NUTRITIONAL ANTHROPOMETRIC AND MORTALITY SURVEY FINAL REPORT MANDERA CENTRAL DISTRICT NORTH EASTERN PROVINCE, KENYA

Transcription

1 NUTRITIONAL ANTHROPOMETRIC AND MORTALITY SURVEY FINAL REPORT MANDERA CENTRAL DISTRICT NORTH EASTERN PROVINCE, KENYA APRIL-MAY

2 Acknowledgements Special thanks are expressed to; CIFF/ELMA and UNICEF financial support to Save the Children Nutrition program and for funding this survey. Provincial administration, ALRMP, Ministry of Agriculture, Ministry of Health and District Development Office through their respective district focal persons for the necessary expertise during the entire survey period. Survey team (supervisors, team leaders, enumerators and drivers) for their tireless efforts to ensure that the survey was conducted professionally and on time. Community members who willingly participated in the survey and provided the information needed. 2

3 TABLE OF CONTENTS Acknowledgements... 2 TABLE OF CONTENTS... 3 List of abbreviations and acronyms... 5 Executive summary... 8 Area Covered... 8 Specific Objectives... 8 Methodology... 9 Main survey results... 9 Results summary for water, hygiene and sanitation Recommendations Introduction Relief Programmes currently in the area: Humanitarian interventions in Mandera Central district Specific Objectives Methodology Parameters used in the determination of mortality and anthropometry data (21.9% U5 population) Sampling procedure: selecting households and children Case definitions and inclusion criteria Children s data Anthropometric data: Programme coverage Infant and Young Child feeding (IYCF) Mortality data Causes of malnutrition data Nutritional Status Cut-off Points Weight-for-height (WFH) and MUAC Wasting for Children Weight-for-age (WFA) Underweight Height-for-age (HFA) Stunting Mid upper arm circumference (MUAC) Mortality Questionnaire, training and supervision Questionnaire Survey teams and supervision Training Data analysis Results Anthropometric results (based on WHO standards 2006): Malnutrition by MUAC Chronic Malnutrition Prevalenceof underweight Prevalence of stunting Mortality results Children's morbidity Health seeking behaviour Vaccination Results : OPV 1&3 and BCG for 6-59 months and measles for 9-59 months : Micronutrient supplementation and deworming Programme coverage Discussion Nutritional status Under five nutrition status Caretaker s nutrition status Mortality Causes of malnutrition Health status:

4 Infant and Young Child Feeding (IYCF) Water Sanitation and hygiene Main water source Water treatment Handwashing practices Access to toilet facilities Conclusions Recommendations and priorities Immediate Medium term Long term References Appendix Appendix Appendix Appendix Appendix LIST OF TABLES Table 1: Results Summary... 9 Table 2: Main Results WASH Table 3: Seasonal timeline Table 4: Sample size calculation Table 5 : population sex pyramid Table 6: Prevalence of malnutrition based on WHO 2006 standards Table 7: Health seeking behaviour Table 8: Vaccination coverage: OPV 1&3 and BCG for 6-59 months and measles for 9-59 months Table 9: Survey trends Table 10: Caretakers Nutrition Status Table 11: Proportion of children 0-23 months put to the breast within 1 hour of birth Table 12: proportion of children exclusively breastfed Table 13: Minimum dietary diversity (n=285) Table 14: Minimum meal times for breastfed children 6-8 months (n=20) Table 15: Minimum meal times for breastfed children 9-23 months (n=133) Table 16: Minimum meal times for Non breastfed children 6-23 months (n=130) Table 17: Main current water sources Table 18: Treatment given to drinking water Table 19: When hands were washed Table 20: what was used to clean hands LIST OF FIGURES No table of figures entries found. 4

5 List of abbreviations and acronyms ALRMP II - Arid Lands Resource Management Project II AMREF - African Medical Research Foundation APHIA -Aids Population Health Integrated Assistance Project ASAL - Arid and Semi-Arid Lands CDR - Crude Death Rate COCOP - Consortium of cooperating partners CI - Confidence Interval CMR - Crude Mortality Rate CSB - Corn Soya Blend ENA - Emergency Nutrition Assessment 5

6 EPI - Extended Programme of Immunization GAM - Global Acute Malnutrition GFD - General Food Distribution HAZ - Height-for-Age Z-score HINI - High Impact Nutrition Interventions HSNP - Hunger Safety Net Project KFSSG - Kenya Food Security Steering Group L/HAZ - Length/ Height for Age Z-score MOH - Ministry of Health MUAC - Mid-Upper Arm Circumference NEP - North Eastern Province OPV - Oral Polio Vaccine OTP - Out-patient Therapeutic Program SAM - Severe Acute Malnutrition SC - Stabilization Centre SD - Standard Deviation SFP - Supplementary Feeding Programme SMART Standardized Monitoring and Assessment of Relief and Transitions U5MR - Under Five-Mortality Rate UNICEF - United Nations Children s Fund CIFF - Children investment Funds Foundation/ URTI - Upper Respiratory Tract Infection WAZ - Weight-for-Age Z-score WFP - World Food Programme WHM - Weight for Height Median WHO - World Health Organization WHZ - Weight-for-Height/length Z-scores 6

7 Executive summary Mandera Central is one of the districts that form the North Eastern Province (NEP) and is one of the 19 districts 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 Mandera East District and Somalia to the east, Mandera West District and Wajir North District to the west, Wajir District to the south and Ethiopia to the north. The town of El Wak is the District headquarter, which administratively consists of 5 divisions including El Wak, Shimbir Fatuma, Wargadud, Qalanqalesa and Kotulo. The main livelihood activity in the district is pastoralism and being predominantly arid, the district experiences chronic food insecurity and high incidences of malnutrition. Predictable rainy and dry seasons can no longer be counted upon to provide adequate dry season grazing and water for pastoral populations, whose resilience is increasingly eroded by broader economic factors in the region. Food aid continues to be a key source of food for a majority of the population. The district is predominantly inhabited by one clan Garre with 2 major sub clans namely Save the Children UK (SCUK) operates in all the 5 divisions. Within the four divisions there are a total of 7 GOK health facilities including El Wak district hospital. The projected population for the survey area is 64, The District is geographically isolated from the rest of the country with it being characterized with poor infrastructure and thus poor access to services. The area is prone to extreme climatic conditions characterized by successive droughts and floods leading to chronic food insecurity. This has rendered the population reliant on food aid. The securityin the district is volatile since the incursionof the Kenyan Army into Somalia AreaCovered Save the children in conjunction with the MOPHS and MOMS have been carrying out IMAM activities in the 5 divisions of Mandera Central namely Elwak, Shimbir Fatuma, Qalanqalesa, Kotulo and Wargadud since August Nutrition surveys have been conducted in the area on the same month (March) since 2006 in order to evaluate impact and as well serve as a surveillance system. This survey was conducted from 26th of April to 7 th May Specific Objectives The survey aimed at estimating the; The prevalence of acute and chronic malnutrition in children aged 6-59 months; The nutrition status pregnant women and mothers with children <5 years ; The crude and under five mortality rate and causes of death; The proportion of households with access to improved water and sanitation; The coverage and content of the general food distribution; The food access and dietary diversity at household level; The Coverage of measles, OPV/Pentavalent 1&3 and BCG vaccination among target children; 1 Figures obtained from the District Development Office- Mandera Central. 7

8 Infant and Young Child feeding practices (children between 0-23 months). The Coverage rate of Vitamin A. supplementation and de worming; The Morbidity rates of children 6-59 months 2 weeks prior to the survey; To recommend appropriate interventions based on the survey findings; Methodology Two different sampling methodologies were applied. Emergency Nutrition Assessment (ENA) for Standardized Monitoring of Relief and Transition (SMART) was used to calculate Anthropometry and mortality samples while IYCF multi survey sampling calculator was used to calculate for IYCF sample. Probability of Proportion to Population Size (PPS) was used to identify clusters within a study area after collecting population data from all villages/ sub location that were considered as clusters. The target population for the anthropometric survey was children aged 6-59 months while that for IYCF was children 0-24 months. The total sample size of households was arrived at by collating both the Anthropometry, IYCF and Mortality samples. The final sample size was 574 households from 34 clusters. Data was collected on anthropometry, morbidity, vaccination and de-worming status, Vitamin A supplementation, hygiene and sanitation practices, IYCF, food security and livelihoods. This data was triangulated with feeding programme data to help in the interpretation of results. Retrospective information on mortality was collected using the current household census method, with a recall period of 94 days, from all households visited including those without children under the age of five. A total of 578 households were visited and 1071 children from 6 to 59 months were assessed for anthropometry and other indicators. The final analysis was on 1068 children after exclusion of 3 records. Anthropometric and mortality data were analyzed using the ENA software beta version May IYCF data was analysis on Excel and Qualitative and quantitative data was analyzed using the EPIINFO software. Main survey results Table 1: Results Summary Characteristic N n % ( 95% CI) GAM (WFH <-2 Z score or presence of oedema) - WHO % ( ) SAM (WFH <-3 Z score or presence of oedema) - WHO % ( ) Prevalence of GAM by MUAC (<12.5cm) % [ ] Proportion of children sick two weeks prior to survey % 8

9 Proportion of caretakers seeking medical care when % child is ill BCG Scar Measles immunization (card and confirmation) % OPV1 immunization (card and confirmation) % OPV3 immunization (card and confirmation) % Vitamin A supplementation coverage (>12 month) % time Vitamin A supplementation coverage (>12 month) % times Vitamin A supplementation coverage (6-11 months) % time Proportion of children >1 year de-wormed 1 time % Proportion of children >1 year de-wormed 2 time %% Iron-folate Supplementation for pregnant mothers % Appropriate hand-washing with soap/ash 47.5% Proportion of children 6-59 months supplemented with % Zinc the last time they had diarrhoea IYCF Key Indicator - Timely Breast-feeding Initiation % IYCF Key Indicator - Exclusive Breastfeeding % IYCF Key Indicator - Minimum Dietary Diversity> % foods BF IYCF Key Indicator - Minimum Dietary Diversity > % foods NBF IYCF Key Indicator meal frequency 6-8 months % times IYCF Key Indicator meal frequency 9-93 months % times IYCF Key Indicator meal frequency 6-93 months % times Crude mortality rate (deaths/10000/day) 0.18( ) Under-five mortality rate (deaths/10000/day) 0.22( ) Results summary for water, hygiene and sanitation Table 2: Main Results WASH Sources of Water Borehole 33.9% Unprotected well 29.1% Dam 18.3% Protected well 7.3% 9

10 Water tap 6.3% Water tracking 4.9% WATER TREATMENT Nothing 94.3% Use of chemicals 6.6% Boiling 1.9% ACCESS TO A TOILET FACILITY Yes 48.5% IF NO TOILET WHAT WAS USED Bush 78% HANDWASHING PRACTICES Before eating food 83.2% After visiting toilet 75% After cleaning children s bottoms 64.5% Before preparing food 66% The prevalence of acute malnutrition in Mandera Central district is still critical with global acute malnutrition (GAM) of 17.9% ( % C.I.) and Severe Acute Malnutrition (SAM) rate of 3.4.% ( % C.I.). Compared with the survey undertaken in March of 2011 however which indicated GAM of 27.5% ( % CI) and SAM of 3.4% ( ), there is a reduction in the level of GAM which is statistically significant(p=0.001) while there was no much change in SAM. The levels of Immunization (OPV1&3, Measles, BCG) were also within the recommended national levels of above 80% both by card and recall. Some other HINI indicators like use of Zinc in the management of diarrhoe, deworming and Vitamin A supplementation for the Months were however not up to scale. This was also the case as regards to Hygiene and Sanitation pracices. An analysis of IYCF indicators showed that the IYCF practices are poor with high percentage of children not receiving optimal infant feeding practices (with the exception of timely initiation of breastfeeding reported at above 80%). Recommendations Immediate Continue supporting to the MOH with OJT, HINI,supportive supervision and logistical support. Promotion of IYCF activities geared towards optimal complementary feeding and dietary diversity e.g. kitchen gardening and cooking demostration. Incooporating DRR in normal programming through activities like provision of health, nutrition and hygiene promotion activities to school health clubs. Scale up of the HINI package with special focus on Zinc supplementation. As a start sensitization of health workers and supply chain management of the Zinc tablets should be adressed. Medium term MOH to develop a health workers retention strategy to reduce the high staffs turn over. Through SCUK WASH programmestrengthen Hygiene promotion hygiene practices to 10

11 Long term reduce the incidence of diarrhoeal disease including health and nutrition promotion toeducate the community on basic WASH i.e. domestic treatment of drinking water and proper disposal of faecal waste. Through SCUK WASH programme, Provide 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. This can be piloted in one division (to be agreed among all stakeholders) and depending on how it works it can be scaled up to the others. 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. 1. Introduction Mandera Central is one of the districts that form the North Eastern Province (NEP) and is one of the 19 districts 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 Mandera East District and Somalia to the east, Mandera West District and Wajir North District to the west, Wajir District to the south and Ethiopia to the north. The town of El Wak is the District headquarter, which administratively consists of 5 divisions including El Wak, Qalanqalesa, Shimbir Fatuma, Wargadud and Kotulo. The district experiences chronic food insecurity and high incidences of malnutrition. Predictable rainy and dry seasons can no longer be counted upon to provide adequate dry season grazing and water for pastoral populations, whose resilience is increasingly eroded by broader economic factors in the region. Food aid continues to be a key source of food for a majority of the population The estimated population for the district is 63,025 2 with the people being sparsely populated. Residents are mainly from the Somali community speaking the Garre language. The main livelihood activity in the district is pastoralism with a number of Peri-urban destitutes (PUDs) who have dropped out of pastoralism due to loss of livestock to shocks and settled near urban centers. 2 Figures obtained from the District Development Office- Mandera Central. 11

12 The district has one main road connecting the District to other districts in the province (Wajir East and Mandera East) and other minor roads to the divisions and to Mandera West. The roads are however in bad condition rendering them impassible especially during the rainy season. Save the Children UK (SCUK) operates in all the 5 divisions. Within the divisions, there are a total of 7 GOK health facilities including El Wak district hospital. Worth to note however is that, out of the seven health facilities, currently 2 are not fully operational due to transfer of the skilled staff with only CHWs left to provided minimal services. In the course of its work, Save the children is supporting the MOMs and MOPHS in implementing Health and Nutrition, and has also a Food security and Livelihood support projects to vulnerable HHs in Mandera and Wajir Districts through DFID funded HSNP project. Under the health and nutrition project there is a components of WASH mainly targeted at the health facilities by rehabilitation of water and sanitation facilities. The projects utilize integrated approaches to address immediate and underlying causes of malnutrition Relief Programmes currently in the area: Kenya Red Cross: Emergency relief SCUK: IMAM, HSNP, Health Outreach, WATSAN COCOP/WFP : Food Aid ADRA: Primary Health Care AMREF: MCH/HIV/AIDS Northern Aid: WATSAN, HIV/AIDS Office of the President: Food Aid DANIDA: Nomadic Clinic 12

13 Table 3: Seasonal timeline Short Dry Spell (Jilaal) Long Reason (Gu ) Rainy Long Dry Spell (Hagai) Short Season (Deyr) Rainy Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Migration, Conflicts, Watering of Livestock, Pasture Surveys, mating season, Livestock diseases, Calving, Kidding Migration, 13

14 Pressure on boreholes Planting Labour Demand Period Conflict Humanitarian interventions in Mandera Central district Save the Children has been implementing programmes in Mandera Central district since Our current integrated approach; Nutrition, Health, Food security and Livelihoods Support programmes, aim to address the underlying causes of malnutrition through strengthening health systems, treatment for acute malnutrition and enhancement of house hold food security and livelihoods in the medium term while at the same time linking these to long term livelihood strategies. The World Food Programme (WFP) through Arid Lands Development Focus (ALDEF) has been carrying out general food distribution (GFD) in this area. The GFD food basket provides a 75% ration scale of 2,100Kcal/person, the daily per capita energy requirement 3. The Ministry of special programmes through the District Commissioner s office occasionally supplies food to the region and this is usually divided equally among the divisions. School feeding programme is also available in all government schools which is run by WFP. Other actors on the ground include: ADRA providing health services, Kenya Red Cross society undertaking emergency relief operations and AMREF who havebeen supporting the MoH in combating HIV /AIDS and in matters related to reproductive health. 1.2 Specific Objectives The survey aimed at estimating the; The prevalence of acute and chronic malnutrition in children aged 6-59 months; The nutrition status pregnant women and mothers with children <5 years ; The IYCF practices (children 0-23 months) The crude and under five mortality rate and causes of death; The proportion of households with access to improved water and sanitation; The coverage and content of the general food distribution; The food access and dietary diversity at household level; The Coverage of measles and BCG vaccination among target children; The Coverage rate of Vitamin A. supplementation and de worming; The Morbidity rates of children 6-59 months 2 weeks prior to the survey; To recommend appropriate interventions based on the survey findings; 3 Based on UNHCR/UNICEF/WFP/WHO Guidelines for Food and Nutrition Needs in Emergencies 14

15 2. Methodology Two different sampling methodologies were applied; Emergency Nutrition Assessment (ENA) for Standardized Monitoring of Relief and Transition (SMART) was used to calculate Anthropometry and mortality samples while IYCF multi survey sampling calculator was used to calculate for IYCF sample. A 2 stage cluster sampling method with Probability of Proportion to Population Size (PPS) was used to identify clusters within a study area after collecting population data from all villages that were to be considered as clusters. The required sample size was calculated on the nutritional status for children 6-59 months and on the Crude Mortality Rate (CMR) for the household sample. Sample size for infants and young children (0-5 months) was calculated separately using IYCF sampling calculator calculating sample size for each of the IYCF indicators. The sample size for the survey was calculated and adjusted for absentees and refusals using previous results of surveys conducted in the district. 15

16 Sample size for anthropometry was calculated using the ENA for SMART methodology which gave 667 children. IYCF sample size was calculated using multiple survey sample size calculation considering current rates of the most critical IYCF indicators to be considered (Timely initiation of breast feeding, Exclusive breast feeding, continued breast feeding, minimum dietary diversity and minimum meal frequency). Assumptions of 10% improvement rate were made since indicators did not have target rate for improvements (arrived at following discussions with consultants who have researched on IYCF over time and through a blog on ENN). Hence, the highest from IYCF sample size (Exclusive breast feeding) was considered which 782 are 4. It was then assumed that 80% of these children will however be captured in the overall anthropometry sample. Thus, 20% (156) of the 782 was added to the anthropometry sample to account remaining age group making the total sample of children 823. In order to calculate the number of households to visit in the duration of the survey, total number of children was divided by 1.3 (number of children/household) based on previous surveys giving rise to 633 HH Parameters used in the determination of mortality and anthropometry data (21.9% U5 population) 1). the estimated prevalence of malnutrition is 27.5 % 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 ) The average number of persons per household is 7 and 1 mother per household. Sample size for mortality is calculated based March 2011, survey showing death rate of /10,000/day, a desired precision of 0.4, design effect 2 non-response rate of 3% and 90 days recall period. This was keyed in to ENA for SMART with family size of 7 and gave a sample of 3659 and 539 households. To calculate number of clusters to visit, the total sample for anthropometry and IYCF was used. Number of households (633) was divided by number of HH to be reached per day (17) gives 37 clusters. The table below summarizes the sample size calculation. Table 4: Sample size calculation Sample of IYCF Sample of Anthropo metry Total sample of children # of HH to visit # of HH for mort ality Final Sample size considere d # of childre n per cluster # of clusters 4 Rates of IYCF indictors for the district were based on Save the Children KPC survey Sept malnutrition rates (2011 nutrition survey) 6 From the March 2011 Mandera Central nutrition survey 7 CMR rates March 2011 nutrition survey 16

17 Sampling procedure: selecting households and children The second stage sampling stage comprised of the household selection. Only the randomly sampled villages were assessed during data collection. In the selected village, the Expanded Programme on Immunization (EPI) method was applied in order to determine the starting point. At the center of the village, a pen was spun to determine the starting direction. The team then moved to the periphery along the pointed direction. At the end of the village, the pen was re-spun and a direction obtained. Just like the first stage, the survey team moved along the pointed direction but this time counting all households in that direction to the edge. A table of random numbers was used to determine the first household. Mortality and anthropometric questionnaires were administered accordingly and subsequent households determined by going to the next house to the right. In villages with more than one cluster, the village was subdivided and the center of each subdivision determined and households selected as described above. In a cluster that was sparsely populated, all the households in the cluster were visited. A household was defined as a group of people who lived together and shared a common cooking pot. In polygamous families with several structures within the same compound but with different wives having their own cooking pots, the structures were considered as separate households and assessed separately. All children aged 6-59 in every household visited were included in the anthropometric survey and 0-24 month category included in IYCF survey. In cases where there was no eligible child, a household was still considered part of the sample and its mortality data were collected. If a respondent was absent during the time of household visit, the teams left a message and re-visited later to collect data for the missing person, with no substitution of households allowed. The teams visited the nearest adjacent village (not among those sampled) to make up for the required number of households if the selected village yielded a number below 22 children and 17 households, following the SMART methodology Case definitions and inclusion criteria Children s data Anthropometric data: Age: the age of the child was recorded based on a combination child health cards, the mothers /caretakers knowledge of the birth date and use of a calendar of events for the district developed in collaboration with the survey team. Sex: it was recorded whether a child was male or female. 8 SMART (2006): Measuring Mortality, Nutritional Status and Food Security in Crises Situations: SMART METHODOLOGY 17

18 Bilateral oedema: normal thumb pressure was applied on the top part of both feet for 3 seconds. If pitting occurred on both feet upon release of the fingers, nutritional oedema was indicated. Weight: the weights of children were taken with minimal or light clothing on, using UNICEF Salter Scales with a threshold of 25kgs and recorded to the nearest 0.1kg. Length/height: children were measured bareheaded and barefooted using wooden UNICEF height boards with a precision of 0.1cm. Children under the age of two years were measured while lying down (length) and those over two years while standing upright (height). If child age could not be accurately determined, proxy heights were used to determine cases where height would be taken in a supine position (<87cm) or in an upright position ( 87cm). Height rods with a marking at 87cm were used to assist in determining measuring position. Mid Upper Arm Circumference (MUAC): the MUAC of children was taken at the midpoint of the upper left arm using a MUAC tape and recorded to the nearest 0.1cm. Retrospective morbidity of children: The caretaker with the child at the time of the survey was asked to recall if the child had any illness in the 2-weeks prior to the survey. Vaccination status and coverage: For all children 6-59 months, information on Penta- valent 1 and Oral polio Vaccine (OPV) 1 and Penta- valent 3 and OPV 3 and measles vaccination was collected using health cards and recall from caregivers. The vaccination coverage was calculated as the proportion of children immunized based on records and recall. BCG: For all children 6-59 months, the information was collected by checking whether the characteristic BCG scar was present or not. Vitamin A supplementation status: For all children 6-59 months of age, information on Vitamin A supplementation was collected using the child welfare cards and recall from caregivers. Information on how many times the child had received supplementation in the last 6 months was collected. Vitamin A capsules were also shown to the mothers to aid in recall. De-worming status: Information was solicited from the care takers as to whether their child/children 6-59 months had been de-wormed in the last 3 months. A local calendar of events was used to refer to 3 months recall period Programme coverage For all children 6-59 months of age, the caretakers/mothers were asked to state whether the child was enrolled in a supplementary feeding program (SFP), an outpatient feeding program (OTP) and Blanket Supplementary Feeding programme (BSFP) at the time of the survey. Children found to be malnourished based on MUAC measurements were referred to the nearest health facility for treatment Infant and Young Child feeding (IYCF) Data on IYCF was collected from children aged 0-24 months and was based on mothers recall of feeding practices including a 24 hour dietary recall. 18

19 2.6. Mortality data Retrospective mortality data was collected using the current household census method in all the visited households, including those with no children aged less than five years old. The recall period was 94 days. Information was collected on the age and sex of the household members, their residence status, the number of household members present within the recall period, the number of persons who arrived or left, and the number of births and deaths over the recall period. The presumed causes of death were recorded based on the following case definitions: Diarrhea (watery stool >3/24H); Bloody diarrhea; Measles (fever with rash); Fever; Lower respiratory tract infection (fever, cough, chest pin, difficulty breathing); Malnutrition; Injury; Other (specify); Unknown; 2.7. Causes of malnutrition data Secondary data on causes of malnutrition was mainly obtained from previous surveys undertaken in the area. Primary data on the causes of malnutrition was obtained from interviewing mothers/caretakers of children based on the household questionnaire that contained questions of water sources and hand washing practice, main sources of food and income, use of mosquito nets, dietary diversity and nutritional status of mothers/caretakers. The questionnaires were based on the national guidelines for nutritional assessments in Kenya, and modified slightly to collect context specific data for Wajir East. Data was collected from 578 households. Government officials and other NGOs working in the area were visited to provide information on the on-going interventions in the area Nutritional Status Cut-off Points The following nutritional indices and cut-off points were used in this survey: The following indices and cut-off points were used in this survey: Weight-for-height (WFH) and MUAC Wasting for Children Wasting reflects the current health/nutritional status of an individual. The results on wasting are presented as Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM): Children whose WFH Z scores fell below -2 standard deviations from the median of the NCHS reference population/who standards or had bilateral oedema were classified as wasted (to reflect GAM) Children whose WFH Z scores fell below -3 standard deviations from the median of the NCHS reference population/who standards or had bilateral oedema were classified as severely wasted (to reflect SAM) 19

20 Children whose WFH indices were <80% of the NCHS median or had bilateral oedema were classified as wasted (to reflect GAM) Children whose WFH indices were <70% of the NCHS median or had bilateral oedema were classified as severely wasted (to reflect SAM) Weight-for-age (WFA) Underweight The measure of underweight gives a mixed reflection of both the current and past nutritional experience by a population and is very useful in growth monitoring. Children whose WFA Z scores fell below -2 standard deviations from the median of the NCHS reference population or had bilateral oedema were classified as underweight Children whose WFA Z scores fell below -3 standard deviations from the median of the NCHS reference population or had bilateral oedema were classified as severely underweight Height-for-age (HFA) Stunting Height-for-age is a measure of linear growth and therefore an unequivocal reflection of cumulative past nutritional inadequacy. Children whose HFA Z scores fell below -2 standard deviations from the median of the NCHS reference population were classified as stunted (to reflect Global Stunting) Children whose HFA Z scores fell below -3 standard deviations from the median of the NCHS reference population were classified as severely stunted Mid upper arm circumference (MUAC) The guidelines used for < MUAC for under- fives was as follows; MUAC < 11.5 cm severe malnutrition and high risk of mortality MUAC _ 11.5 cm and <12.5cm moderate malnutrition MUAC _12.5 and < 13.5 cm moderate risk of malnutrition MUAC _ 13.5 cm satisfactory nutritional status The cut-off point for pregnant women s MUAC was < 23.0 cm and that of non-pregnant women <21.0 cm (as indicators of delineating energy deficiency) according to SPHERE standards 8 Table 4: Maternal MUAC cut-off points Nutritional status Pregnant Nonpregnant Normal 23.0cm 21.0cm GAM < 23.0cm < 21.0cm Severe wasting < 20.7cm < 18.5cm 8 The SPHERE Project Handbook (2011), Humanitarian Charter and Minimum Standards in Disaster Response. 20

21 Mortality The crude death rate is defined as the number of people in the total population who died between the star of the recall period and the time of the survey. It is calculated using the following: Crude mortality Rate (CMR) = 10,000/a*f/ (b_+f/2+d/2-c/2), where a =number of recall days b =number of current households residents c =number of people who joined the HH d =number of people who left the HH e =number of births during recall f =number of deaths during recall period. The result is expressed per 10,000 people per day. Table 5: Mortality Thresholds Total population CMR Under-five population U5MR Alert level: 1/10,000 people/day 2/10,000 children/day Emergency level: 2/10,000 people/day 4/10,000 children/day 2.9. Questionnaire, training and supervision Questionnaire The standard nutrition survey questionnaire as recommended in the nutrition guidelines was adapted to include additional information on the high Impact nutrition interventions. The IYCF questionnaire as recommended in the CARE IYCF step by step guide was used to collect information on IYCF. The questionnaire was developed in English and the enumerators trained on the questionnaire. During the training session, the enumerators translated the questionnaires as they would ask during data collection and an agreed way of asking the questions during data collection was agreed upon. The questionnaires were not translated into Somali language however; all interviews were conducted in Somali language. The questionnaire was pre-tested a day before the actual survey began and the final questionnaire used is annexed in the report Survey teams and supervision The survey was executed by 5 teams each comprising of 1 team leader and 2 anthropometric measurers. Four of the team leaders were from Ministry of Health (MOMS/MOPHS),one from Arid Lands Resource Management Project (ALRMP) and one from the District development Office. The survey was led and supervised by trained staff from Save the Children UK. The anthropometric measurers were recruited from the district and spoke the local language as well as English. The measurers were required to be literate and at least have completed high school to participate in the study. The team leaders were practitioners either in health, food security and nutrition and were 21

22 sourced from the government and Save the Children. The survey was supervised by the nutrition technical specialist from save the Children UK Training Training for the survey teams was undertaken by Save the Children staff (the nutrition technical specialist). The training was undertaken for 3 days and covered an introduction to nutrition and nutrition assessments, the survey objectives, anthropometric measurements, household selection procedures, data collection and interviewing skills and the survey questionnaire. The anthropometric standardization exercise, as recommended by the SMART methodology was undertaken with 10 children, each measurer taking measurements on each child twice. Each enumerator was closely observed and guided by supervisors and manually given a score of competence based on performing measurements with accuracy and precision. After the class room training, practical field experience was conducted to pre-test the questionnaire, take anthropometric measurements of children and caretakers, conduct interviews and fill questionnaires; pre-testing exercise was performed on 12 households. The pre-testing exercise facilitated some changes on the structure of the questionnaire. In addition, a team of data clerks who were trained on the operation of ENA for SMART for the data entry and these were closely supervised by the M&E officer from Save the Children Data analysis Anthropometric and mortality data entry and processing was done using the ENA for SMART software Beta version May 2011 where the World Health Organization Growth Standards (WHO- GS) data cleaning and flagging procedures were used to identify outliers which enabled data cleaning as well as exclusion of discordant measurements from anthropometric analysis. The SMART/ENA software generated weight-for-height, height-for-age and weight-for-age Z scores to classify them into various nutritional status categories using WHO 9 standards and cut-off points. IYCF data was analysed in Excel using guidance from the Infant and Young Child Feeding Practices collecting and using data: a step- by- step guide. All the other quantitative data were entered and analysed in the EPIINFO version. 9 WHO

23 3. Results Table 6: Demography Number of children 6-59 months surveyed 1071 Number of children 6-59 months analyzed 1068 Number of anthropometry data excluded using Plausibility Check 3 Household Census: Number of total population surveyed for mortality 3743 Number of children under five surveyed for mortality 1071 Number of HH covered in the mortality survey 711 Number of persons who joined the household during the recall period Number of persons who left the household during the recall period Number of under five children who joined the household during the recall period Number of under five children who left the household during the recall period Number of births during the recall period DEMOGRAPHY Number of persons per HH 3743/ Number of children per HH 1071/ % of children under five in the population 28% 3.1 Anthropometric results (based on WHO standards 2006): 23

24 Definitions of acute malnutrition should be given (for example, global acute malnutrition is defined as <-2 z scores weight-for-height and/or oedema, severe acute malnutrition is defined as <-3z scores weight-for-height and/or oedema) Exclusion of z-scores from Zero (reference mean) WHO flags: WHZ -5 to 5; HAZ -6 to 6; WAZ -6 to 5 Table 7: Distribution of age and sex of sample Boys Girls Total Ratio AGE (mo) no. % no. % no. % Boy: girl Total The overall sex ratio was 1.0 (p-value = 0.445) indicating that both boys and girls were equally represented. The overall age distribution (p-value = 0.019) Meaning there was significant diffrence which was the same for the overall sex/age distribution with a p-value = There was an under representation of the children between the ages 6-17 months and this may be attributed to the difficulty in estimating actual ages of children due to absence of health cards. Age estimation was mainly done through use of the events calendar. Table5 : population sex pyramid Sex Pyramid BOYS GIRLS % -40% -20% 0% 20% 40% 60% Table 8: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex Prevalence of global malnutrition (<-2 z-score and/or oedema) All n = 1068 Boys n = 546 Girls n = 522 (191) 17.9 % (108) 19.8 % (83) 15.9 % ( ( ( % C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate (154) 14.4 % (87) 15.9 % (67) 12.8 % 24

25 malnutrition (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema) ( % C.I.) (37) 3.5 % ( % C.I.) ( % C.I.) (21) 3.8 % ( % C.I.) ( % C.I.) (16) 3.1 % ( % C.I.) The prevalence of oedema is 0.1 %. There was one case of oedema reported Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema Severe wasting (<-3 z-score) Moderate wasting (>= -3 and <-2 z-score ) Normal (> = -2 z score) Oedema Age Total No. % No. % No. % No. % (mo) no Total Table 10: Distribution of acute malnutrition and oedema based on weight-for-height z-scores <-3 z-score >=-3 z-score Oedema present Marasmic kwashiorkor No. 0 Kwashiorkor No. 1 (0.1 %) (0.0 %) Oedema absent Marasmic No. 36 (3.4 %) Not severely malnourished No (96.5 %) No cases of Marasmic kwashiorkor were met during the survey. One case of Kwashiorkor was however reported. The figures below show the weight for height distribution curves of the surveys sample in Z-scores for comparison with both the WHO and the NCHS reference populations. The weight for height distribution curves of the sample are shifted to the left, with a mean Z-score of -1.22±1.20, which indicates a suboptimal nutrition status compared to the reference population (WHO reference table). Table6: Prevalence of malnutrition based on WHO 2006 standards 25

26 3.2. Malnutrition by MUAC Malnutrition rates by MUAC were reported atgam of 10.1% with a SAM 1.7% Table 3.5: Prevalence of acute malnutrition based on MUAC cut offs(and/or oedema) and by sex Table 11: prevalence of Malnutrition rates by MUAC Prevalence of global malnutrition (< 125 mm and/or oedema) Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema) Prevalence of severe malnutrition (< 115 mm and/or oedema) All n = 1071 Boys n = 548 Girls n = 523 (108) 10.1 % (54) 9.9 % (54) 10.3 % ( ( ( % C.I.) 95% C.I.) 95% C.I.) (90) 8.4 % ( % C.I.) (18) 1.7 % ( % C.I.) (45) 8.2 % ( % C.I.) (9) 1.6 % ( % C.I.) (45) 8.6 % ( % C.I.) (9) 1.7 % ( % C.I.) Table 12: Prevalence of acute malnutrition by age, based on MUAC cut offs and/or oedema Severe wasting (< 115 mm) Moderate wasting (>= 115 mm and < 125 mm) Normal (> = 125 mm ) Oedema Age Total No. % No. % No. % No. % (mo) no

27 Total Chronic Malnutrition Prevalenceof underweight Table 13: Prevalence of underweight based on weight-for-age z-scores by sex Prevalence of underweight (<-2 z- score) Prevalence of moderate underweight (<-2 z-score and >=- 3 z-score) Prevalence of severe underweight (<-3 z-score) All n = 1070 Boys n = 547 Girls n = 523 (269) 25.1 % (148) 27.1 % ( ( % C.I.) 95% C.I.) (219) 20.5 % ( % C.I.) (50) 4.7 % ( % C.I.) (121) 22.1 % ( % C.I.) (27) 4.9 % ( % C.I.) (121) 23.1 % ( % C.I.) (98) 18.7 % ( % C.I.) (23) 4.4 % ( % C.I.) Table 14: Prevalence of underweight by age, based on weight-for-age z-scores Severe underweight (<-3 z-score) Moderate underweight (>= -3 and <-2 z-score ) Normal (> = -2 z score) Oedema Age Total No. % No. % No. % No. % (mo) no Total Prevalence of stunting Table 15: Prevalence of stunting based on height-for-age z-scores and by sex Prevalence of stunting (<-2 z- score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) All n = 1070 Boys n = 547 Girls n = 523 (285) 26.6 % (152) 27.8 % (133) 25.4 % ( % ( % ( C.I.) C.I.) 95% C.I.) (188) 17.6 % ( % C.I.) (97) 17.7 % ( % C.I.) (91) 17.4 % ( % C.I.) 27

28 Prevalence of severe stunting (<-3 z-score) (97) 9.1 % ( % C.I.) (55) 10.1 % ( % C.I.) (42) 8.0 % ( % C.I.) Table 16: Prevalence of stunting by age based on height-for-age z-scores Severe stunting (<-3 z-score) Moderate stunting (>= -3 and <-2 z- score ) Normal (> = -2 z score) Age Total No. % No. % No. % (mo) no Total Table 17: Mean z-scores, Design Effects and excluded subjects Indicator n Mean z- scores ± SD Weight-for- Design Effect (zscore < -2) z-scores not available* ± Height Weight-for-Age ± Height-for-Age ± * contains for WHZ and WAZ the children with Oedema. z-scores out of range 3.4. Mortality results Table 18: Mortality rates CMR (total deaths/10,000 people / day): 0.36 ( ) (95% CI) U5MR (deaths in children under five/10,000 children under five / day): 0.22( CI) In total there were 6 reported deaths 2 in under-fives and 4 for those above the age of Report the main causes of death as given by the respondents were; Diarrhoea 33.3% Suspected measles 16.7% Unknown 50% 3.5. Children's morbidity Out of the 1070 children who participated in the survey, 398 of them reported to having been sick two weeks prior to the survey. Table 3.14: Prevalence of reported illness in children in the two weeks prior to interview (n=398) Table 19: Children mortality 28

29 6-59 months Prevalence of reported illness 38.6% Table 20: Symptom breakdown in the children in the two weeks prior to interview (n=398) 6-59 months Diarrhoea 23.4% Cough 37.2% Fever 20.9% Vomiting 19.1% Other 23.4% *it was possible for a child to report more than one illness Acute respiratory tract infections was the most common disease reported at 37% diarrhoea, fever and vomiting came in close succession at 23.4%, 20.9% and 19.1% respectively. Of those who reported to have been sick 83.7% reported to have sought help in the health facilities as shown in the figure below; Health seeking behaviour Table7: Health seeking behaviour Health Seeking Behaviour Percentage 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 83.7% Health facility 11.1% Outreach sites 1.3% 1.0% Herbalists where Assistance Was sought Other Percent 3.6 Vaccination Results 3.6.1: OPV 1&3 and BCG for 6-59 months and measles for 9-59 months Vaccination was reported at above the recommended EPI >80% for all the antigens as shown in in the figure below. The same was seen in the case for BCG which was reported at 94% Table8: Vaccination coverage: OPV 1&3 and BCG for 6-59 months and measles for 9-59 months 29

30 OPV 1, 3 AND MEASLES COVERAGE FACTOR OPV 1 OPV 3 Measles % 46% 65% 48% 67% 46% 31% 51% 29% 49% 29% 51% 1% 3% 2% 2% 1% 3.1% By Card By Recall No 0% 20% 40% 60% 80% 100% PERCENTAGE 3.6.2: Micronutrient supplementation and deworming Table 21: Micronutrients and deworming coverage Factor Mandera Central Vitamin A supplementation ( time 82% (68) months) Vitamin A supplementation 1 time 47% (464) ( 12months) 2 times 38% (374) De-worming Children aged > 12 months 1 time 38% (289) 2 times 37%(284) Iron/folate Pregnant women 46.5%(72) supplementation Zinc In Diarrhoea management 1.1%(1) From the table above, Vitamin A supplementation for the ages above 11months (Post immunization age) were suboptimal reported at 2 times 38% this was the same for Deworming and especially so in the Zinc supplementation in the management of diarrhoea which was only reported at 1% 3.7 Programme coverage This information was not collected but a SQUEAC survey is scheduled for the month of August which will be used to provide information on coverage. 30

31 4. Discussion 4.1 Nutritional status Under five nutrition status The prevalence of Global Acute Malnutrition for Mandera Central is 17.9 % ( % C.I.) and Severe Acute Malnutrition at 3.5 % ( % C.I.).These rates indicate an improvement in the nutrition status compared with the rates reported in a survey conducted in the district in March 2011 which showed a GAM of 27.5% ( % C.I). Further analysis with the CDC calculator indicates an improvement in the nutrition status that is statistically significant (p=0.001). Possible reasons for this could be better food security situation in the district following better amounts of short rains received in the district in October-December 2011 and as well quite a number of measures that had been put in place in the district following the emergency that had affected the district between April and October This included the BSFP programme, increase of outreaches from 15 to 25, other players providing foods like Kenya Red-cross and ADRA at the height of the drought among others. Table9: Survey trends 31

32 GAM and SAM trends for MC PERCENT WHO GAM WHO SAM MUAC GAM Threshold GAM YEAR Comparing the GAM rates by WFH with those by MUAC there seems to be a reverse trend where as one increases the other seems to be decreasing (2010 to 2012) Caretaker s nutrition status Table10: Caretakers Nutrition Status 32

33 Women physiological Status 25.0% 20.0% 21.2% 21.5% Percentage 15.0% 10.0% 13.3% 6.3% Percent 5.0% 1.6% 0.1% 0.0% Currently pregnant B/feeding < 6 mts infant B/feeding 6 24 months Pgnt and b/feeding Not Pgnt Nt b/feeding B/feeding > 24 months Physiological Status Most of the caretakers were either pregnant or lactating(79%) of the pregnant and lactating mothers their MUAC data was as follows; Table 22: Caretakers MUAC CATEGORY MUAC <21 CM MUAC >21 All women(15-49 years) 95(14.3%) 5969(85.7%) PLW 28(6.4%) 419(93.6%) 4.2 Mortality The Crude mortality rate (CMR) for this survey was 0.41 ( % CI) and the Under 5 mortality rate (U5MR) was 0.67 ( % CI). From the results, the CMR and the under 5 Mortality rates were within the normal rates. Compared to last year the differences in the mortality rates were not statistically significant. It is worth noting however that discussions related to death in the district are taboo/ related. 33

34 4.3 Causes of malnutrition The nutrition survey was undertaken during after the long rains at the end of the Month of April and the beginning of May. The rainfall recording in the district was ******. Malnutrition in amongst children in Mandera Central was affected by the following factors: Health status: Morbidity: Morbidity rates were high with 39% of the respondents reporting to having been sick two weeks prior to the survey. The main causes of morbidity reported were; acute respiratory tract infections (37%), followed by diarrhoea (23%), fever with chills like Malaria (20.9) and Vomiting reported at 19%. The disease patterns in the community were said to be typical for the season Vaccination, Micronutrient supplementation and De-worming coverage The immunization coverage for BCG (95.6%), Measles (98%) and Pentavalent/OPV 3 (94%) both by card and by recall were good and above the MOH target of 80%. These 4 vaccines are used in the survey as proxy for the immunization coverage at population level. The Malezi bora campaigns and the integrated outreaches supported by Save the Children have helped improve the immunization coverage. These strategies should continue to be supported to keep the coverage high and should also be used to improve the micronutrient supplementation coverage. Vitamin A supplementation was suboptimal especially for the group above the age of 12 months (post immunization) reported at 38%. Deworming and Iron Folate supplementation was also low reported at 37% and 47% respectively. Worst however was Zinc in the management of diarrhoea which was only reported by 1.1% of all the respondents who reported to have had diarrhoea two weeks prior to the survey. This was due to their no being any deliberate effort in the promotion of the same and this is something that should be done in future with the adoption of the HINI strategy Infant and Young Child Feeding (IYCF) Infant and young child feeding is a continuum of critical nutrition and health practices that begin during pregnancy and continue through at least the first two years of life. The sharpest increase in malnutrition occurs between 6 and 24 months of age, the time when children grow most rapidly and are introduced to other foods in addition to breast milk.appropriate IYCF practices include timely initiation of breastfeeding within 1 hour of birth, exclusive breastfeeding for the first 6 months, complementary feeding after 6 months with continued breastfeeding upto 2 years, and improved feeding during and after illness. In this survey, the IYCF practices were considered to be suboptimal and likely to contribute to the high malnutrition rates Timely initiation of breastfeeding: This relates to putting an infant to the breast within one hour of birth. Of the 332 children aged 6-23 in the survey, 286 (86%) reported to have put their infants on the breast within one hour of birth as shown in the figure below; Table11: Proportion of children 0-23 months put to the breast within 1 hour of birth 34

35 100.0% 90.0% 80.0% 70.0% 60.0% 86.1% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Immediately (within 1 hr) How soon the baby was put on the breast 10.8% Within first day 2.1% 0.6% 0.3% Within first 3 After 3 days Don t Know days Percent Exclusive Breastfeeding: Exclusive breastfeeding was reported at 51% within the recommended HINI targets of 50%. The rates were however slightly higher in girls than in boys at 55% and 48% respectively. Table12: proportion of children exclusively breastfed Exclusive breast feeding rates Mnths Male Female EBF HINI Minimum Dietary Diversity Dietary diversity was less than optimal with the worst being minimum dietary diversity for 6-23 months with only 39% reporting to eating food from more then three food groups as shown below. Table13: Minimum dietary diversity (n=285) 35

36 6-23 months > 3 food groups 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 6-23months Males 6-23 Females 6-23 F>3+ FGPS Minimum meal frequency Minimum meal frequency was below the recommended HINI standards of 80%. For the group between 6-8 months the indicators were slightly better with the feeding reported at 70%. The lowest rates were reported for the 6-23 months non breastfed infants which was reported at 60% Table14: Minimum meal times for breastfed children 6-8 months (n=20) 6-8 months BF fed 2 times a day months Males 6-8 Females BF F>2+ Times Table15: Minimum meal times for breastfed children 9-23 months (n=133) 36

37 9-23 Months breast fed children 3+ times months Males 9-23 Females BF F>3+ Times Table16: Minimum meal times for Non breastfed children 6-23 months (n=130) Meal frequency NBF 6-23 months 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 60.0% 31.0% 29.0% 6-23 months Males 6-23 Females NBF F>4+ Times 4.4. Water Sanitation and hygiene Main water source The main sources of water for a majority of the population were borehole(33.9%),unprotected wells (29%), and private and public dams (18.3%). A few of the households got water from protected wells and water taps as shown below; Table17: Main current water sources 37

38 Main Source of Water Percentage 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 6.3% 33.9% 29.1% 7.3% 4.9% 18.3% Percent Source of Water Water treatment Though quite a numebr of the repondednts reported to having used water for unsafe sources (around 47%), most respondent did not do anything to their drinking water (94.3%). Chemical use in water treatment was reported by around 7% of the respondents as shown in the figure below; Table18: Treatment given to drinking water Water treatment Percentage 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 94.3% 1.9% 1.8% 6.6% 0.3% Percent Treatment Handwashing practices Around two thirds of the respondents reported to washing hands at the most critical times. However it is worth noting that most of them used water only(85%) as shown in figure 4.11 and 4.12 below; Table19: When hands were washed 38

39 When Hands were Washed Percentage 100.0% 75.0% 83.2% 66.6% 80.0% 60.0% 40.0% 20.0% 0.0% 47.1% 64.5% 10.0% Percent When Table20: what was used to clean hands What was used to clean Hands 100.0% 85.0% Percentage 80.0% 60.0% 40.0% 20.0% 47.5% 35.1% 0.4% Percent 0.0% Water only Water & soap Water & ash Others What was used for cleaning Access to toilet facilities Only 48% of the respondents reported to having access to a toilet facility( either own or neighbours). This was mainly reported in the urban areas with the rural areas reported to using bush.this indicates poor human waste disposal methods that have the potential to contaminate the open water sources leading to diarrhoea and other water borne diseases. 5. Conclusions 39