THREE NUTRITIONAL ANTHROPOMETRIC SURVEYS FINAL REPORT MANDERA EAST AND WEST DISTRICTS, NORTH-EASTERN PROVINCE, KENYA

Transcription

1 THREE NUTRITIONAL ANTHROPOMETRIC SURVEYS FINAL REPORT MANDERA EAST AND WEST DISTRICTS, NORTH-EASTERN PROVINCE, KENYA 14 TH MARCH 9 TH APRIL, 2008 Christoph Andert, Nutrition Survey Manager Onesmus Muinde, Assistant Nutrition Coordinator Kenya Funded by

2 2 ACKNOWLEDGMENTS On behalf of Action Against Hunger USA (ACF-USA) the authors would like to express their deep gratitude to the Ministry of Health in Mandera district, for releasing two staff to participate in the survey. We would like to thank ACF-USA staff, particularly the management team in the four bases in Mandera, Malkamari, Banisa and Takaba for the preparation of the survey, logistics, personnel and administrative issues and fieldwork without which this survey would not have been possible. Furthermore, we thank all team members (measures, data recorders and team leaders) who were involved in ensuring the survey obtained good quality data. Thanks also to all the drivers who ensured timely movement of field staff. Special thanks to the chiefs of all the divisions and the elders of Mandera Central, Khalalio, Rhamu Dimtu, Malkamari, Banisa, Takaba and Dandu, for their support during the survey, and to the elders and some home visitors for their support during the survey. We finally like to say many thanks to the mothers and the fathers who pleasantly allowed the team to measure their children and patiently sat through the interviews and shared with the team valuable information. For the funding of the surveys Action Against Hunger USA thanks the Department for International Development (DFID).

3 3 LIST OF ABBREVIATIONS EXECUTIVE SUMMARY... 5 OBJECTIVES... 5 METHODOLOGY... 5 FIELD WORK... 6 RESULTS INTRODUCTION METHODOLOGY TYPE OF SURVEY AND SAMPLE SIZE DATA COLLECTION INDICATORS, GUIDELINES, AND FORMULA S USED FIELD WORK DATA ANALYSIS RESULTS OF THE ANTHROPOMETRIC SURVEY ANTHROPOMETRIC RESULTS BANISA, MALKAMARI AND RHAMU DIMTU DIVISIONS - SURVEY ANTHROPOMETRIC RESULTS TAKABA AND DANDU DIVISIONS - SURVEY ANTHROPOMETRIC RESULTS MANDERA CENTRAL AND KHALALIO DIVISIONS - SURVEY MEASLES VACCINATION COVERAGE HOUSEHOLD STATUS COMPOSITION OF THE HOUSEHOLDS RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY DISCUSSION AND CONCLUSION APPENDIX I B: SAMPLE SIZE AND CLUSTER DETERMINATION TAKABA AND DANDU I C: SAMPLE SIZE AND CLUSTER DETERMINATION MANDERA CENTRAL AND KHALALIO SURVEY... 35

4 4 List of abbreviations ACF CHW CMR EPI GAM GFD HH INGO MS MoH MUAC NCHS OTP SAM SD SFP SMART SPHERE SPSS TFC U5MR UK UNICEF USA WFH WFP WHO Action Contre la Faim, Action Against Hunger Community Health Worker Crude mortality rate, Crude death rate Expanded Programme on Immunisation Global acute malnutrition General food distribution Household International Non-Governmental Organisation Microsoft Ministry of Health Mid-upper arm circumference National Centre for Health Statistic Outpatient Treatment Programme Severe acute malnutrition Standard deviation Supplementary Feeding Programme Standardized Monitoring and Assessment of Relief and Transition Humanitarian Charter and Minimum Standards in Disaster Response Statistical Package for Social Science Therapeutic Feeding Centre Under-five mortality rate, Under-five death rate United Kingdom United Nations Children and Educational Fund United States of America Weight-for-Height World Food Programme of the United Nations World Health Organisation

5 5 1 Executive summary Mandera West and East districts are located in the North Eastern Province of Kenya. The total population size is estimated around 168,500. The districts have been facing perennial food insecurity as a result of extreme climates, characterized by a succession of drought and floods over the past years. In the mainly pastoralist dominated and arid region where the availability of and the access to water is a main concern, agricultural outcomes are extremely poor, leading to a lack of market for livestock and employment opportunities. Since the 2004/2006 droughts WFP, UNICEF and other nutrition INGOs have being providing relief food to communities in order to prevent adverse effects from malnutrition and rehabilitate the acutely malnourished population. Most people, in pastoral and marginal agricultural areas in particular rely heavily on relief food (maize rations and water) 1. Still, malnutrition rates remain well above the emergency level for the past decade. Since October 2004 Action Against Hunger (ACF-USA) has been present in Mandera district to assist communities to overcome the aftermath of drought, perennial food insecurity and water scarcity with selective feeding programmes (TFC, OTP and SFP), water & sanitation and health education programs in 8 divisions in Mandera East and West districts. In order to monitor the nutritional situation ACF-USA conducts nutrition surveys in these areas of operation each year before the long rains (Gu u/gan) starting in April. Three anthropometric nutrition surveys were implemented in Mandera East and West districts from March 14 th to April 9 th The geographical areas surveyed were similar to those assessed in 2007 as listed below. OBJECTIVES Survey 1: Banisa, Malkamari and Rhamu Dimtu Divisions Survey 2: Takaba and Dandu Divisions Survey 3: Mandera Central and Khalalio Divisions The objectives for each survey were: To evaluate the prevalence of malnutrition in children aged 6 to 59 months To evaluate the crude mortality rate and under five mortality rate among communities To evaluate the measles immunisation coverage of children aged 9 to 59 months METHODOLOGY Two-stage cluster sampling using SMART methodology was applied to randomly identify clusters with the probability of being selected proportional to the population size in each cluster. One extra cluster for Survey 1 and 2 and two extra clusters for Survey 3 were selected in order to ensure the necessary number of complete data sets. The sample for each survey was as follows: Survey 1: 37 clusters of 18 children below 5 years Survey 2: 36 clusters of 18 children below 5 years Survey 3: 36 clusters of 19 children below 5 years 1 Kenya Food Security Update October 9, 2006

6 6 Map 1 : Geographical locations of the three surveys The sampling frame covered all accessible villages in the selected divisions. At cluster level, households were randomly selected and surveyed using the EPI method. All children aged between 6 and 59 months of the same family, defined as a woman and her own and adopted children living the same household, were included in the survey for anthropometric measurements. A retrospective mortality survey over the past three months was undertaken alongside the anthropometric survey, using SMART methodology. Anthropometric and mortality data were analyzed using Nutrisurvey version October 2007 software. FIELD WORK The surveys were carried out by six teams, each team comprising four members: 1 team leader, 1 data collector and 2 measurers. 4 team leaders were ACF-USA s TFC and SFC staff and 2 team leaders were MoH staff. Team leaders and data collectors received 2.5-day intensive training in Mandera prior the start of the surveys. This training provided the theoretical background for team leaders and data collectors. Measurers were recruited for each survey separately with clan balancing ensuring that all communities are equally represented in the survey teams. Measurers received a 1-day training including theoretical and practical components. Team leaders and data collectors joined the practical training to form the teams in each survey area anew. This training included the standardization test. Provided the fact that Survey 1 and 2 were conducted in similar living conditions only one pilot was deemed necessary. One further pilot was conducted for the urban setting of Mandera town. All teams were closely supervised during their field work throughout the whole survey time by the expat Nutrition Survey Manager and the Assistant Medical Nutrition Coordinator. The surveys were carried out from March 14 th to April 9 th The schedule is detailed below: Survey 1: 14 th 21 st March 2008, included 2 days of traveling and training Survey 2: 25 th 30 th March 2008 Survey 3: 4 th 9 th April 2008

7 7 RESULTS Table 1, 2 and 3 below provide a summary of the findings of the three surveys. Table 1 Survey 1 - Banisa, Malkamari and Rhamu Dimtu Divisions INDEX INDICATOR RESULTS 2 (n=677) NCHS WHO MUAC Z- scores % Median Z-scores % Median Height> 65 cm Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H < -3 z and/or oedema Global Acute Malnutrition W/H < 80% and/or oedema Severe Acute Malnutrition W/H < 70% and/or oedema Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H < -3 z and/or oedema Global Acute Malnutrition W/H < 80% and/or oedema Severe Acute Malnutrition W/H < 70% and/or oedema 21.6% [17.8%-25.3%] 1.0% [0.3% - 1.8%] 9.7% [7.2% %] 0.1% [0.1% - 0.4%] 21.3% [17.7% %] 3.4% [1.9% - 4.9% ] 5.3% [3.5% - 7.1%] 0.0% [0.0% - 0.0%] Global Acute Malnutrition MUAC (<120) 2.4% Severe Acute Malnutrition MUAC (<110) 0.2% Total crude retrospective mortality (last 3 months) /10,000/day Under five crude retrospective mortality /10,000/day 0.43 [ ] 1.57 [ ] Measles immunization coverage (N=627 children 9 months old) By card According to caretaker 3 Not immunized 13.9% 57.7% 28.4% 2 Results in bracket are at 95% confidence intervals. 3 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

8 8 Table 2 Survey 2 - Takaba and Dandu Divisions INDEX INDICATOR RESULTS 4 (n=700) NCHS WHO MUAC Z- scores % Median Z-scores % Median Height> 65 cm Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H < -3 z and/or oedema Global Acute Malnutrition W/H < 80% and/or oedema Severe Acute Malnutrition W/H < 70% and/or oedema Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H < -3 z and/or oedema Global Acute Malnutrition W/H < 80% and/or oedema Severe Acute Malnutrition W/H < 70% and/or oedema 20.3 % [15.6%-25.0%] 1.1 % [0.2%- 2.1%] 8.1 % [5.3% %] 0.0 % [0.0% - 0.0%] 21.7 % [17.0%-26.5%] 2.3 % [0.8%- 3.8%] 5.0 % [2.9% - 7.1%] 0.0 % [0.0% - 0.0%] Global Acute Malnutrition MUAC (<120) 1.3 % Severe Acute Malnutrition MUAC (<110) 0.1 % Total crude retrospective mortality (last 3 months) /10,000/day Under five crude retrospective mortality /10,000/day 0.48 [ ] 1.09 [ ] Measles immunization coverage (N=659 children 9 months old) By card According to caretaker 5 Not immunized 15.9 % 54.2 % 29.9 % 4 Results in bracket are at 95% confidence intervals. 5 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

9 9 Table 3 Survey 3 - Mandera Central and Khalalio Divisions INDEX INDICATOR RESULTS 6 (n=699) NCHS WHO MUAC Z- scores % Median Z-scores % Median Height> 65 cm Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H < -3 z and/or oedema Global Acute Malnutrition W/H < 80% and/or oedema Severe Acute Malnutrition W/H < 70% and/or oedema Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H < -3 z and/or oedema Global Acute Malnutrition W/H < 80% and/or oedema Severe Acute Malnutrition W/H < 70% and/or oedema 27.9% [24.0% %] 2.0% [1.1% - 2.9%] 14.3% [11.6% %] 0.0% [0.0% - 0.0%] 27.2% [23.4% %] 4.7% [3.2% - 6.2%] 8.2% [6.1% %] 0.0% [0.0% - 0.0%] Global Acute Malnutrition MUAC (<120) 0.9% Severe Acute Malnutrition MUAC (<110) 0.0% Total crude retrospective mortality (last 3 months) /10,000/day Under five crude retrospective mortality /10,000/day 0.31 [ ] 0.40 [ ] Measles immunization coverage (N=665 children 9 months old) By card According to caretaker 7 Not immunized 22.4% 73.1% 4.5% The prevalence of global acute malnutrition has increased in all Mandera divisions compared to last year s (see table 4 and Fig. 7). The increase in the Western divisions of Malkamari, Banisa and Rhamu Dimtu; Takaba and Dandu is marginal with 2.9% and 2.8%, respectively. The difference is statistical significant only for Takaba and Dandu divisions (p < 0.01). Mandera Central, Khalalio divisions showed a significant increase of 7% compared to last year (p < 0.001). Since 2005 all divisions showed global acute malnutrition rates well above emergency level. Severe acute malnutrition has decreased in Banisa, Malkamari, Rhamu Dimtu and Takaba, Dandu compared with However, Mandera Central, Khalalio survey showed an increase in SAM. This survey was done at a more advanced time of the year when compared with previous year s surveys which possible have affected malnutrition rates to slightly increase. Compared to last year, significantly more people where found to be on the move (people left households or empty households) in pursuit of water since first rains of the Gu u/gan rains in March/April set in during the time of the survey field work. Retrospective mortality rates (CMR and U5MR) showed to be below their respective alarming levels, and are therefore acceptable. Measles vaccination coverage (confirmed by card) has increased compared to last year. It is, however, still extremely low, which is a problem for the prevention of epidemics, and also reveals a poor health access. Results of this survey are in line with results released by the INGOs Islamic Relief and Save the Children UK for neighbouring divisions of Mandera East and West districts in February and March Acute malnutrition in Mandera district is wide spread and above the international recognized emergency threshold of 15%. The humanitarian intervention in response to the drought in 2004 brought down malnutrition 6 Results in bracket are at 95% confidence intervals. 7 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

10 10 rates in the operational area of ACF-USA which seems to be stabilized at pre-drought level 8. The significant deterioration of the nutrition situation in Mandera Central, Khalalio divisions is of concern and needs to be thoroughly investigated and addressed accordingly. Table 4 Trends of malnutrition in Mandera East and West Districts DIVISIONS Mar 2005 Feb 2006 Feb 2007 Apr 2008 Banisa, Malkamari and Rhamu Dimtu GAM SAM n/a n/a 23.6%* ( ) 2.4% ( ) 18.7% ( ) 1.7% ( ) 21.6% (17.8%-25.3%) 1.0% (0.3% - 1.8%) Takaba and Dandu GAM SAM n/a n/a 23.6%* ( ) 2.4% ( ) 17.5% ( ) 2.3% ( ) 20.3 % (15.6%-25.0%) 1.1 % (0.2%- 2.1%) Mandera Central and Khalalio GAM SAM 26.6% ( ) 3.5% ( ) 21.0% ( ) 2.1% ( ) 20.9% ( ) 1.2% ( ) 27.9% (24.0% %) 2.0% (1.1% - 2.9%) * Geographical areas surveyed in the 2006 survey is not the same than the one in 2008: comparison cannot be done as such, but the rates of 2006 are given here as indictor. The current state of nutrition status can be explained by the following factors. Lack of access to adequate health care The two surveyed districts are situated in an environment of high prevalence of water borne diseases and malaria which especially in rainy season results in high incidence of morbidities. Though the population density in the districts is low, the number of health care facilities is limited and the latter are difficult to reach (lack of movement means and infrastructures), thus, preventing most of the population from easy access to basic medical care. Existing mobile clinics to rural places run by the MoH are infrequent and prone to delay or cancellation when resources are short. This leads to sick individuals in the communities lacking treatment, which further affects their health and nutrition status. Furthermore, national health care facilities are understaffed (only one nurse present in most of the health facilities); due to the perceived hardship posting in the North-Eastern Province, the motivation is low, but the number of patients high. Lack of safe drinking water and sanitation facilities Availability and accessibility of potable water is a major problem in larger Mandera region. Mandera East is endowed with accessibility of water from boreholes, River Daua, swallow wells and rain water stored in underground tanks. In Mandera West especially Malkamari, Banisa, Takaba and Dandu Division s availability of water is a challenge. The last years October to December long rains were poor hence not enough water collected in the available earth pans and underground tanks. Ministry of Water and Arid lands have been doing water trucking in the region since the beginning of the year. Water trucking can not provide enough water for the whole population. In some of the villages surveyed, water was observed to be rationed. Households received 5 liters per household per day at the period of survey, way below SPHERE minimum standards of 15 liters per day. According to A KAP survey done in March by ACF, analysis of water accessibility by settlement reveals that 18.1% of Agro pastoralist communities and only 17.4% of the urban/peri urban dwellers are able to access water at less than 500 meters away; 40.1% of the people in Agro Pastoralist communities and 22% in Urban/Peri Urban areas access water from more than 500 meters away. 76.0% of the Agro Pastoralist spends 8 Since 1998 all nutrition surveys conducted in the wider Mandera area showed GAM of well above the 15% emergency threshold.

11 11 more than 15 minutes queuing for water compared to 21.6% of the urban /peri urban communities. The quality of water in the area also questionable as water in the earth pans was seen to be turbid and some of the underground tanks were not well protected resulting in contamination by dead birds and other objects. Hygiene and sanitation in the region has improved as some of the communities have constructed toilets 54.1% of the households had latrines 9 but still many of the households dispose their human waste openly; animals share the same source of water and once dead are left on the ground to decay. The lack of water challenges a lot hygiene and sanitation practices as this can be wholly achieved only with the availability of sufficient water. Inadequate hygienic and sanitary practices lead to waterborne diseases. Many diarrhea cases were reported in the region which could be attributed to poor hygiene and sanitation. Persistent food insecurity The food security situation has not changed since last year and still of great concern. Communities are primarily pastoralist with minimal agricultural activities mainly in Mandera East along the Daua River. Scanty rainfall and floods observed for the several past years led to poor agricultural production and pasture growth, which exposes the communities to perennial food shortage. Without other income opportunities for most of the inhabitants of Mandera East and West people rely solely on the well-being of their herds and are very vulnerable at times of delayed or bad rains. As in 2005 a drought hit the country people experienced major loss of livestock resulting in a sharp decline of food security with subsequent increase of acute malnutrition. Since then WFP/COCOP has increased the already in place relief food distributions for the majority of the communities who up to now rely on this monthly donation for enhancing their food security. Lack of knowledge on nutrition/malnutrition and health issues Nutrition and health education is poorly developed among the majority of the population. Adequate breastfeeding practices are hardly followed and knowledge about suitable weaning foods and energy/proteinrich diets for growing infants and children is scarce. A recent vulnerability analysis of our beneficiaries done by ACF in Mandera revealed that 68.9% mothers gave other food than breast milk within 2 weeks of birth; 47.9% said they did so because of traditions. Therefore, food is of poor quality predisposing children to a high risk of malnutrition as they lack essential nutrients required for their optimal growth. Also, understanding and concerns about malnutrition and its consequences among mothers/caretakers is poorly developed. In an environment which is suffering from a chronic malnutrition emergency for many decades now people seemed to have adjusted to the unhealthy living situation with all its negative consequences. Poor child care and feeding practices Child care remains wanting in the region, since mothers/caretakers do have heavy workload in their daily life. Most mothers are involved in taking care of livestock, fetching water and firewood, thus leaving young children at home unattended. This ultimately leads to poor breastfeeding for infants and younger children and reduces the number of meals and/or amount of food taken during the day. Communities are nomads and roam in search for grazing lands and water for their herds hence, this reduces the availability of animal milk for children at times when men and young adults travel to grazing lands leaving children and women at home. Following are the recommendations in order to improve the nutrition situation of the surveyed communities: The consecutive shocks (recurrent droughts, measures restraining livestock marketing, limited livelihoods restoration...) quaked this agro-pastoralist population relying mostly on resources becoming scarce. Thus, they have progressively led them to an extremely fragile situation of food insecurity. Solutions to malnutrition in that context definitely lie in an integrated approach where a better therapeutic management of acute malnutrition, a more considered approach of the population in terms of health education should be combined. An increased and adequate access to water in term of quantity and quality to agropastoralist population settling more and more should be comprehensively developed. 9 KAP survey March 2008 by ACF

12 12 In the light of these figures, malnutrition issue should not any more be considered as an isolated component otherwise any success linked to punctual interventions might not sustain unless the roots of the problem are clearly identified and thoroughly addressed. Health and nutrition Implement a relief response (blanket feeding with use of RUTF as a result of high GAM rates for children below 3 years and targeted SFP for children between 3 and 5 years) to the current nutritional situation in order to prevent further deterioration (increase of SAM and mortality): o Ensure adapted access to treatment for severely and moderately malnourished children o Adapted comprehensive support for most vulnerable households Strengthen community screening/active case finding through CHWs in all operational areas in parallel with the development of comprehensive community mobilization activities. Integrate nutrition treatment activities in the existing health facilities to ensure sustainability in the long run Capacity-build MoH staff in the district on the treatment of malnourished children Advocate for regular EPI campaigns to ensure that all the children are vaccinated against childhood diseases Water and Sanitation Improve accessibility to water by constructing/rehabilitating earth pans and water storage tanks in the Mandera West districts Improve the water quality in the earth pans by introducing cheap methods to filter water that are affordable and sustainable by the community at the household level. Expand sanitation programmes such as water protection, education and safe human waste disposal. Health education Continue with a district wide awareness campaign to inform communities about symptoms, treatment and health risks of acute malnutrition focused on children and pregnant and lactating women Continue nutrition education activities in the districts, focusing on improving the quality of food prepared from locally available foods as well as doing cooking demonstrations Institute an elaborate program on the promotion of infant care practices on much emphasis on breastfeeding and weaning. Continue health education programmes in the communities, schools and other institutions to improve hygiene and sanitation practices; include nutrition/malnutrition aspects in all health education session Food Security Device ways of enhancing food security of pastoralist communities, especially improving grazing lands, establishing markets for livestock and crop cultivation along the rivers Improve small scale irrigation for crop cultivation along the Daua River Assess other opportunities for income generating activities among local communities

13 13 2 INTRODUCTION Mandera East and Mandera West Districts are two of the three newly formed districts derived from the formally Mandera district in the North-Eastern Province of Kenya bordering Ethiopia to the north and Somalia to the east. The capital of Mandera East and West are Mandera Town and Takaba, respectively. Together with Mandera Central District the population is estimated at 250, inhabiting an area of 26,474 km 2 of arid land spotted with low-lying rock hills. To the north there is the seasonal river Daua which forms the border to Ethiopia and serves as a natural water supply during rainy season. The two districts are mainly populated by pastoralist communities. About 15% of the population who live along the river is agro-pastoralist with some access to irrigation.the prominent ethnic group is Somali-Muslim. The ethnic group is, however, not homogenous, but a grouping of broad clan federations divided by language and clan conflicts that flare up from time to time. The major clans living in Mandera East district are Murle, Dogodia, Gare, and Corner; in Mandera West district are Gare and Dogodias clans the major inhabitants. The rainfall pattern in the districts is bimodal. Long and short rains are experienced from March/April to June and September/October to December, respectively. Average annual rainfall is a low 255 mm and temperatures ranging from 24 0 C to 42 0 C 11. As a result of the climate extremities and the El Niño phenomenon the area has been victim of droughts and floods for the last decades. Agricultural activities are quite limited; except for the communities living along the seasonal Daua River, most of the population depends entirely on pastoral activities (keeping camels, cattle, goats and sheep). The weather conditions and lack of employment opportunities have confined communities to humanitarian assistance for decades as most of the people are poor and cannot afford to buy food for their own. The humanitarian crisis worsened in December 2005 when drought hit the region resulting in major loss of livestock and high rates of malnutrition. Furthermore, floods hit the region in December 2006 triggering waterborne diseases which deteriorated the heath and nutrition status of the population even further. From December 2006 to mid 2007 Rift Valley Fever led to a ban of livestock sales in the country making residents of the North-east most vulnerable to malnutrition as most of them depend on livestock as the only source of livelihood. The availability of and the access to safe drinking water is of major concern in the region especially in Mandera West where many settlements entirely rely on water trucking during the dry season. Food insecurity and water scarcity in the region has lead to humanitarian crisis with aid agencies such as WFP, UNICEF, Action Against Hunger - USA, Islamic Relief, Save the Children UK implementing health, water and nutrition programmes to improve the quality of life and prevent mortality in assisted communities. Action Against Hunger - USA has being implementing nutrition, hygiene and water/sanitation programmes in Mandera East district since October Intervention in Mandera West started in METHODOLOGY 3.1 Type of Survey and Sample Size Two-stage cluster sampling using SMART methodology was applied to randomly identify clusters with the probability of being selected proportional to the population size in each cluster. Therefore, population data of all accessible settlements in the survey area was taken from Arid Resources Management (ALRMP), Kenya, 2005 and divided by administrative boundaries according to the three survey areas.the geographical units and their respective population was then entered into Nutrisurvey for SMART software October 2007 for cluster selection. One extra cluster for Survey 1 and 2, and two extra clusters for Survey 3 were selected in order to ensure the necessary number of complete data sets. The total population for all accessible villages in the different surveys is estimated as following: census 11 Mandera District KFSG short rains assessment 2008 report 4 th - 8 th February 2008

14 14 Survey 1 Banisa, Malkamari and Rhamu Dimtu Divisions.72,848 Survey 2 Takaba and Dandu Divisions.30,138 Survey 3 Mandera Central and Khalalio Divisions..65,294 At the first stage, the sample size was determined by entering necessary information into the Nutrisurvey software for both anthropometric and mortality surveys. The information included estimated population sizes, estimated prevalence rates of mortality and malnutrition, the desired precision and design effect. Survey 1 Banisa, Malkamari and Rhamu Dimtu Divisions sample size calculation Using a malnutrition prevalence of 24% based on previous surveys with a precision of 4.7%, a design effect of 2, a sample size of 621 children was obtained. In the mortality session an estimated prevalence of 0.6, a desired precision of 0.4, a design effect of 2 and 85 days for recall period resulted in a sample size of 3,296. A buffer of 5% in sample size was included in order to compensate for missing data, thus, resulting in a sample size of 655 children in the anthropometric survey and 3,461 for the mortality. Given the operational circumstances and the fact that one cluster needed to be finished in one working day, 18 children aged 6-59 months were estimated to be measured in one cluster which yielded in a total of 36 clusters (655/18). For the mortality session 95 people present at the time of the survey were included for each cluster (3,461/36 clusters). One extra cluster was included to balance out a disproportion of population in the nomadic setting of North-east Kenya. See appendix I (A) Survey 2 Takaba and Dandu Divisions sample size calculation Using a malnutrition prevalence of 24% based on previous surveys with a precision of 4.7% a design effect of 2, a sample size of 603 children was obtained. In the mortality session an estimated prevalence of 0.6, a desired precision of 0.4, a design effect of 2 and 96 days for recall period resulted in a sample size of 2,843. A buffer of 5% in sample size was included in order to compensate for missing data, thus, resulting in a sample size of 633 children in the anthropometric survey and 2,985 for the mortality. Given the operational circumstances and the fact that one cluster needed to be finished in one working day, 18 children aged 6-59 months were estimated to be measured in one cluster which yielded in a total of 35 clusters (633/18). For the mortality session 85 people present at the time of the survey were included for each cluster (2,985/35 clusters). One extra cluster was included to make balance out a disproportion of population in the nomadic setting of North-east Kenya. See Appendix I (B) Survey 3 Mandera central and Khalalio Division Sample size calculation Using a malnutrition prevalence of 24% based on previous surveys with a precision of 4.7% a design effect of 2, a sample size of 619 children was obtained. In the mortality session an estimated prevalence of 0.6, a desired precision of 0.4, a design effect of 2 and 97 days for recall period resulted in a sample size of 3,746. A buffer of 5% in sample size was included in order to compensate for missing data, thus, resulting in a sample size of 650 children in the anthropometric survey and 3,933 for the mortality. Given the operational circumstances and the fact that one cluster needed to be finished in one working day, 19 children aged 6-59 months were estimated to be measured in one cluster which yielded in a total of 34 clusters (650/19). For the mortality session 115 people present at the time of the survey were included for each cluster (3,933/34 clusters). Two extra clusters were included to make balance out a disproportion of population in the nomadic setting of North-east Kenya. See appendix I (C) At the second stage, selection of households to be visited in each cluster was done using EPI method. Teams were led to the centre of the cluster by a village representative randomly choosing the direction to head for by spinning a pen. The team then walked in the direction indicated by the pen till the edge of the village or cluster boundary was reached. At the edge of the village/cluster the pen was spun again, until it pointed into the body of the village/cluster. The team then walked along this second line counting each house on the way. Using simple table of random number, the first house to be visited was selected at random by drawing a number between one and the number of households counted when walking. The second house and each following were taken by proximity, always choosing the houses on the right hand when standing with the back to the main door. If several families were found to be living in the same compound, all families were counted and families then

15 15 randomly choose by random number table. One family was chosen if 9 or less families were living in the compound. Two families were chosen if 10 or more families were found to inhabit the compound. In the selected household, all children aged 6-59 months in were included in the nutritional survey. If there was more than one wife/caretaker in the household 12, each wife was considered separately. If there were no children in a household, the house remained a part of the sample that contributed zero children to the nutritional part of the survey. The household was recorded on the nutritional data sheet as having no eligible children. The mortality questionnaire was administered to all households that were selected with the above mentioned methodology. 3.2 Data Collection Measurers and data collectors were subjected to a standardization test to ascertain their capability in taking accurate and precise measurements, so as to minimize errors during data collection. Anthropometrical survey For each eligible child aged 6-59 months, information was collected during the anthropometric survey using an anthropometric questionnaire. The information included (See appendix). Age: determined only with the help of a local calendar of events (See appendix) Sex: recorded as m for male and f for female Weight: Children were weighed to the nearest 100 g with a Salter Hanging Scale of 25 kg. All scales were checked daily by using a standard weight of 5 kg and adjusted (to 0 with an empty weighing pant for boys or empty weighing pant plus standard dress for girls) before each measurement. Boys were measured undressed. Girls were undressed and redressed with a standard dress before measuring the weight. If the caretaker refused to have the child weighed by the above describe methodology child s own cloth was used to adjust the scale to zero. The child was then redressed to be weighed. Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm were measured lying down, while those greater than or equal to 85cm were measured standing up. Mid-Upper Arm Circumference: MUAC was measured in cm at mid-point of left upper arm (between olecranon and the acromion process) to the nearest 0.1 cm with a non-stretchable tape. Bilateral Oedema: assessed by the application of moderate thumb pressure for at least 3 seconds to both feet (upper side). Only children with bilateral oedema were recorded as having nutritional oedema. Measles vaccination: Measles vaccination status for children aged 9-59 months was copied from their vaccination cards. If no card was available at the time of the survey, the caretaker was asked if the child had been immunized against measles or not. For children with confirmed immunization (by date) on the vaccination card, the status was recorded as C (Card) otherwise as N (No). Oral confirmation without proof was recorded as M (Mother confirmed). N was also recorded if the child was less than 9 months old. Mortality survey Each family selected at random (even if there was no child aged 5-59 months), was asked to state all family members and indicate their age and sex. The family was then asked to indicate which of the listed family members were present now and at the beginning of the recall period, which members joined or left during the recall period, and whether there was any birth or death in the family during the recall period. Following are the dates which were chosen as the start of the recall period for each survey and the total recall time: Survey 1 19 th December 2007 (Eid Arafat celebration day) Survey 2 19 th December 2007 (Eid Arafat celebration day) Survey 3 27 th December 2007 (National Election day) total recall of 85 days total recall of 96 days total recall of 97 days 12 A household refers to a mother and her own or adopted children

16 Indicators, Guidelines, and Formula s Used Acute Malnutrition Weight for Height Index Acute malnutrition rates are estimated from the weight for height (WFH) index values combined with the presence of oedema. The WFH indices are expressed in both, Z-scores (standard deviation or SD score) and percentage of the median, according to both, NCHS 13 and WHO references 14. The complete analysis is, however, done with the NCHS reference. The expression in Z-scores has true statistical value and allows interstudy comparison. The percentage of the median, on the other hand, is commonly used to identify children eligible for admission to feeding programmes. Guidelines for the results expressed in Z-score: Severe acute malnutrition.wfh < -3 SD and/or existing bilateral oedema Moderate acute malnutrition.wfh < -2 SD and -3 SD and no oedema Global acute malnutrition..wfh < -2 SD and/or existing bilateral oedema Guidelines for the results expressed in percentage of median: Severe acute malnutrition.wfh < 70 % and/or existing bilateral oedema Moderate acute malnutrition.wfh < 80 % and 70 % and no oedema Global acute malnutrition..wfh < 80 % and/or existing bilateral oedema Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However, the mid-upper arm circumference is a useful tool for rapid screening of children at a higher risk of mortality. MUAC measurements are significant for children with a height of 65 cm or one year and above. The guidelines are as follows: MUAC < 110 mm MUAC 110 mm and <120 mm MUAC 120 mm and <125 mm MUAC 125 mm and <135 mm MUAC 135 mm severe acute malnutrition and high risk of mortality moderate acute malnutrition and moderate risk of mortality high risk of malnutrition moderate risk of malnutrition adequate nutritional statuses Mortality Mortality data was collected using Standardized Monitoring and Assessment of Relief (SMART). The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR is calculated using Nutrisurvey for SMART software for Emergency Nutrition Assessment. The formula below is applied: Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where: a = Number of recall days 15 b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period The result is expressed per 10,000-people / day. The thresholds are defined as follows 16 : 13 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, WHO reference, See chapter 3.2 for specific recall days used in each survey 16 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee s nutrition, ACC / SCN, Nov 95.

17 17 Crude Mortality Rate (CMR): Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day Under Five Mortality Rate (U5MR): Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day 3.4 Field Work The surveys were carried out by six teams, each team comprising four members: 1 team leader, 1 data collector and 2 measurers. 4 team leaders were ACF-USA s TFC and SFC staff and 2 team leaders were MoH staff. Team leaders and data collectors received 2.5-day intensive training in Mandera prior the start of the surveys. This training provided the theoretical background for team leaders and data collectors. Measurers were recruited for each survey separately with clan balancing ensuring that all communities are equally represented in the survey teams. Measurers received a 1-day training including theoretical and practical components. Team leaders and data collectors joined the practical training to form the teams in each survey area anew. This training included the standardization test. Provided the fact that Survey 1 and 2 were conducted in similar living conditions only one pilot was deemed necessary. One further pilot was conducted for the urban setting of Mandera town. All teams were closely supervised during their field work throughout the whole survey time by the Nutrition Survey Manager and the Assistant Medical Nutrition Coordinator. The three surveys (including training, data collection and travelling) were carried out in a time period of 32 days. 3.5 Data Analysis Data was entered on a daily basis into ENA database and analyzed for plausibility for immediate feedback to the field teams next morning. Data processing and analysis for both, anthropometric and mortality were carried out using Nutrisurvey for SMART software, October 2007 version with both, NCHS and WHO references. SPSS 10.0 and Epi 5 were used to perform Chi-square and t-test analysis. MS Excel was used to carry out analysis on MUAC, measles immunization coverage, and household composition. 4 RESULTS OF THE ANTHROPOMETRIC SURVEY 4.1 Anthropometric results Banisa, Malkamari and Rhamu Dimtu Divisions - Survey 1 A total of 688 children were included in the nutritional anthropometric survey but 11 children were excluded from the final analysis due to incoherence of data. Though a total of 677 children were included in the final analysis with 51.7% (n=350) of them being aged 6-29 months. One cluster had to be canceled half way through due to negative propaganda of one local who was upset of not being selected to work as measurer in the ACF - USA survey team. The team went to a close by village to finish the cluster Distribution by Age and Sex The distribution of the nutrition survey sample by sex and age group shows a total boy/girl sex ratio of 1.0 which is within the normal limits ( ). Similarly, sex ratio within the age groups indicates a normal distribution.

18 18 Table 5 Distribution by age and sex in Banisa, Malkamari and Rhamu Dimtu Divisions Age groups Boys Girls Total Sex (months) n % n % n % ratio Total Fig. 1 Distribution by age group and sex Distribution of Age and Sex in Banisa, Malkamari and Rhamu Dimtu Divisions, March/April Age groups in Months Boys Girls % -40% -20% 0% 20% 40% 60% Anthropometric Analysis Distribution of Acute Malnutrition in Z-Scores In the entire sample, the prevalence of global acute malnutrition was 21.6%, severe acute malnutrition 1.0%. There is no significant difference in the prevalence of malnutrition between boys and girls or children aged 6-29 months and those aged months (see Table 6).

19 19 Table 6 Weight for Height distribution by age groups in Z-scores Banisa, Malkamari and Rhamu Dimtu Divisions (NCHS Reference) Age groups (months) N Severe wasting (<-3 z-scores) Moderate wasting (>= -3 and <-2 z- scores) No wasting (> = -2 z scores) Oedema n % N % n % n % Total As shown in Table 7 below no cases of nutritional oedema were found in the surveyed population. Table 7 Weight for height vs. oedema in Banisa, Malkamari and Rhamu Dimtu Divisions (NCHS Reference) Oedema present Oedema absent <-3 z-scores >=-3 z-scores Marasmic kwashiorkor Kwashiorkor 0 (0.0 %) 0 (0.0 %) Marasmic Normal 146 (21.6 %) 531 (78.4 %) Fig. 2 shows the weight for height distribution curve of the survey sample in Z-scores compared to the NCHS reference population. The entire weight for height distribution curve of the sample is shifted to the left, with a mean Z-score of ± 0.80 which indicates a suboptimal nutrition status compared to the reference population (NCHS reference table). Fig. 2 Z-scores distribution Weight-for-Height, Banisa, Malkamari and Rhamu Divisions

20 20 Table 8 Global and Severe Acute Malnutrition in Z-score Global acute malnutrition Severe acute malnutrition NCHS Reference 21.6 % ( ) 1.0 % ( ) WHO Reference 21.3 % ( ) 3.4 % ( ) Distribution of Malnutrition in Percentage of the Median Table 9 Distribution of Weight/Height by age groups in percentage of the median in Banisa, Malkamari and Rhamu Dimtu Divisions (NCHS Reference) Age groups (months) N Severe wasting (< 70%) Moderate wasting (>= 70% and <80%) No wasting (> = 80%) Oedema N % n % n % n % Total Table 10 Global and Severe Acute Malnutrition in % of the median Global acute malnutrition Severe acute malnutrition Risk of Mortality: Children s MUAC NCHS Reference 9.7 % ( ) 0.1 % ( ) WHO Reference 5.3 % ( ) 0.0 % ( ) All children measured were included in the MUAC analysis (Table11). According to the MUAC of children from 65 cm and above, 0.3 % of the children were found to be severely malnourished, 2.4 % were under acute malnutrition criteria and 21.9 % were found at risk of malnutrition (>=120 and <135mm). Table 11 MUAC distribution in Banisa,,Malkamari and Rhamu Dimtu Divisions MUAC (mm) >= 65 cm to < 75 cm height >=75 to < 90 cm >=90 cm Total < % 0 0.0% 0 0.0% 2 0.3% 110<= MUAC< % 7 2.8% 1 0.3% % 120<= MUAC< % 9 3.6% 2 0.7% % 125<= MUAC < % % % % MUAC>= % % % % TOTAL % % % %

21 Anthropometric results Takaba and Dandu Divisions - Survey 2 A total of 700 children were included in the nutritional anthropometric survey, 52.1% (n=365) of them being aged 6-29 months. 4 children were excluded from the final analysis due to incoherence of data Distribution by Age and Sex The distribution of the nutrition survey sample by sex and age group shows a total boy/girl sex ratio of 0.9 which is within the normal limits ( ). Age groups and months showed a unusual high number of girls which might be due to migratory reasons since 45 children <5 years left the households during the last three months. Table 12 Distribution by age group and sex in Takaba and Dandu Divisions (NCHS Reference) Age groups Boys Girls Total Sex (months) n % n % n % ratio Total Fig. 3: Distribution by age and sex Distribution of Age and Sex Takaba and Dandu Divisions March/April Age groups in Months Boys Girls % -40% -20% 0% 20% 40% 60% Anthropometrics Analysis Distribution of Acute Malnutrition in Z-Scores In the entire sample, the prevalence of global acute malnutrition in Z-scores was 20.3%, and severe acute malnutrition 1.1% (Table 13). Compared to the 2007 survey this is a significant increase by 2.8% (p < 0.01). There is no significant difference in the prevalence of malnutrition between boys and girls. However, children aged months had a 1.62 times higher risk of malnutrition than children aged 6-29 months (p < 0.01).

22 22 Table 13 Weight for Height distribution by age groups in Z-score in Takaba and Dandu Divisions (NCHS Reference) Age groups (months) N Severe wasting (<-3 z-scores) Moderate wasting (>= -3 and <-2 z- scores) No wasting (> = -2 z scores) Oedema n % n % n % n % Total No case of nutritional oedema was found in the surveyed population (Table 14). Table 14 Weight for height vs. oedema Takaba and Dandu Divisions (NCHS Reference) Oedema present Oedema absent <-3 z-scores >=-3 z-scores Marasmic kwashiorkor Kwashiorkor 0 (0.0 %) 0 (0.0 %) Marasmic Normal 142 (20.3 %) 558 (79.7 %) Fig. 4 shows the weight for height distribution curve of the survey sample in Z-scores compared to the NCHS reference population. The mean Z-score is ± 0.82 which indicates a suboptimal nutrition status compared to the well-nourished US reference population. Fig. 4 Z-scores distribution Weight for height in Takaba and Dandu Divisions Table 15 Global and Severe Acute Malnutrition in Z-scores in Takaba and Dandu Divisions Global acute malnutrition Severe acute malnutrition NCHS Reference 20.3 % ( ) 1.1 % ( ) WHO Reference 21.7 % ( ) 2.3 % ( ) Distribution of Malnutrition in Percentage of the Median