Garissa office

NUTRITION AND HEALTH SURVEY OF AND DISTRICTS (SEPTEMBER, 2000)

Emily Mwadime – Nutrition Consultant In collaboration with Feleke B.Teshome (Nutritionist) Executive summary

The drought in has led to severe food shortages in the arid and semi- arid lands. According to Recent studies, Garissa District (including Ijara) is one of the 22 drought impacted districts in Kenya. Inadequate food intake is an immediate cause of malnutrition in the area. Therefore, this survey was carried out with the aim of identifying communities that are faced with malnutrition with the intention of improving their food intake and nutrition.

This was a cross- sectional survey conducted in all the 15 divisions (inclusive of the new Ijara district). The survey was conducted from 23rd –31st September 2000. The sample size was 1806 children of the age between 6 - 59 months. To obtain this sample size, a 27% prevalence rate of malnutrition was used at 5 % level of precision. The district was divided into three geographical zones for comparison reasons and thirty clusters were randomly selected from each zone. In every cluster (in this case defined as a bulla) all target children had their anthropometric measurements taken and clinical signs observed.

The actual anthropometric data was collected from 1702 children and out of this, 745 were randomly selected as index children representing every household. Number of children included in the Z-score analysis was 1634. Two wet feeding centers were purposively selected to obtain information on the criteria for entry and exist and to identify areas of intervention.

The prevalence of global acute malnutrition, using weight for height Z-score less than –2 SD was found to be 21.1% of this 8.4% were severely malnourished. The results from the survey indicated that malnutrition rate varied with the geographical zones and that the highest level of malnutrition was in the northern zone (22.7%) followed by Southern zone (20.8%) and Central zone (20.7%) Further nutritional analysis showed that Modogashe and Mbalambala divisions in the Northern zone and Sangailu in the Southern zone were the most affected by malnutrition, exhibiting more than 22% wasting rate.

Malnutrition rate of the target children by sex and age showed that more malnourished children were in the age category of 24-59 months of age (19.3%) than in 6-23 months (18.9%). Severe wasting, however, was higher for children between 6-23 months (8.1%) than the older children (4.6%). There was no significance difference in the malnutrition rate between the sexes.

The most common diseases were cough/cold (44%), diarrhoea (38%), and malaria (33%) and worm infestation (19%). The prevalence of diarrhoea was highest in the northern zones (44%) followed by southern (31%) and central zones (26%). Cough/cold prevalence was highest in the central Zone.

During the survey period 70% of the households obtained their food from the general food ration and market, majority of them being from the Northern and

i Central zones while those from the Southern obtained their food from markets and own farm produce.

As regards food aid distribution in the month of September, 70% of the households admitted to have received food ration, mainly maize, pulses, rice, and oil. And of this, 98% were from the central and northern zones. The remaining 2% were from Bura division situated in the Southern Zone.

Accessibility to health facilities indicated that on average most households live about 14km and /or 5 hours walk from the nearest health distance. Water points were situated at an average of 26km and/or 4 hours walk from the households.

Inadequate food intakes, severe water shortage, diseases and lack of health facilities are the major factors contributing to the high malnutrition level within the districts. Therefore, food ration distribution should continue and wet supplementary feeding programmes should be initiated in the areas of highest malnutrition. Type of food ration given should be based on the understanding of the beneficiaries’ food habits, customs, method of preparation and cooking. There is need for multi-sectoral collaboration to curb the underlying causes of malnutrition in emergency situation. The on going wet feeding programmes need support to handle the high numbers of malnourished children, pregnant mothers and lactating mothers.

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Acknowledgement

I do acknowledge with gratitude the efforts provided by the entire CARE-kenya staff during planning and implementation of the survey. Thanks to UNICEF for provision of guidelines used during the planning.

Special thanks to all the government officials from the ministries of Health, Agriculture and rural development, planning and District development office. Thanks to all the institutions namely, Catholic diocese and the Therapeutic feeding programme (Garissa general hospital) involved with wet feeding programme for their technical assistance.

My gratitude also go to all field team leaders (MOH-Nutritionists), enumerators, food monitors, field guides and data clerks who tirelessly worked hard to ensure that the data was collected and handled in the correct manner. Special thanks go to Halima Nasra (nutritionist) for all assistance and support during the field work and supervision.

Finally, I wish to thank all the GOK administration personnel in the target communities i.e. District officers, chiefs, assistant chiefs, community elders and all the community members for their cooperation during the survey.

iii Table of content Page Executive Summary i Acknowledgement iii Glossary vi

1.0 Introduction 1.1 Background information 1 1.2 Statement of the problem 2 1.3 Objectives of the survey 3 2.0 Methodology 2.1 study design 4 2.2 sample size determination 4 2.3 sampling procedure 4 2.4 survey instruments 5 2.5 implementation of survey activities 5 2.6 data quality control 6 2.7 data processing and analysis 6 2.8 constraints 7 3.0 Results and discussions 3.1 household characteristic 8 3.2 prevalence of malnutrition 8 3.3 geographical distribution of malnourished children 10 3.4 morbidity rate and immunization 11 3.5 food availability and consumption 12 3.6 child care practices 12 3.7 food aid in the district 12 3.8 access to health facilities 13 3.9 water availability 13 4.0 Wet feeding programme – CASE STUDY 4.1 mother-child feeding center (SFP) 15 4.2 therapeutic feeding programme (TFP) 17 4.3 recommendation for intervention and selection criteria 19 5.0 Conclusion and Recommendation 5.1 conclusion 20 5.2 recommendation 21

References 22

Annex A Sampling table 23 Annex B Distribution of villages 24 Annex C List of enumerators 25

iv List of figures Figure 1 Garissa district 1 Figure 2 Prevalence of malnutrition by georaphical zones 9 Figure 3 Prevalence of morbidity by geographical zones 10

List of tables Table 1 Household characteristics of survey population 8 Table 2 Distribution of children by Z-score, percent of median, MUAC 9 Table 3 Distribution of weight for height Z-score by age and sex 10 Table 4 Prevalence of malnutrition by geographical zones 10 Table 5 Distribution of children by common illnesses 11 Table 6 Distribution of household that received food aid 13 Table 7 Average time and distance covered to and from water points 14 Table 8 Daily feeding programme (SFP) 16 Table 9 Daily feeding programme (TFP) 18

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Glossary

1.1 Abbreviations

ANP Applied Nutrition Programme

CRS Catholic Relief Services

DSM Dry Skimmed Milk

GOK Government of Kenya

MOH Ministry of Health

MT Metric tone

MUAC Mid-Upper Arm Circumference

NCHS Nutrition Center for Health Statutory

PEM Protein-Energy Malnutrition

SPP Supplementary Feeding Programme

SPSS Statistical Package for Social Science

TFP Therapeutic Feeding Programme

WFP World Food Programme

WHO World Health Organisation

1.2 Description of local words/foods

Bulla a village that comprises of more than 10 households

Manyatta a dome shaped hut made out of grass. Sometimes a group of 3-4 huts are referred to as a manyatta.

Ugali stiff porridge

Uji porridge

vi 1. Introduction Figure 1 1.1 Background

District profile Garissa district is situated in the North-Eastern Province of Kenya. Recently, the district was divided into two districts, Garissa and Ijara. The Ijara District was curved out from the southern part of the Garissa district. Both districts cover an area of 43,931 square kilometers. The districts are classified as DIVISIONS arid and semi- arid land region. The 1.mbalambala 2.Sankuri districts are also classified as one of the 3.Shanta-abak 4. Modogashe 5.Benane 6.Danyere 7. Dadaab ten drought-prone districts in Kenya 8.Central 9.Liboi 10. Jarajilla (ANP, 1997). Administratively, both districts 11.Bura 12. Masalani 13. Ijara 14. Sangailu 15. Hulugho are divided into 15 divisions, 51 locations ZONES and 79 sub-locations (see Figure 1) Northern central Southern

The two-district population was estimated at 391,009 in 1999 and about a third (i.e. 124,580) of these population size is made up of refugees who occupy three refugee camps within the district. The main inhabitants of the study districts are and are of Islamic religion.

Nomadic pastoralism is the dominant form of land use, and the local people depend on their livestock for livelihood, except for the few farmers who practice arable farming along the which runs across the western boundary of the district. This latter type of farming is also practiced in some areas of seasonal rivers, but in a much lower capacity (Garissa District Development Plan, 1997- 2000). Livestock production is based on 4 species (cattle, camels, goats and sheep) and is the major economic activity. While the dominant crops produced are maize, sorghum, pulses and fruits like banana and mangoes.

The community living outside the town centers, live in temporary huts constructed from grass and tree branches. In this setting, the temporary structures are grouped into about 3-4 huts to form a homestead commonly referred to as a manyatta. The Somali community lives together in villages comprising of an average of 10-20 manyattas and these villages are commonly called bulla.

Health services in the districts are provided through one Provincial general hospital, 21 dispensaries, 5 health centers and mobile clinic run by an international NGO (Mikono). There are 60 primary schools, 9 secondary schools, 1 medical training college, 1 teachers college, 1 farmers training center and 2 polytechnics in the districts. There are only two permanent water sources, Tana

1 river and small fresh Water Lake at Ijara; other sources of water are 13 boreholes 9 of, which are operational while the remaining, are partly operational. There are also 12 water pans constructed by the GOK all of which are currently dry except for those situated in the Hulugho and Ijara regions, which have water from the recent rains. The road from to Garissa town is the only good class A tarmac road. Most of the rest of the roads are dry weather roads.

Household food security In many parts of Kenya the April/May rains failed, and Garissa became one of the 22 drought impacted districts, this recent prolonged drought has worsened food insecurity within the area. According to the district drought-monitoring bulletin of August 2000, livestock condition continued to deteriorate and the ability of the pastoralists to purchase cereals continued to decline due to low prices of livestock combined with an increase in the prices of cereals. And, it was estimated that approximately 50% of its population needed relief food. Reports from the District agriculture office indicated that there is a major problem of in- puts availability for the cultivation of cereals and pulses. This factor coupled with the lack of rainfall has led to these crops not being grown especially in the northern part of the district hence the need to receive relief food.

Emergency food supplied by the GOK and WFP is being distributed to the drought-affected households by CARE Kenya. About 987 MT cereals, 173MT pulses, and 54 MT oil was distributed to a targeted population of 103,225 persons until August 2000. However, the amount distributed was much lower when compared to the demand of food at household level and further reports from the district agriculture office indicate that the total demand of cereals and pulses in the district are at 2982MT and 434MT respectively which is an indicator that there is definitely a deficit that needs to be met.

Health and nutrition situation According to a nutritional survey carried out in Modogashe division of Garissa by the Applied Human Nutrition Programme (University of Nairobi), acute malnutrition rate was found to be 27.2% (using weight for height below –2.0 Z- scores) and of severe malnutrition (<-3 Z-scores) to be 6.6%. In general a malnutrition rate of >10% is considered acceptable to warrant population level intervention. However, with this high level of malnutrition indication, there are very few wet supplementary feeding programmes in the district. Two of the ones present are run by Garissa regional district hospital and catholic diocese (see Feeding programmes report on pages 15-19).

1.2 Statement of the problem With the food insecurity situation worsening and the relief food targets not being met, the health and nutrition situation of vulnerable households was definitely deteriorating. Nutritional information that represents the whole district was, therefore, required to target the most needy communities for nutritional intervention, specifically for supplementary feeding programme.

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1.3 Objectives of the survey The main goal of the survey was to identify communities in which to improve maternal and child nutrition during emergency.

The specific objectives were: 1. To assess the prevalence of malnutrition in children aged between 6 months and 59 months by anthropometry in Garissa and Ijara districts and to use the data for targeting, 2. To assess the coverage of supplementary feeding programmes in the district, 3. To determine the source and types of food consumed by the local households and their children, 4. To assess the health situation of the children living within the target communities. 5. To determine the accessibility of water and health facilities within the districts.

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2. Methodology

2.1 Study design A cross-sectional community study in nutrition and health was conducted in Garissa and Ijara districts from 23rd to 31th September 2000. The survey covered all the divisions in the study districts. For the purpose of statistical comparisons, the districts were divided into three geographical zones, northern, central and southern (Ijara). The study unit was a child aged between 6 months and 59 months of age. Trained enumerators took anthropometric measurements and administered the questionnaires. The mother and/or the father of the child were the target respondents.

2.2 Sample size The sample size of this survey was 903 households with 1806 children. This gave a large enough sample of under five year old children to represent the districts. The Nutrition survey guide prepared by UNICEF Kenya country office (2000) was used for conducting the survey. At 27% expected prevalence of malnutrition and 5% precision, 602 children were required to represent each geographical zone from 30 clusters. Totally, 1806 children between 6-59 months age were randomly selected from the three survey zones.

2.3 Sampling procedure

The total population size and that of children under five years old was obtained from CARE office and the District development office. However, since the number of children under five years was unknown for the southern region, a 20% estimate of the total population was used to determine the population size of children under five years old. To determine the cluster size (or the sample interval), the total children in each geographical zones were divided by three times the number of the sample clusters. Small villages with number of under five children less than the cluster size were regrouped together and big areas with number of under five children more than twice the cluster size were divided in to two or more clusters. Random numbers were chosen from a random table to identify the location of the first sample cluster. Then, the sample interval was added successively to the first random cluster number until the 30 clusters were identified (see annex 1).

After identifying the clusters which in this case was the bulla, the survey team went to every household with children below five years old and interviewed either the mother or the father of the child and took the anthropometric measurements. Only children between 6 months (>65cm length/height) and 59 months of age (<115cm length/height) were measured. The respondent was asked for a health card, which was used to confirm the age of the child and in cases where this was not present, the child’s height was taken and any child whose height was above 115 was not considered eligible. In this survey, a household was defined as a

4 group of persons living together under a single hut and shares a common cooking pot and is answerable to the same head. To verify the size of household, the interviewers were to record only the number of people living within the households and are not visitors. An index child was, also, selected randomly from the under fives in the household to collect further information on child health and feeding practice. Where the child was not found in the household, the enumerators noted down the child’s mother’s name and went back later to interview the respondent and take measurements of the child. All disabled children or those found to be kwashiorkor cases were not included in the anthropometric measurement.

2.4 Survey instrument A structured questionnaire was used to collect data on household characteristic, morbidity, breast-feeding practices, immunization, food consumption pattern, food ration distribution, supplementary feeding, Health facilities and water accessibility. The tools used for anthropometric measurements were; salter scales and hanging plastic pants, length/height boards and MUAC tape. Age determination of the study children was obtained using the clinic cards or directly from mothers recalls and it was recorded in months. Computers and calculators were used for data entry and analysis.

2.5 Implementation of survey activities

Training of field team and pre-testing of questionnaires Three teams were involved in the survey. A team was designated to carry out the survey in a zone. Each team was composed of a nutritionist as the team leader, three enumerators and a guide. All the enumerators had a secondary school leaving certificate education level.

The consultant nutritionist trained the field workers for two days. The training covered the study objectives, the survey instrument, interview techniques, interviewer code, anthropometric measurement techniques, questionnaire familiarization and recording of answers. In the second day, actual practical session on anthropometric measurements, interviews and filling out of questionnaires was conducted on 15 households and a total of 30 children. The pre-testing exercise facilitated changes on the structure of the questionnaire.

Data collection The questionnaires were applied on the mother or father of the study child and the response was recorded.

The hanging salter scales (25kg) were used to take the weight of each child and measurements recorded to the nearest 0.1 kg. The reading was done by the enumerator and verified by the other partner enumerator or nutritionist then recorded accordingly. The scale was calibrated together with the weight of the plastic pant before each measurement was taken.

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Height measurements were taken using a calibrated height/ length wooden board with a well fitting head /foot piece and measurements recorded to the nearest 0.1cm. Children less than 24 months of age were measured lying down and children over 24 months of age measured standing up. The readings were done by both the enumerators and recorded immediately.

For the vitamin C deficiency each child was checked for swollen and bleeding gums and joints and observations recorded immediately. At the same time the child was examined for edema on both feet and hands.

2.6 Data quality control Procedure used to ensure quality data included careful training of interviewers, close supervision during the actual survey and daily check by the nutritionists for consistency, completeness and clarity of the completed questionnaires. Two anthropometric measurements were recorded to ensure validation of the data. Common historical events, e.g. the el-nino rains and 1997 general elections were used to verify the dates of childbirth in cases where the mother was not certain.

2.7 Data processing and analysis Data were entered, cleaned and processed in Dbase and SPSS computer packages. The anthropometry data was further processed into nutritional indexes using EPI-INFO programme. The SPSS version 8 was used for data analysis. Descriptive statistics and few analytical test statistics presented most of the findings.

Nutritional status indicators For the assessment of the acute malnutrition rate, weight for height (WfH) was the main indicator used. The nutritional status data was compared with the NCHS reference data and presented in both Z-scores and percentage of median.

The following cut-off points were used for nutritional status determination · below –2 Z-scores------acute malnutrition · below –3 Z-scores------severe malnutrition · below 80% of the median-----acute malnutrition · below 70% 0f the median-----severe malnutrition

In this survey, Z-score values were used more instead of percentage of median because the cut-off value in the percentage of media (that is 80%) does not follow the reference normal distribution and has different meaning at different height value although it is used for screening children for supplementary feeding in line with MUAC measurements (WHO, 1995). MUAC measurement analysis was only used to substantiate the findings.

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2.7 Constraints Data collection in some parts of Dadaab, Hulugho and Jarajilla was not possible because of the constraints mentioned below. As a result, data from 104 children could not be collected. These constraints were, · Inaccessibility - Poor road condition and lack of roads in some areas of Hulugho division made it impossible to reach the targeted villages. · Insecurity - recently there has been clashes in one of the communities living in Dadaab. · Movement of nomads -some target areas were abandoned because of the movement of the communities looking for pasture and water for their livestock.

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3. Result and Discussion

3.1 Household characteristics of the study children Demographic characteristics of the study households are shown in Table 1. A total of 745 households were visited during the survey, covering a total population of 5,513 persons. The study households had about 7.4 persons per household and about three-quarters of them had between 5-10 people per household. The mean household size was higher compared to the Kenyan national average of 5 persons per household (GOK, 1996). The 6 months to 59 months old children (1,702) comprised about 31% of the total study population with a mean of 2.3 children per household. About 91% of the children caretakers were reported to be the mothers and 95% of them did not have formal education.

Table 1 Household characteristics of the study population by division Divisions Number of Population Number of Number of Geographical villages size households Study children zones Northern Modogashe 4 548 74 169 Mbalambala 5 303 41 93 Shanta-abak 1 274 37 84 Sankuri 5 266 36 82 Benane 2 289 39 88 Danyere 3 296 40 92 Sub-total 6 20 1976 267 608 Central Central 9 891 114 272 Jarajilla 4 303 41 92 Dadaab 2 311 42 94 Liboi 1 303 41 94 Sub-total 4 16 1808 238 552 Southern Ijara 4 364 49 114 Hulugho 4 281 38 87 Sangaillu 6 349 47 110 Maslani 3 371 57 117 Bura 3 364 49 114 Sub-total 5 20 1729 240 542 Total 15 56 5513 745 1702 * For the names of villages (clusters ) see Annex 2

3.2 Prevalence of malnutrition Data for children whose Z-score was below -6 SD and above 6SD were considered to be outliers and therefore not included in the final analysis. This resulted in the loss of 19 children. In addition to this, 49 children were flagged off because of missing record on age and height. The actual number of children that were included in the Z-score analysis was 1634. Including 41 edema cases, the total number of children included in the nutritional status analysis was 1675.

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The prevalence of global acute malnutrition is given in Table 2. The prevalence of acute malnutrition was found to be 21.1%. Of this, 8.4% were severely malnourished. It is clear that the study districts have high unacceptable level of wasting rate. A malnutrition rate of 21.1% calls for targeted feeding Programmes, like supplementary feeding for the malnourished and therapeutic feeding for the severely malnourished.

The figure of acute malnutrition rate as determined by Z-scores in this survey is below what was reported by the Applied human Nutrition programme survey conducted at modogashe division of Garissa (27.3%). Nutritional status improvement might have been seen because of emergency food distribution to the drought-affected areas.

Table 2 Distribution of children by z-scores, percent of median and MUAC. Z-scores Number Number Number Of % of % of of %of of % of children children median children children MUAC children children N 1675 1690 1701

Not malnourished (>-2SD) 1321 78.9 >80% 1420 84.0 >12.5cm 1490 87.6

Malnourished (<-2SD +edema ) 354 21.1 <80% 271 16.0 <12.5cm 211 12.4 Severely malnourished (<-3SD +edema) 141 8.4 <70% 103 6.1 <11.0cm 63 3.7 Edema 41 2.5 41 2.4 41 2.4

Malnutrition rate of the study children by sex and age groups is as shown in Table 3 below. More malnourished children were in the age group 24-59 months (19.3%) than in 6-23 months category (18.9%). The probable reason for a higher percent of malnourished children in the older category is because these children share food from the family pot which is definitely not enough. On the other hand, severe wasting was noted to be higher among 6-24 months of old children (8.1%) than in 24-59 months (4.6%). There was no significant difference in the nutrition status of boys and girls.

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Table 3 Distribution of weight for height z-scores by age and sex Age Sex 6-23 months 24-59 months Male Female (n=408) (n=1226) (n=826) (n=808) Z-scores No. % No. % No. % No. % >-2SD 331 81.9 989 80.6 671 81.2 655 81.1 <-2SD 77 18.9 237 19.3 155 18.7 153 18.9 <-3SD 33 8.1 57 4.6 49 5.9 49 6.6

3.3 Geographical distribution of malnourished children As indicated in Table 4 and Figure 2, the malnutrition rate was higher in the northern (22.7%) than southern zones (20.8%) and central (20.7%). However, statistically, there was no significant difference in the malnutrition rate among study zones. In fact, the prevalence of wasting in all the study zones indicated a serious problem and a predictor of elevated mortality (ACC/SCN, 1994). According to this finding, all three study zones need nutritional intervention.

Table 4 Prevalence of malnutrition by the study zones Northern Central Southern (n=602) (n=538) (n=535) Z-score No. % No. % No. % >-2SD 465 77.3 427 79.3 420 78.3 <-2SD + edema 137 22.7 111 20.7 111 20.8 <-3SD + edema 56 9.3 54 10.0 40 7.5

Figure 2 Prevalence of malnutrition by geographical zones

Malnorished 25 22.7 20.7 20.8 Severly 20 malnorished 15 9.3 10 10 7.5 5 % of malnorished 0 Northern Central Southern

Further nutritional status analysis has, also, shown that modogashe and mbalambala divisions in the north, and Sangailu division in the south were the

10 most affected by protein-energy malnutrition, exhibiting more than 22% wasting rate.

According to the clinical assessment done for vitamin C deficiency symptoms, from 735 children 2.2% were found to have both painful joints, and swollen and bleeding gums, while 1.6% had only swollen and bleeding gums, and 1.4% had only painful joints.

3.4 Morbidity rate and immunization The most common diseases of the study children as indicated by the respondents are presented in Table 5. About 76% of the children studied were reported to be ill. This evidently shows that there is a high morbidity rate among the under five children in the districts. Diarrhea, cough/cold and fever/malaria associated with malnutrition were the most common diseases of children in the districts. It was also noted that more than half of the study children had more than one illness.

Table 5 Distribution of study children by the common illness within the last two weeks of the study.

Symptoms Children ill Symptoms Children ill Number % Number % Diarrhea 635 38 Worm infestation 315 19 Cough/cold 715 44 Skin disease 148 9 Fever/malaria 550 33 Biliharzia 80 5

As shown in Figure 3, the prevalence of diarrhea was the highest in the northern (44%) followed by southern (31%) and central (26%) zones. On the other hand, cold/cough prevalence was the highest in the central zone while malaria/ fever was the highest in the southern zone. There was a significant difference in the prevalence rate of the above diseases across the three zones.

Figure 3 prevalence of morbidity by geographical zones

45 43.8 44.8 Diarrhoea 40 38.6 Cough/cold 33.5 Malaria/fever 35 31.1 31.4 30 25.7 26.3 25 23.1 20 15 10 % 0f sick children 5 0 Northern Central Southern

11 About 82% of the respondents reported that their children were immunized for measles and 85% said their child immunized for polio. Immunization status of the study child (index child) was determined by interviews of the mothers or verification from their immunization clinic cards. Only 30% of the children were verified using a health card. About 60% of the 721 respondents reported that their children received vitamin A supplement in the last 6 months.

3.5 Food availability and consumption At this particular time, two-third (70%) of households reported that their food came from the local market and relief food. Only 30% reported that their source of food was the market and own production. Among the households that reported their food source to be the local market and own production, 90% of them were from the southern zone. It was observed that for those who had to purchase from the market had to sell part of their livestock in exchange for cereals, sugar and oil.

The data further indicated that most people in the study area had 1-2 meals a day. About half of the respondents said that they had only one meal per day. Inadequate food and lack of money to buy food explained the low number of meals. Taking two meals per day may also be the cultural habit of the population because this habit was also found among most pastoral communities in Kenya (ANP, 1997). According to the data collected from 24 hour recall, the major types of food consumed in the households in their order of importance were; maize, Ugali, tea, rice, milk and porridge. Though the beneficiaries were receiving maize, yellow peas, oil and rice, they said that they did not like yellow peas because of its smell and the fact that it makes the young children have stomach pains.

3.6 Child feeding practice The duration of breast-feeding is associated with nutritional condition of the child. Generally, due to poor sanitation conditions, exclusive breast-feeding in the first four months is recommended for rural communities. After the four months, the child should be weaned but breast-feeding continues preferably up to, or more than 18 months. In this study, the average duration of exclusive breast-feeding was 4.2 months and one- third (34%) of the index children of the study households were currently being breast-fed. More than half (65%) of the mothers said that they breast- feed their children for more than 9 months. Breast-feeding was found to be a common practice and encouraging among the study mothers.

About 80% of the respondents reported that the same family food was shared to the children (especially in the 24-59 month category). In this situation, protein- energy malnutrition among children might have been contributed by the inadequate food intake. All the respondents said that they were not receiving any supplementary feeding. Common weaning foods were maize porridge and animal milk. General observation indicated that children who were supplemented with camel milk were of better nutritional status.

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3.7 Food aid in the study districts In the study areas, about 73% of the households responded to have received food ration distributed in the month of September. Among households who received ration in the month of September by Care International, about 98% were from northern and central zones.

The response of household by the amount of food is shown In Table 6. In average, households received about 12kg maize, 5kg rice, 4kg pulses and 5kg oil per household. When each food item was divided by the average household size of 7.4, the amount received was 1.6kg maize, 0.7kg rice, 0.6kg pulses and 0.7 oil per person per month. This is very much below compared to the amount recommended by WFP of 13.5kg of maize, 2.4kg of pulses and 0.75kg of oil per person per month, which should be provided in emergency situation unless it was presumed that the household would cover the deficit.

Table 6 Number of households received food aid by amount of food Amount in kg % of household received per household Maize (n=534) Rice (n=344) Pulses (n=519) Oil (n=507) 1-5kg 19 70 86 96 6-10kg 33 25 12 4 11-15kg 16 5 2 - 16-20kg 11 - - - >20kg 13 - - -

3.8 Access to health facilities Insufficient access to health services is said to be one of the underlying causes of malnutrition because it can determine whether the child receives proper attention when sick or not. Since it is established that malnutrition and infection are synergetic to each other, it implies that access to health services and hence usage, will influence the cause and prevalence of certain diseases. In this study, a physical accessibility to health services has been considered. The result shows that, on average most families live 14km and/or 5 hours far from the health facilities. About Half (55%) of the respondents also reported that they did not have health centers near their villages. And, 83% of them said that they did not have community health workers.

3.9 Water availability At the time of the survey, water was the most inaccessible commodity in the districts. About 26% of the households said their main source of water was river, 22% dams, 20% bore holes and 19 % said shallow wells. For most of the communities, drinking water sources were not clean. This lack of clean water impacted negatively on the communities health. The distance to water points by division is indicated in Table 7. In average, households in the study area, took 4.6 hours and/or 26km to reach the water points and back.

13 The data on the distances from the water sources suggests that household with malnourished children were further from the water sources in terms of time and distance taken to walk to and fro the water source. The distance of water points coupled with insufficiency resulted in scarcity of water for drinking, for food preparation, sanitation and other domestic uses.

Table 7 Average walking tine and distance to water points by divisions Divisions Average time (hr) Average distance (km) (n=676) (n=122) Modogashe 7.4 36 Mbalambala 10.0 50 Shantabak 7.2 - Sankuri 3.4 - Benane 3.8 - Danyere 4.2

Central 4.6 30 Jarajilla 6.0 32 Dadaab 4.0 24 Liboi 4.9 30

Ijara 3.0 - Hulugho 2.6 - Sangaillu 2.6 - Maslani 2.6 - Bura 2.8 -

Average 4.6 26

During the survey it was observed that in some areas water shortage was so severe to an extend that the households could not have enough water to cook or prepare the dry food ratio given. In meal preparation plenty of water was required to soak maize for a period of six hours before pounding it to obtain flour for the preparation of Ugali or porridge. In areas where water for cooking was not available the maize was cooked whole and the young children had difficulty in digestion.

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4.0 FEEDING PROGRAMMES REPORT (CASE STUDY)

The aim of obtaining information from two feeding programmes namely, Mother- child supplementary feeding programme (SFP) and Therapeutic-feeding programme (TFP) was for the purpose of:

§ Determining the criteria for entry and exist into a feeding programme § Determining the amount of rations required with the intention of supporting existing programmes.

4.1 CATHOLIC DIOCESE (Mother- child Supplementary Feeding Programme)

Aim of the Programme This programme was started in the 1991 with the initial intention of feeding children from the local community who were observed to be malnourished. Later on their mothers were included in the programme due to their high level of malnutrition and more so because of the fact that they could not fend for themselves because of merger resources available to them.

Target The main target populations were women of reproductive age; pregnant and lactating mothers and all children below the age of 15 years. The programme provides two meals, breakfast and lunch for women and children within the center and also supplies lunch-meals for children coming from schools living within the same vicinity.

A school programme was birthed as a result of the feeding programme. Currently there are 3 categories of children those who are still breastfeeding, those below five years, and those between 5-15 years. The former category spend much of their time playing, singing and reciting nursery rhymes and the latter group spend their time learning how to read and write.

The highest target number enrolled at one given time was a sum of 600 children and mothers. Within the last two weeks the center had enrolled an average of 40 mothers and 280 children. The center has never admitted less than 100 children per day at any given time. The high level of enrolment is a clear indication that food is not available at household level.

Criteria for selection 1. Referrals from the provincial general hospital It was clear that there was no use of anthropometric measurements as basis for admission into the center except for children and mothers referred from the hospital.

15 2. General observations This is the most commonly used method of enrolling participant in the programme. Physical characteristics, such as, general body weakness and, illnesses were used as indicators. The center has no specific duration for every beneficiary; the length of time a beneficiary is allowed to stay is determined by availability of food in their homes. As a result, most beneficiaries can visit the center in the entire period of food shortage. The feeding centers is opened five days a week (from Monday to Friday) and closed over the weekend.

Types of food Maize, beans, rice, oil and CSB (CSB was not available during the interview) are the main foods offered within the center. The table below gives a break down of the food distribution to the beneficiaries within one day. MEAL TIME BENEFICIARY TYPE OF MEAL AMOUNT/BENFEF ICIARY Breakfast Mother & > 5yrs child Porridge* 2 cups

< 5 yrs child Porridge* + milk 1 cup

Lunch Mother & > 10 yrs child Githeri ** 2 cups

5-9 yrs child Githeri and rice ½ githeri + ½ rice

< 5 years old Rice and pulses*** 1 cup · * Porridge is made of white maize floor and sugar and in the Month of April-CBS was used to make the porridge. · ** Githeri is made of maize, beans oil and occasionally add tomatoes and onions · *** Pulses referred to here are cowpeas, beans or green grams. The use of these varies depending on what is available in the market. · Cups for mothers and > 5 years old children is 350 mls size. Cups for < 5 years is 200mls size.

Consumption of food within a given week for at least 100 children and 40 mothers was as outlined below. Maize - 180 kg Beans- 60 kg Cowpeas or green grams – 50kg Oil- 5 liters

Staff capacity The center has one trained nurse and 2 sisters who assist in the daily activities including serving and sometimes teaching. At least 10 women assist every day in food preparation, cooking and cleaning up. These women are given a token in terms of food ratio. Each child is expected to bring a piece of firewood every morning for cooking the days meals. There are also 4 teachers who work on volunteer basis.

16 Other support projects The center administers Vitamin A and Iron supplements to its beneficiaries. Another project is the soft loan project, which assist mothers to start income generating projects. One major problem that this project has faced is default of loan payments and only about a quarter of them pays back. The main reason given for this mishap was that women use the money to purchase food for their households members. In another project, the center purchases donkeys for the women who in-turn earn income by rendering donkey cart services. This project was reported to be doing quite well and the women who now own the donkeys have been able to sustain their families in terms of providing adequate foods. Other medical services are administering of painkillers and assisting the beneficiaries in procuring medicines, not available in hospitals, from chemists or sometimes from Nairobi.

Source of Fund The Catholic diocese is the main financer of the progrmme with assistance from individual well wishers and institutions that may contribute in terms of tangible goods like cereals, pulses and oil. Currently there are no plans to expand the programme due to lack of sufficient funds

Constraints · Inadequate food supply · Staff shortage

4.2 GARISSA PROVINCIAL HOSPITAL (Therapeutic feeding programme (TFP))

Aim of the programme The programme was started about 10 months ago with the intention of reducing high rates of malnourished children admitted in the hospital. At least 20% of the patients in the pediatric wards are severely malnourished.

Target The main beneficiaries are all admitted cases of severe kwashiorkor and marasmus in the general hospital.

Criteria for entry Use of cut- off points for nutritional status, mainly < 70% of median.

Criteria for exist The children are weighed every other day to determine any positive changes in the nutritional status. Children who are found to be above 75% are discharged from the hospital. These children are usually discharged through the maternal

17 and child health care (MCH) for purpose of follow-up. Every child is expected to visit the MCH once every week. Type of food In this feeding programme, the kind of food given entirely depends on the level and type of malnutrition. The table below gives a summary of a one-day feeding activity. MEAL TIME BENEFICIARIES TYPE OF FOOD AMOUNT/BENEFICIARY Breakfast Malnourished child Less enriched Adlib Lactating mother porridge*

Snack Malnourished child High energy milk** adlib /enriched porridge*** Lunch Malnourished child Ugali, meat stew, - Lactating mother green vegetables,oil Dinner As above Rice, bean stew, ¾ of the ration given at vegetables, oil lunch time Others Malnourished child Milk and eggs Egg on alternating days · *less enriched porridge is made of maize floor, milk and sugar · **high energy milk is made of skimmed milk, sugar, oil and eggs sometimes flavorings · *** enriched porridge is made of maize floor,milk,sugar,oil · - no precise information was gathered on the amount of food consumed for lunch. The eggs are given on alternating days because they are expensive. The quantity of food given at every meal depends on the number of patients available in the ward. The more the patients the less the quantities and vice versa. The severely sick patients require more milk and enriched porridge and/or nutritious soups because they cannot eat solid foods. The total requirements /quantity needed for 15 children per week Sugar- 147kg Oil- 88.2kg DSM- 235.2kg Water-2940 litres

Staff Capacity The programme is running with only 6 nutritionist. There is need for more qualified staff to assist in the pediatric wards and the kitchen. This shortage of staff has incapacitated active counseling and follow up which has led to high cases of relapse, that is out of every ten children discharged 3-4 cases are readmitted.

Other support programmes The MCH programme which handles supplementary feeding for malnourished children, pregnant mothers and lactating mothers assist the TFP in monitoring the nutritional status of its beneficiaries.On average the number of needy cases in the MCH ranges between 5-7 per day and these require a total of 7 kg of UNIMIX per week. The MCH also administers Vitamin A supplements. The TFP programme also offers counsel to mother on health and nutrition subjects such as, better feeding practices, hygiene, balanced diet, weaning

18 foods, immunization and discourage bottle feeding while encouraging breast feeding. This counsel is done daily to individual mothers whose children are admitted to the wards. Source of Fund The programme is fully supported by the government of Kenya.

Constraints · Inadequate supply of food and water · Food shortage · Inadequate kitchen facilities

4.3 Recommendations for Intervention and selection criteria. · A therapeutic feeding programme (TFP) is intended to save lives of children with severe protein energy malnutrition by meeting their full nutritional needs in terms of energy, protein and micronutrient. Reports from the Garissa hospital TFP indicated that due to low food availability, the center is not able to provide a diet, which can give maximum growth rate and promote rapid edema loss for each child as expected. The high level for admission has led to the children consuming less than the recommended 100-250 kcal/kg body weight per day of energy and less than 3-4g/kg body weight per day of protein. Hence there is need for quick intervention in terms of food supply. The kitchen facilities were also noted to be in fairly poor conditions. Lack of repair and replacement for some of this equipment has led to the kitchen not being utilized to its capacity. The center experiences water shortage, which has been caused by lack of water storage facility, hence there is need for a clean and reliable source of water.

· The Catholic diocese SFP experiences food shortages, the food aid intervention selected should aim at restoring food security of the target community rather than targeting groups of people who are more susceptible to develop nutritional deficiency. Initiation of income generating projects that are feasible would be of help to the impoverished target communities. An expansion of the donkey cart project is highly recommended.

· For the selection criteria, moderately malnourished children under five years of age are targeted as priority group where as severely malnourished children should be considered as priority for TFP. The Malnourished children can be identified through the use of anthropometric measurements or by clinical signs such as pitting edemas, xeropthalmia. Referrals from the medical services to the SFP should always be accompanied by a medical personnel or have a medical certificate.

· Finally, Nutrition education should go hand in with other factors mentioned above so as to strengthen dietary improvement and discourage poor feeding habits. The advice given when teaching nutrition must be appropriate therefore a qualified nutritionist should manage the wet feeding centers.

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5.0 Conclusion and Recommendation

5.1 Conclusion Good nutrition plays a very important role in the survival, growth and development of children. In this survey, Inadequate household food supply due to drought and inadequate access to water and health facilities were sighted as the main reasons of the high malnutrition rates among the children under five years.

High and unacceptable level of malnutrition was observed in the two study districts. The rate of malnutrition varied with the geographical zones whereby the northern zones recorded the highest rates.

Information obtained concerning low food production from the northern and central zones was supported by reports from the ministry of Agriculture. The survey was able to establish that majority of the households in the Northern and Central zones obtained their food from the local market and relief while those in the Southern had their main source of food as market and own production. Sale of livestock was noted to be a good coping mechanism, however, at this particular time it does not provide adequate amounts of food and subsequently adequate nutrients hence the high malnutrition rates.

The most common diseases were diarrhea, cough/colds and malaria. The northern zone recorded the highest level of diarrhea an indicator of malnutrition while the central zone recorded the highest level of cough/colds and malaria was most common in the southern zone. The survey established good immunization coverage for measles and polio, much of which was carried out this year. Vitamin C deficiency was not common while Vitamin A supplementation covered half of the target children.

Among the survey population, supplementary feeding was not reported at all. Most households fed their children from the family pot, which in most case consisted of maize, Ugali, rice, animal milk or porridge and rarely vegetables. This poor meal combination was a contributing factor to the poor nutritional status. Breast-feeding was a common practice but the survey results indicated that most mothers exclusively breast fed their children for a period of 4 months and would continue breast-feeding for a period of 18 months after introduction of weaning foods.

Poor accessibility of water and health facilities were among the major contributing factors to the high malnutrition rate in the communities. Lack of health facilities led to the sick children not getting medical attention immediately. This prolonged disease condition reduced food intake through, decreased appetite, nutrient absorption, and utilization.

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5.2 Recommendation 1. Distribution of food rations should continue until the rains come and beneficiaries have produced enough food to sustain themselves.

2. The General food ration distribution should be extended to the Ijara district.

3. Supplementary feeding is necessary for the vulnerable group mainly, < 5 year old children, pregnant and lactating mothers. Therefore wet supplementary feeding centers should be established In Modogashe, Mbalambala and Sangailu.

4. Assist the existing TFP and SFP in: · Supply of supplementary food such as UNIMIX, CSB, dry skimmed milk and/or high-energy biscuit. · Support and increase staff capacity. · Improve available equipment and resources.

5. In areas of water shortages, either start water projects or provide wet supplementary feeding instead of giving dry rations . 6. Type of food ration supplied should be based on the local community’s food habits, customs, and method of food preparation and cooking.

7. The tedious, cumbersome and time consuming method of pounding maize into flour calls for the introduction of appropriate technology that can simplify the process of maize grinding.

8. Health facilities should be provided to the communities living near the water points. Either by constructing community based health centers or availing mobile clinics. More Community health workers should also be trained.

9. There should be a periodic nutrition survey to assess the nutrition and health situation and the impact of general food distribution.

10. Multi-sectoral collaboration should be enhanced to curb multiple nutrition- related problems such as water, health facility, and food.

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References

ACC/SCN (1994). Update on the nutrition situation.

ANP (1997). Food and nutrition assessment in drought prone district of Kenya. Part two district profile. Applied Human Nutrition Programme, University of Nairobi.

GOK (2000) Ministry of Agriculture and rural development, Garissa district, monthly reports. (July-August)

GOK (1996). Fifth nutrition Survey of Kenya.

WHO (1995). Physical status; the use and interpretation of anthropometry, Geneva.

22 Annex A Cluster sampling table

Geographi- Districts Divisions Total No. of Cluster Total Sample cal zones Population <5 size/ clusters clusters

children interval

Northern Garissa Modogashe 11740 2042 14 7

Mbalambala 8779 1620 11 6

Shanta-bak 10413 2061 14 4

Sankuri 17107 2743 19 6

Benane 8614 1690 12 4

Danyere 8465 2800 20 3

Sub-total 65118 12956 140 90 30

Central Garissa Central 40582 5000 50 15

Jarajilla 4385 1245 12 5

Dadaab 13728 1418 14 7

Liboi 9600 1918 19 3

Sub-total 68292 9581 100 95 30

Southern Ijara Ijara 17355 3471 21 6

Hulugho 20889 4178 26 9

Sangaillu 11403 2281 14 6

Maslani 13326 2665 16 5

Bura 9969 2281 14 4

Sub-total 72942 14876 160 91 30

Total 2 16 216123 37443 275 90

· Information on population size and number of children for Garissa district and Bura division was taken from Care-Kenya Garissa office. · Population size for Ijara district was taken from the district development office. · Number of children for the Ijara district was calculated assuming 20% of the population would be children under five years old.

23 Annex B Geographical Zones, divisions and villages Zone/Divisions Villages/ Zone/Divisions Village/ Zone/Divisions Villages/ Clusters Clusters clusters Northern zone Bulla-digis1 Central zone Southern/Ijara Modogashe Bulla-digis2 Liboi Damajalle1 Bura Bura Bulla-digis3 Damajalle2 Shabaha Lango yato A Damajalle3 Waberi1 Lango yato B Damajalle4 Waberi2 Maalim Dadaab Borehole5A Waberi3 Secondary Borehole5B Masalani Iftin Mbalambala Air Labasigalle1 Korisa1 Akalar Labasigalle2 Korisa2 Barka Central Bulla mzuri Korisa3 Central1 Bahati Korisa4 Central2 Bashal Skedek Dujis Bulla-adey Sangailu Bulla-koroga Shanta-abak Cheron1 Bulla-jaribu Hodan1 Cheron2 Bulla-nur Hodan2 Cheron3 Dekarbur1 Korogai Cheron4 Dekarbur2 Koran Katkat Benane Elder Dekarbur3 Matarba Tokojo1 Dekarbur4 Wakab-hara Tokojo2 Dekarbur5 Ijara Bulla-bahala Tokojo3 Iskadek Bulla-harerai Danyeyere Central Korakora1 Bulla-kokan1 Daaddable1 Korakora2 Bulla-kokan2 Daaddable1 Korakora3 Dibayu1 Skley Jarajilla Alinjugur Dibayu2 Sankuri Barka Bulla-masijid1 Hulugho Bulla-balaka LegderaB Bulla-masijid2 Bulla-rik Raya1 Dobley Bulla-bahala Raya1 Jabuti Koyro1 LegedraA Koyro2 Farya Total 6 30 Total 4 28 Total 5 29

25 Annex C Names field workers

Southern Zone 1. Evelyne Cheprigor (Nutritionist- team leader) 2. Yustur Mohamed Farah 3. Hilowle Hassan Sugal 4. Fardosa Ismael

Central zone

1. Leyla Ahmed (Nutritionist- team leader) 2. Ismael Hassan 3. Siyad Abdi Mohamed 4. Kassim Adan Hussein

Northern zone

1. Idriss Sheikh (Nutritionist- team leader) 2. Warsame Noor Bundid 3. Mohamed Dubow Aden 4. Abdi Ismael Dalal

(Note: each team was accompanied by a guide and food monitors)

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