.5%) of the children (267) under five years were cough (63%), diarrhoea (60%), fever 94%) and vomiting (34%). Upsurge of pneumonia and diarrhoea cases was also observed in outreach mobile clinics, health facilities and stabilization centre.

Table 26: Prevalence of reported illnesses in children in the two weeks prior to interview (n=267)

Illness Number 6-59 months Diarrhoea 168 60 % Cough 160 63 % Fever 108 40 % Measles 0 0% Other(vomiting) 90 34% Eye infection 10 4% Stomach ache 7 3% Malnutrition 6 2% Skin infections 5 2%

Figure 4: Symptoms breakdown in the children in the last two weeks prior to interview (n=267)

Figure 5: Caretaker’s health seeking behaviour

Health care seeking behaviours determines the preference and quality of health services obtained whenever a child falls ill. Quality health of health services and the duration before a sick child receives medical attention contributes to the severity of the illness. Of the 267 children who were reported to be ill within the last two weeks, only 1% who did not seek ant medical assistance. However 4% reported to have sought assistance from traditional healers. The Percent of those who did not seek assistance had greatly improved from 16% in the previous survey to 1% reported.

Table 27: Vaccination, deworming and Vitamin A coverage BCG SCAR Present 96.3% (817) Absent 3.7% (31) MEASLES 9-59 MONTHS By card 51.20% (434) According to caretaker 44.14% (374) OPV 1 By card 54.8% (468) According to caretaker 42.3% (359) OPV 3 By card 54.2% (460) According to caretaker 42.1% (357) De-worming Given Once 50.4% (427) Given twice 29.0% (246) Vitamin A supplementation (in Once 70% (61) the last 6 months)-6-11 Months Twice 20% (17) Vitamin A 12-59 Months Once 61% (466) Twice 34% (257)

By using both Child Welfare Clinic (CWC) card and caretakers recall from the caregivers, there is good coverage for all the vaccinations, which are above the recommended Kenya Expanded Programme on Immunization (KEPI) target of 80%. Only 42.7% respondents reported to have immunization cards. This is an improvement compared to the same survey conducted last year which was at 25%.Deworming coverage had greatly improved from last survey that is from 34.6% in May 2011 to 79.4%.This may have been attributed by the scale up of interventions during the emergency drought. However approximately 42% of the coverage reported here was based on recall and not evidenced by and EPI card.

Figure 6: Vitamin supplementation coverage

Of the children surveyed, over half (56%) reported to have received Vitamin A supplementation once while slightly less than a third (30%) reported to have received supplementation twice in the last one year. Compared to the previous survey there was an improvement which may have been attributed to the two Malezi bora sessions in 2011 and the emergency Blanket Supplementary Feeding programme which was covering all children under five years, pregnant and lactating mothers.

4.5 Water and sanitation Almost half (46%) of the households surveyed said boreholes were their main current sources of water, with 27% getting water from water pans which had been filled by the short rains experienced between October and early December 2011.eleven Percent (11%) reported to be receiving water from water trucking as shown in the graph below.

Figure 7: source of water

Figure 8: Time taken on water collection

Water treatment

Majority (88.7%) of the households interviewed did nothing to their water before drinking. This may have been the major contributor to high incidences of diarrhoea and vomiting reported both in the health facilities and outreach sites mobile clinics. It’s worth noting that some locations reported to be using PUR to purify water from the water pans However there is an improvement compared to last survey report of 98% who had been reported not doing anything to water before drinking.

Figure 9: Methods of water treatment

Access to toilet facilities Slightly less than a third (26%) reported having access to a toilet facility which was either their own, neighbour or a public toilet.71% of those who reported not to have access 74.8% reported to be defecating in the bush.

Figure 10: Types of toilet facilities

Handwashing

Only 22% of the households surveyed reported to be washing their hands with water and soap while and 0.2 % washed with water and ash. The rest wash with water only. The community reported to their hand washing times to be as shown in the table below;

Table 28: Hand washing time

Hand washing time Count %

After visiting the toilet 75 15.69% Before feeding the child 30 6.28%

Before eating 174 36.40% Before preparing food 32 6.69%

When dirty 47 9.83% When water available 28 5.86%

After cleaning children’s bottoms 29 6.07%

Other (Before prayers) 62 12.97%

5.0 Food Security and Utilization

5.1 Infant and Young Child Feeding Practices Information on Infant and young child feeding practices (IYCF) based on a 24-hour recall, in line with WHO guidelines to minimize recall bias and thus obtain a more valid data. Information on breastfeeding practices was obtained for children aged 0-23 months.

Figure 11: Initiation of breastfeeding

All mothers reported to have breastfed their children. As shown above on 28% of the children were reported to have been put on breast in the first hour of birth.

Figure 12: Exclusive breastfeeding in the last 24 hours

Half the proportion of children 0-5 months was reported to have been exclusively breastfed in the last 24 hours as indicated in the graph above.

Dietary Diversity

For this indicator only a third (33%) mothers who reported to have practiced a dietary diversity of three or more food groups while feeding the children with complementary foods. Most of them reported that they fed their children with what was commonly available and accessible in the market. Table 29: Dietary diversity amongst children 6-23 months

Dietary diversity-6-23 months No. Percent

3+ Food groups breastfed 78 33%

4+ Food groups non-breastfed 1 0%

Minimum meal times for children 6-23 months

For the average healthy breastfed infant, complimentary foods9 time should be 2-3 times per day at 6-8 months, 3-4 times per day at 9-11 months of age, with additional snacks offered 1-2 times per day as desired (WHO IYCF participants manual pp. 185 2006)

Table 30: Minimum meal times -6-23 months

Minimum meal times No. Percent At least 2 times a day-6-8 months 32 13%

At least 3 times a day-6-23 months 118 50% 4 times for non-breastfed 1 0%

5.2 Food diversity at household levels According the t survey the main source of food was purchase at 81.3% with 43.9% indicating livestock sale as the main source of income. Food diversity analysis done on the survey findings was based on the foods consumed in the last 7 days and 24-hour recall period. The graphs below show that most common foods consumed by households were;-cereal based foods (mainly pasta, maize, maize meal and Corn Soya Blend (CSB), milk and milk products, sweets, oils/fats and pulses/legumes. Availability of milk and milk products was as a result of heavy rainfall experienced in the country between October and December 2011.However the milk supply was reported to be low as many livestock’s did not calf in the previous year due to the drought experienced. Despite the fact that Wajir South community was a pastoralist community, only a small proportion of households consumed meat. The low consumption of meat was explained by lack of butcheries in most of the locations visited. Moreover most of the animals had died due to the prolonged drought experienced previously and the community valued the only few left for bringing back the life of their livestock’s herds hence were not keen in slaughtering them.

Households also cited high food prices as a result of inflation and closure of border points had led to consumption of less preferred foods. This in turn led to reduction in sizes and number of meals consumption by the households. Of the households interviewed, 74% had received food aid from WFP in the last three months. However food aid delivery was not done for two months (October and

9 Complimentary food any foods given to children from 6 months of age while they are still breastfeeding 31

November 2011) due to pipeline breakdown as a result of heavy rains that rendered roads impassable hence hampering the delivery of food aid commodities both to and from the warehouse.

Figure 12 shows that almost all (99.1%) the respondents reported to have used cereals for the last seven days prior to the survey, followed by sweets (91.2%), milk and milk products (90.2%) and oils/fats (89.8%).These results indicates that this pastoralist community was able to access milk due to pastures regeneration. On the other hand, the proportion of respondents that consumed meat was quite low at 18%, those that consumed green leafy and vitamin A rich vegetables are negligible at 5.4% and 4.5% respectively.

Figure 13: Food consumption 7 days and 24-hour recall.

5.3 Main livelihoods activities

The survey showed that 38.4% of the households’ main livelihood activities were livestock herding. This was followed by petty trade at 10.2% which included sale of firewood and small kiosks and sale of milk and milk products near trading centres. Waged /casual labour at 9.6% which mainly included use of donkey carts services

Figure 14: Main Livelihood activities

6.0 Discussion

6.1 Nutritional status

A total number of 847 children aged between 6-59 months were measured and included in the analysis of this survey. The overall age sex ratio was 1.04 which is within the acceptable range of 0.8-1.2. The GAM rates at 23.1% (19.5-27.3) 95 CI scores are above the emergency threshold of >15%10. Compared with the survey undertaken in May 2011 which indicated GAM of 28.5% (24.4-33.0 95% CI) and SAM of 4.6% (3.5-6.3), the acute malnutrition rates have reduced though not statistically significant due to overlapping confidence intervals.

Figure 15: Comparison of malnutrition rates based on WFH Z-scores in Wajir South (2009-2012)

10 Interpretation of level; Global Acute malnutrition(GAM): prevalence of GAM <5 termed as acceptable, 5-9% poor, 10-14% serious and > 15 critical 33

Table 31: Comparison of acute malnutrition expressed by MUAC 2011 and 2012

Divisions covered May 2011 Jan 2012 Habaswein, GAM (MUAC <125 mm) 4.6% 9.4% Sabuli, Diif, SAM (MUAC<115 mm) 0.8% 1.5% Kulaaley and At risk (MUAC <135mm) 31.9% 21.8% Banane

MUAC is a better predictor of mortality than weight for height. A comparison between the two surveys undertaken reveals that in 2012 there were more children in all the three MUAC categories

OTP programme coverage of 54%was good but considering the on-going drought migration of communities and establishment of new settlements is on the increase.

6.2 Mortality According to the survey results, the crude mortality of 0.30 (0.13-0.68) under five mortality rate (U5MR) of 0.54 (0.03-1.70) were within normal ranges. Compared with the previous two years, the mortality rates decreased slightly. During the survey, it was noted that the community was under reporting deaths especially amongst neonates as according to the community death is considered an act of God.

Figure 16: Comparison mortality rates 2009-2012

6.3 Targeted Feeding Programme coverage A coverage survey conducted in December 2011 using the Semi Quantitative Evaluation of Access and coverage (SQUEAC) indicated that Outpatient Therapeutic Programme (OTP) coverage was in line with SPHERE standards as indicated in the table below

April 2011 Dec 2011

OTP OTP Point coverage 50% 54% CI: (29.4 – 70.7%) CI: (39.1-68.8%) Period Coverage 75.7% 71.2% CI: (63.8 -85.3%) CI: (59.1 -83.3%)

Compared to the results of the same survey conducted in April 2011 the point coverage seems to have slightly improved from 50% to 54 %. The potential barriers to the coverage as reported were’ Inaccessible roads, migration, insecurity, time/ Health Seeking, inadequate inclusion of key sources of referral, challenges associated with MOH managing malnutrition within health facilities and apathy.

6.4 Blanket feeding programme As a result of the 2011 drought in the Horn of Africa (HOA), Blanket Supplementary Feeding Programme was initiated in ASAL district, Wajir South being one of them to mitigate the escalating levels of malnutrition. The 5 –month programme was covering all children under five years, pregnant and lactating mothers began in August 2011 and is ending in March 2012. This has contributed to a decrease in malnutrition levels in the district.

6.5 Causes of malnutrition

Morbidity was reported with quarter (25.6%) of the all the children reported to have been ill with diarrhoea, Acute Respiratory infections (ARI), Malaria and vomiting accounting for over 93.6% of all the causes of morbidity.

The De-worming status for the last one year according to the survey was found to be low with 50.4% reporting to have been dewormed once and 29.0% twice in the year. Considering the standard deworming period to be after every 3 months. This finding is worrying considering the water sources, poor water availability and accessibility experienced in most parts of the district as well as poor sanitation that predisposes the children to helminthes infestation, making de-worming a crucial exercise.

This survey was carried out in January after the heavy short rains in October to December which caused floods some locations in the district. All the water pans were filled with water that had run over the animal carcases. Considering the low (12.3%) water treatment status as reported in the survey, this could be the attributing cause to high diarrhoea and vomiting cases which in return led to increased admissions in the stabilization centre as a result of malnutrition. The rains had also come after a rainfall failure for 3 consecutive periods hence most of the communities were still recovering from the prolonged drought.

Immunization coverage was above the national targets and this is largely due to the efforts of MOH and Save the Children who are providing health and immunization outreach services in most of the hard to reach areas. Following a suspected dengue fever outbreak in some parts of the district, a mop-up measles campaign and Vitamin A supplementation was conducted in the district in the month of July. Moreover with the emergency Blanket Supplementary Feeding Programme (BSFP) in place all the children in this programme benefitted from systematic treatment which included Vitamin A supplementation, deworming and immunization.

Market prices of food commodities have increased drastically due to country inflation and closure of border due to the incursion of Kenya Defence force into Somali. While prices of basic commodities are 35

increasing, the prices of livestock are also increasing. Most community members are keeping their animals for fattening due to availability of pastures and for calving purpose. The animals market prices for December 2011 and January 2012 were as follows;- December 2011 January 2012 Price- price- Kshs. Kshs Cattle 7560 8120 Goat 2550 2618 Camel 20,240 20,480

Milk from cattle and goats was very scarce in the areas visited and the little available from camels was highly overpriced between 80-100/-per litre (against normal 20- ) hence unaffordable to majority of households. Meat was also scarce and expensive going for 400/- per kg against a normal of 240/- per kg. Chicken was selling at Kshs.500 compared to the same time last year when it was costing half price.

Poor sanitation and hygiene practises have resulted to high prevalence of diarrhoea cases. Households reported using untreated water from unprotected sources. Vulnerability to illness increases because of unhygienic practices like open field defecation, open disposal of animal carcasses which can also cause diarrhoea which can lead to malnutrition.

During the survey there was a general cry from the community for support through the following interventions  Deployment of health workers and provision of medical supplies in the newly constructed health facilities i.e. Gerilley, Kulaaley and Hara Khot Khot.  Provision of filters and water treatment chemicals  Provision of foliage for the livestock  Water trucking and borehole drilling in the areas without permanent water sources

7.0 Conclusions

The prevalence of acute malnutrition in wajir south district is considered “critical” with global acute malnutrition (GAM) of 23.1% (19.5-27.3% CI ) and Severe Acute Malnutrition (SAM) rate of 4.6% (3.5-6.3 CI) Compared with the survey undertaken in May 2011 which indicated GAM of 28.5 % (24.4 - 33.0 95% C.I.) and SAM of 4.5 % (2.7 - 7.4 95% C.I.). the acute malnutrition rates have increased though not statistically significant due to overlapping confidence intervals.

Overall the underlying factors are high morbidity, inadequate IYCF and care practices, poor food security and dietary, poor sanitation and lack of adequate and unsafe drinking water.

8.0 Recommendations

Immediate

• Scale up treatment of the malnourished especially at the health facilities through increasing support to MOH staffs (Capacity building, on-the job trainings, regular supervisions and logistical support). • Provision of blanket supplementary feeding programme to prevent acute malnutrition among children, pregnant women and lactating mothers from deteriorating. • Scale up community mobilization activities through the empowerment of the community in the detection and referral of acutely malnourished children less than 5 years. 36

• Mass campaigns to improve Vitamin A and De-worming coverage (including targeting ECDs and Madrasa) • Scale up provision of water trucking and water storage equipment’s to areas affected by water stress as well as fuel subsidies and repairs/ maintenance as an emergency mitigation measure.

Medium term

• Continued health outreach in locations inaccessible to health facilities to offer basic primary health care package  Strengthen continuous nutrition surveillance through regular nutrition assessments and ongoing MUAC screening • Strengthening of hygiene promotion to encourage practices to reduce the incidence of diarrhoeal disease including health education to educate the community on domestic treatment of drinking water.

Long term

• Provision of toilet facilities through community participatory approaches i.e. Community Led Total Sanitation (CLTS) coupled with awareness campaign on the importance of using such facilities. • Disaster risk reduction strategy in programming .This includes but not limited to strategic de stocking, educating the community on management of disaster risk reduction and encouraging the communities to establish pasture range reserve /reseeding to avoid mass losses of animals (livelihood) during drought. • Harnessing untapped irrigation potential in Habaswein division near Ewaso Nyiro.

9.0 References

1. SPHERE minimum standards 2011 2. KFSSG Short rains assessment 2012 report 3. KFSSG Short Rains Assessment 2011 Report 4. North Eastern Province Drought Assessment report April 2011 5. Save the Children Wajir South Nutrition survey report 2009, 2010,2011

10.0 Appendices

Appendix 1

Plausibility Report Plausibility check for: KEN-180212-HABS.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 (1.1 %) Overall Sex ratio Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 0 (p=0.257) Overall Age distrib Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 4 (p=0.002) Dig pref score - weight Incl # 0-5 5-10 10-20 > 20 0 2 4 10 0 (5) Dig pref score - height Incl # 0-5 5-10 10-20 > 20 0 2 4 10 2 (7) Standard Dev. WHZ Excl SD <1.1 <1.15 <1.20 >1.20 0 2 6 20 0 (1.07) Skewness WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (0.20) Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (0.10) Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <0.000 0 1 3 5 1 (p=0.013) Timing Excl Not determined yet 0 1 3 5 OVERALL SCORE WHZ = 0-5 5-10 10-15 >15 7 %

At the moment the overall score of this survey is 7 %, this is good.

Appendix 2 Assignment of Clusters

Geographical unit Population size Assigned cluster POPULATION GEOGRAPHICAL UNIT SIZE CLUSTER ARGANE 4026 1 GULLET DEER 2349 2, 3 BURDER 4738 4 MACHEZA 4122 5 KURSIN 3575 6, 7 LEHELEY 7709 8, 9 LAGBOGOL SOUTH 3781 15, 16 EL-ADOW 3346 10,11 KULAALEY 10610 12, 13, 14 TESORIE 4222 17, 18, 19 ALIDUMAL 635 20 DILMANYALE 3395 21 HABASWEIN CENTRAL 2390 22,23 KIWANJA NDEGE 3525 24, 25 KANJARA 1664 26, 27 MERI 4400 28, 29 ABAKORE 7218 30, 31 FADIWEYNE 279 32 SHIMBIR BUL 2346 33 BIYA MADHOW 3459 34, 35 SHIDLEY 463 36 SABULI 3058 37, 38

Appendix 3

Evaluation of Enumerators

Report for Evaluation of Enumerators

Weight:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [W2-W1] [Superv.(W1+W2)- Enum.(W1+W2]

Supervisor 26.08 4/3 warfa 0.00 OK 26.12 OK 0/0 3/5 Ahmed siyad 0.00 OK 26.12 OK 0/0 3/5 Amina adan 0.00 OK 26.12 OK 0/0 3/5 Mohamed abdirahman0.00 OK 26.08 OK 0/0 4/3 Suadha gele 0.00 OK 26.12 OK 0/0 3/5 Yarrow issack 0.00 OK 26.12 OK 0/0 3/5 Abubakar issack 17183.10 POOR 17227.50 POOR 3/0 4/4 Mohamed Ismail 0.33 OK 24.89 OK 4/3 4/4 Mohamed shabin 0.25 OK 24.89 OK 4/3 3/5 Farhiya mohamed 16900.20 POOR 16716.90 POOR 4/4 4/4 Adan Noor 0.07 OK 25.71 OK 2/4 2/6 Shukri 0.04 OK 24.72 OK 2/2 2/5 Maryan bare 0.04 OK 25.68 OK 2/2 2/4 Samson njeru 0.90 OK 24.22 OK 2/4 2/5 Lul abdi 0.03 OK 25.53 OK 1/2 1/5 Idle gedi 0.02 OK 25.32 OK 2/0 1/5 Ahmed nunow 0.01 OK 25.89 OK 0/1 4/3 Adey abdi 0.01 OK 25.89 OK 1/0 4/3

Height:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [H2-H1] [Superv. (H1+H2)- Enum. (H1+H2]

Supervisor 65.29 1/7 Warfa 0.01 OK 78.24 OK 1/0 4/6 Ahmed siyad 0.03 OK 77.82 OK 1/2 4/6 Amina adan 0.01 OK 78.24 OK 1/0 4/6 Mohamed abdirahman121.08 OK 202.01 POOR 2/1 5/5 Suadha gele 2.92 OK 75.33 OK 0/4 5/5

Yarrow issack 8836.02 POOR 8933.21 POOR 1/2 4/6 Abubakar issack 0.21 OK 76.02 OK 1/4 4/6 Mohamed Ismail 1.61 OK 95.80 OK 4/3 8/2 Mohamed shabin 6.02 OK 96.91 OK 4/4 9/1 Farhiya mohamed 1.45 OK 93.98 OK 3/5 8/2 Adan nor 9761.55 POOR 7931.78 POOR 4/5 7/3 Shukri 10020.20 POOR 10610.90 POOR 3/7 8/2 Maryan bare 0.21 OK 110.72 OK 3/7 8/2 Samson njeru 0.16 OK 112.99 OK 5/3 9/1 Lul abdi 0.20 OK 114.41 OK 2/2 10/0 Idle gedi 0.11 OK 114.92 OK 2/1 10/0 Ahmed nunow Error Error 1/2 5/5 Adey abdi 121.08 OK 202.01 POOR 2/1 5/5

MUAC:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [MUAC2-MUAC1] [Superv. (MUAC1+MUAC2)- Enum. (MUAC1+MUAC2]

Supervisor 11.64 3/5 Warfa 0.04 OK 21.28 OK 0/1 1/8 Ahmed siyad 0.06 OK 21.20 OK 0/3 1/8 Amina adan 0.04 OK 21.28 OK 0/1 1/8 Mohamed abdirahman 0.00 OK 26.76 OK 0/0 0/9 Suadha gele 0.10 OK 21.46 OK 1/1 1/8 Yarrow issack 0.68 OK 21.92 OK 1/1 1/9 Abubakar issack 0.02 OK 21.10 OK 2/0 1/8 Mohamed Ismail 2.13 OK 9.79 OK 4/4 4/6 Mohamed shabin 1.50 OK 8.26 OK 5/3 4/6 Farhiya mohamed 1.35 OK 8.55 OK 3/5 4/6 Adan Noor 0.12 OK 22.00 OK 0/4 0/10 Shukri 0.04 OK 20.96 OK 0/4 0/10 Maryan bare 0.84 OK 20.16 OK 1/3 1/9 Samson njeru 0.03 OK 12.41 OK 1/2 1/8 Lul abdi 0.04 OK 11.76 OK 1/0 1/8 Idle gedi 0.00 OK 13.24 OK 0/0 2/7 Ahmed nunow 0.00 OK 26.76 OK 0/0 0/9 Adey abdi 0.00 OK 26.76 OK 0/0 0/9

For evaluating the enumerators the precision and the accuracy of their measurements is calculated. For precision the sum of the square of the differences for the double measurements is calculated. This value should be less than two times the precision value of the supervisor. For the accuracy the sum of the square of the differences between the enumerator values (weight1+weight2) and the supervisor values (weight1+weight2) is calculated. This value should be less than three times the precision value of the supervisor. To check for systematic errors of the enumerators the number of positive and negative 41

deviations can be used.

Calendar of events

Annual 2007 2008 2009 2010 2011 2012 Events January -School Rift 48 36 24 12 0 opening valley Post- First SCUK Zakat (Hot fever. election BSFP season) violence Uuji dii ORAHED Qalalaasa badneed hii SCUK doorashada

February ORAHED/ 59 47 35 23 11 Jilal Rift Post- Safar (Hot valley election season) fever violence March ORAHED/ 58 46 34 22 10 Mowlid Jilal Wajir Stoning of Changing of (Hot South the former electors season) district MP at cards naming Abakore April 45 33 21 9 57 Ocampo Malmadone Six GU (long May rains) 56 44 32 20 8

Al shabab Kura goos Nutrition

Jamaeul- Capturing survey

Awal Fazul in

Dadajabulla

June 55 43 31 19 7 Election Jamaeul- campaign Akheir

July HAGAI 54 42 30 18 6 Rajab (Cool Election 1st SCUK Wajir S MP cloudy campaign nutrition seat season) survey declared vacant (soelitan Kursiki WS) August 53 41 29 17 5 Shaaban Election Census Referendum 2nd SCUK campaign Tiro koob Sharci badel BSFP No/Yes / programme/ Ramadhan September 52 40 28 16 4 Soom Election Ramadhan campaign

October 51 39 27 15 3 Soom Fur Election WS by- Onset of campaign election short rains Doorashadii /Kenyatta DEYR Dayow day-20th (short October

November rains) 50 38 26 14 2 Sigitaal Election Obama Idd Ul Hajj campaign Election

December 49 37 25 13 1 Arafa General Idd weyne elections Dorshada Weyn

WAJIR SOUTH DISTRICT NUTRITION SURVEY QUESTIONNAIRE CHILDREN 6-59 MONTHS (ONE SHEET PER CLUSTER)

Name of Name of the Cluster No Team No Date of Interview (DD/MM/YY) Name of Interviewer Name of Team Leader Division Village

____/____/____

Anthropometry Child Health 1.1 1.2 1.3 Sex 1.4 Age 1.5 1.6 HEIGHT 1.7 1.8 MUAC 1.9 Did the 1.10 1.11 Has 1.12 Has 1.13 In the last 1.15 1.16 In the last 1.17 Has 1.18 If yes, What 1.19 Child HH 1= Male (months) WEIGH (CM) Bilateral (cm) child receive Measles child child one year, how BCG one year, how the child illness did your child When No. No. 2= Use T (Kg) Oedema BSFP in the Vaccina received received many times has mark many times has been sick have in last two weeks? the child Female LOCAL nearest NEAREST Last 1 tion pentavalen pentavalent the child received the child been in the last was sick EVENTS 100g NEAREST 1= Yes 0.1cm month? t 1/OPV1? 3/OPV3? Vitamin A 0= dewormed(Show 2 weeks? MORE THAN 1 where CALENDE 0.1 CM 0= No Confirm by (Show the mother No the mother the ANSWER POSSIBLE did you R card 1=Yes (by 1=Yes (by the capsule so that 1= tablet so that she 1=Yes 1= Diarrhoea seek 1=Yes 0=No card) card) she recalls or Yes recalls or 2=No 2=Vomiting assistan 2=No 1=Yes, 2=Yes (by 2=Yes (by understand). understands). 8= DK 3=Fever with chills like ce? 8=DK card recall) recall) Chec malaria 2= Yes, 3=No 3=No 1=Once k 1=Once 4=Fever, cough, (More recall 8=DK 8=Don’t 2=Twice SCA 2=Twice difficulty in breathing than one 8=DK know 3=No R on 3=No 5=Intestinal Parasite answer 8=DK Left 8=DK 6= Measles is Lowe 7=Eye infections possible r Arm 8=Skin infections ) 9= Accident 10=Malnutrition 11=Stomach-ache 12=Toothache 13=other (specify)

Q1.19=Traditional healer/Sheikh, 2=Community health worker, 3=Private clinic/ pharmacy, 4=Shop/kiosk, 5=Public clinic, 6=Mobile clinic, 7=Relative or friend, 8=No assistance sought

Section 2: SURVEY QUESTIONNAIRRE JANUARY 2012 (ONE SHEET PER CLUSTER) Name of Name of Village Cluster Team No HH Date of Interview Name of Interviewer Name of Team Division No No (dd/mm/yy) Leader

____/____/____

2.1HH 2.20 2.3 2.4 2.5 What is the woman’s 2.6 Question addressed to the 2.6 No. At what times do you usually What do you use to If diarrhoea is yes in the morbidity current physiological status? pregnant mothers MUAC (CM) wash your hands? clean (wash) your question. (Ask carefully and Circle) In your current pregnancy, 1 <21cm (Copy (Multiple answers possible) hands? Was he/she given any of the have you taken iron pills, 2 ≥ 21cm from (Multiple responses) following at any time since he/she 1=Currently pregnant sprinkles with iron, or iron main After defecation/visiting toilet started having the diarrhoea? 2=Breastfeeding (<6months syrup (Show the capsule)? page) ....1 Water only A fluid made from a special packet infant) YES Before handling food …………....1 called Oralite or ORS? 3=Breastfeeding (6- NO …………...2 Water and A home-made sugar-salt solution? 24months) DNK After eating soap……...... 2 Another home-made liquid such as 4=Pregnant and ……………………..3 Water and ash porridge, soup, yoghurt, coconut breastfeeding Before feeding the child ………...3 water, fresh fruit juice, tea, milk? 5=Not pregnant/not ….…….4 Other ORS plus Zinc (Show the breastfeeding After cleaning children’s (specify)……….4 capsule). 6-breastfeeding (>24months) bottom.5 ______5. Others None of the (specify)______above……………….6 Others (specify) ______7

WAJIR SOUTH DISTRICT NUTRITION SURVEY MORTALITY QUESTIONNAIRE (ONE SHEET PER HOUSEHOLD) Name of Name of Village Cluster Team No HH Date of Interview Name of Name of Team Leader Division No No (dd/mm/yy) Interviewer

____/____/____

No Current HH members (Name and Age (Indicate in Sex Present now In- migration Out- migration Births since 20TH Died since Cause of ID) Months if <5 1=Male in HH Since 20TH since 20TH October 2011 20TH October death* All the HH members who have then circle) 2=Female (Tick=YES) October 2011 October 2011 2011 been in the HH since REF date (Tick=YES (Tick=YES) Tick=YES Tick=YES 1 2 3 4 5 6 7 8 9 10

SUMMARY DATA SECTION Current HH members total *CAUSES OF DEATH: Current HH members <5y 1= Diarrhoea (minimum of 3 watery stools/24hrs) Current HH members who are males 2= Bloody Diarrhoea; Current HH members who are females 3= Measles (fever with rash); Current HH members in-migration total 4= Fever; Current HH members in-migration <5y 5= Lower respiratory tract infection (fever, productive cough, chest pain, difficulty Past HH members out-migration total breathing) Past HH members out-migration <5y 6= Malnutrition; 7= Injury; Deaths total 8= Other; Deaths <5y 9=Unknown Total births

SECTION 3: FOOD SECURITY AND LIVELIHOODS (ONE SHEET PER CLUSTER) Name of Name of Village Cluster Team No Date of Interview Name of Interviewer Name of Team Leader Division No (DD/MM/YY)

____/____/____

HH No 3.1 3.2 3.3 3.4 3.7 3.8 3.9 3.10 3.11 Status of Sex of What is your main livelihood What is/are your main Has your If Yes what What food Of the food aid How many days the responden activity/s? current source/s of income HH were the commodities received for what on average did Househol t received sources? were received purpose was it used? the food d 1=Agricultural labour 1=No income food aid (multiple answers commodities 1=Male 2=Livestock herding 2= Sale of livestock in the last 1=WFP/Lead 1= CSB allowed) last? 1=Reside 2=Female 3=Own farm labour 3= Sale of livestock three (3) agency 2=Oil nt 2=IDP 4=Employed (salaried) products months? 2=Red cross 3=Salt 1=Resold in the 1=1 Week 3=tempor 5=Waged (Casual) 4= Sale of crops 3=Governme 4=Pulses market 2= 2 weeks ary 6=Petty trade 5= Petty trading e.g. sale of 1= Yes nt 5=Cereals 2=Bartered for other 3=3weeks resident 7=Unemployed firewood 6=Casual labour 2= No 4=Others item 4= 4 weeks and 4=Resettl 8=Student 7=Permanent job (specify) 3=Shared with kin more ed 9=Merchant/trader 8= Sale of personal assets 4=Saved for seed 5=Refuge 10=Housewife 9= Remittance 5=Consumed by the e 12=Domestic help 10=Other-Specify HH members 13=Hunting, gathering 6= Other 14=Firewood/charcoal 16=handicraft 18=Others (Specify)…… 1 2 3 4 5 SECTION 4: Food Consumption & Dietary Diversity (ONE sheet per HOOUSEHOLD) Name of Name of Village Cluster No Team No HH No Date of Interview Name of Interviewer Name of Team Leader Division (dd/mm/yy)

____/____/____ Twenty four-hour and seven day recall for food consumption in the households: The interviewers should establish whether the previous day and night/seven days were usual or normal for the households. If unusual- feasts, funerals or most members absent, then another day should be selected.

Food group consumed: 4.16 4.17 4.18 *Codes: Did a member If yes, Did a member of your of your how household consume food 1= Own production 5= traded or household many from any these food Bartered consume any days was groups in the last 24 hours 2=Purchases 6=Borrowed food from the food (from this time yesterday 3=Gifts from 7=Gathering/wild these food consume to now)? Include any friends/ families groups in the d in the snacks consumed. last 7 days? last 7 4=Food aid 9= Food vouchers days? 1=Yes 1=Yes 2=No 2=No 10=Others, specify______Type of food 4.19 What is the main source of the dominant food item consumed? (Use codes above)? Cereals and cereal products (e.g. sorghum, maize, spaghetti, pasta, canjera, bread)? Vitamin A rich vegetables and tubers: Pumpkins, carrots, orange sweet potatoes White tubers and roots: White potatoes, white yams, cassava, or foods made from roots Dark green leafy vegetables: Dark green leafy vegetables, including wild ones + locally available vitamin A rich leaves such as cassava leaves etc. Other vegetables (e.g., tomatoes, eggplant, onions)? Vitamin A rich fruits: Ripe mangoes, water melon papayas + other locally available vitamin A rich fruits Other fruits Organ meat (iron rich): Liver, kidney, heart or other organ meats or blood based foods Flesh meats and offal’s: Meat, poultry, offal (e.g. goat/camel meat, beef; chicken/poultry)? Eggs? Fish: Fresh or dries fish or shellfish Pulses/legumes, nuts (e.g. beans, lentils, green grams, cowpeas)? Milk and milk products (e.g. goat/camel/ fermented milk, milk powder)? Oils/fats (e.g. cooking fat or oil, butter, ghee, margarine)? Sweets: Sugar, honey, sweetened soda or sugary foods such as chocolates, sweets or candies Condiments, spices and beverages: 1.20 In general what is the main source of food in household? (*Use codes above) [ ]

1.21 Total number of food groups consumed (filled by enumerator): [ ] 48

SECTION 5: WATER, SANITATION AND HYGIENE PRACTICES (ONE SHEET PER CLUSTER) Name of Name of Village Cluster No Team No Date of Interview Name of Interviewer Name of Team Leader Division (DD/MM/YY)

____/____/____

HH No. 5.1 5.2 5.3 5.4 5.5 5.6 5.7 What is your household main current water What is the total What do you do to Does your If yes, what type If No, where do How do you dispose source? (one answer) time to and from the water before drinking? household of toilet facility? you go/use? of children’s faeces? current main water 1= Nothing have access (probe further) 1=River source? 2=Boiling to a toilet 1=Traditional pit 1= Bush 2=Water tap/water kiosk 3=Use of traditional facility? latrines 1= Bush 2=Open field 3=Borehole 1= less than 30 min methods 2=Ventilated 2=Open field 3 =Near the river 4=Unprotected well 2= 30 min- 1 hour 4=Use chemicals 1=Yes improved pit 3 =Near the river 4 =Behind the house 5=Protected well 3= More than 1 hour 5=filter/sieve 2= No latrine 4 =Behind the 5=Latrine 6=Public pan- 8=DK 6=decant 3=Flush toilet house 6 =Other (specify 7=Tanker/Tracking (Multiple responses) 4=Other Specify 5 =Other 8=Dam- (specify) 9=Laga 10=Rain harvest (from the roof) 11=Other (specify) 1

2 3 4 5 6 7 8 9

N/B; Let the respondent answer the questions and only code what they day; do not assume an answer before asking the question

SECTION 6: MALARIA (ONE SHEET PER CLUSTER) 49

Name of Name of Village Cluster Team No Date of Interview Name of Interviewer Name of Team Leader Division No (DD/MM/YY)

______/______/______

HH No 6.1 6.2 6.3 6.4 6.5 Does this Where did you get it If you got it from the shop, If YES, Who slept under the mosquito net last night? household from have you ever treated your When did you last treat it? (Probe - enter all responses mentioned) have a 1 = A Shop net (soaked or dipped it in mosquito net? 2 = An agency/NGO dawa or chemical to repel 1=Less than one month ago 1) Children less than 5 years If NO go to 3 = Ministry of Health mosquito or insects)? 2=Between one and six 2) Children over 5 years 6.6 4=Other (specify) months ago 3) Pregnant woman 1 = Yes 3=More than six months ago 4) Mother 1 = Yes 2 = No 4=Cannot remember 5) Father 2 = No 6) Nobody uses

SECTION 7: COPING STRATEGIES (ONE QUESTIONNARE PER CLUSTER) HH 7.1 7.2. 7.3 NO. During the Last 6 Months, did your household What is the action your household took to compensate the How Often See options attached experience any incident that affects its usual effect of that incident? Multiple answers allowed e.g. ability to eat and/or buy foods of the quality, (See options attached N=Never quantity or variety you prefer? 1=Once per month 1 = Yes 2=Once per week 2 = No 3=Twice per week 4=3-6 times per week 5=All the time/everyday

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

16 17 18 51

Question 7.2

Reduction in the number of meals per day N. Withdraw child (ren) from school Send children to school to eat O. Skip food consumption for an entire day Begging or engaging in degrading jobs P. Reduction in size of meals Individual migration out of the area Q. Restrict consumption of adults to allow more for children Household migration out of the area R. Swapped consumption to less preferred or cheaper foods Sale of farm implements S. Purchase food on credit Sale of milking livestock T. Consume wild foods (normal wild food) Sale of household goods U. Consume immature crops Disintegration of families V. Consume toxic/taboo foods (acacia pod/bitter fruit) Abandonment of children or elderly W. Food consumption of seed stock Sell of charcoal and/or fire wood X. Send household members to eat elsewhere Part of family migrating with animals to look for grazing Y. Others Send household members to eat elsewhere

. INFANT AND YOUNG CHILD FEEDING PRACTICES (IYCF) FOR CHILDREN 0-23 MONTHS OF AGE (ONE QUESTIONNARE PER HOUSEHOLD)

Name of Name of Name of Cluster Team Household Date of Interview Name of Interviewer Name of Team Leader District Division sub location Number number Number (dd/mm/yy)

____/____/____

Make every effort to speak with the mother. If she is not available, speak with the primary caregiver responsible for feeding of the child. For every question use the child’s name.

CH. Name of Background Information Infant Feeding information No child 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 Child’s date of Source of Age of child Sex of Did you ever If No, why? If yes, How During the first In the first 3 If yes: For the first 6 Are you still breastfeeding Birth: birth date in months child breastfeed long after 3 days after days after months of its life, for how [Name]? (Record the 1 = M [name]? birth did you delivery, did delivery, was long did you breastfeed dd/mm/yy approp. code) 2 = F 1= Yes put [name] on you give [Name] given your baby without giving 2= No the breast? [Name] the anything to any other food or water? 1= Yes 1 = CARD 3=DNK See code fluid/liquid drink other Responses to be given in 2= No 2 = RECALL below for the that came from than breast months 3 = DNK If No, go to 4.6 answers your breasts? milk? If yes, go to 1= Yes, Codes below 4.7 2= No, 3= DNK

Q 4.7 1. Immediately (within 1 hour), 2. Within first day, 3. Within first 3 days 4. After 3 days 5. Others-specify 6.Don’t know Q 4.8.1.Plain Water 2.glucose water 3. Milk (goat/cow/camel/pkt of milk) 4. Porridge 5. Vegetables/fruits 6. Other solid foods 7. others

Name of Name of Name of Cluster Team Household Date of Interview Name of Interviewer Name of Team Leader District Division sub location Number number Number (dd/mm/yy)

____/____/____

Now, I will ask you about what [Name] drank YESTERDAY during the day and the night. During the day and the night, did [Name] receive any of the following fluids? Refer to the name of the child for each question. Kindly probe the mother for responses and record the codes/responses as the mother names the fluids and liquids in their appropriate category

Name of CH. No child 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18

Breast milk Infant formula Other milks: animal Sweetened flavoured ORS Tea/Coffee Plain water Porridge Only one answer ( Mamex, Nan) milk, - reconstituted juices (Quencher, Juice coded as below: 1. Yes powdered milk, (Halwa, for you, Zeitun, Altuza, 1. Yes 2. No Milki, Nido, Safari land, Mushakil, vimto, afia, 2. No 3. DNK Hayat, Coast) juice cola, Savannah,) 1. Yes 1. Yes 3. DNK - Sour milk. Soda 1. Yes 1. Yes 2. No 2. No 1. Yes 2. No 2. No 3. DNK 3. DNK 2. No 1. Yes 3. DNK 3. DNK 3. DNK 2. No 3. DNK

Name of Name of Name of Cluster Team Household Date of Interview Name of Name of Team Leader District Division sub location Number number Number (dd/mm/yy) Interviewer

____/____/____

Now, I will ask you about what solid/ semi solid foods [Name] ate YESTERDAY during the day and the night. YESTERDAY during the day and the night, what food items did [Name] receive? (Ask the mother /caregiver to mention all foods given to the child and record as mentioned in the appropriate category)

Note: Please wait for the mothers response after asking the questions other than reading out the various foods

ChNo Child 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 Name Eggs Porridge Flesh Meats Legumes and Dairy Grains, Roots Vitamin A Rich Other Fruits and Oil (Salad oil), Yesterday made from (Chicken, beef, Nuts Products &Tubers fruits & Vegetables ( fats, Zeitun, (During the day CSB/ Goat,Kidney,Liver, (Beans, (Milk, (Pasta, rice, Vegetables onions, tomatoes, simsim, (camel and at night), 1. Yes Unimix/ Mutton, Camel, Groundnuts, cheese, bread, potatoes, (pawpaw, cabbage, fat, goat’s fat) how many times 2. No millet/ Fish, blood, wild Cowpeas, Ghee, biscuits, melon, Sukuma Oranges, bananas did you feed 3. DNK sorghum/ meat) Lentils, Green fermented mandazi, wiki, carrots, Okra, wild fruits) [Name] solid maize flour Grams,) milk ) chapatti, anjera, cowpea leaves, and semi-solid 1. Yes ugali, cassava, spinach, 1. Yes 1= Yes foods? Use the 2. No 1. Yes sorghum, Avocado, ) 2. No 2= No No. of times correct code. 3. DNK 2. No 1. Yes millet) 3. DNK 3= DNK child was given Only one 3. DNK 2. No 1. Yes food to make it answer. 3. DNK 1. Yes 2. No full. 1. Yes 2. No 3. DNK 2. No 3. DNK 3. DNK