Mathare Sentinel Surveillance Report, April 2009 SUMMARY OF KEY FINDINGS Compared to the January round of surveillance result, the GAM prevalence rate for Mathare in April, based on LQAS decision rule, was <1 which is considered as acceptable or normal. The point estimate also indicates rates of acute malnutrition below 1. Inadequate breastfeeding and weaning practices, insufficient hygiene and sanitation facilities continue to be the main vulnerability factors. The three most common childhood illnesses include fever, cough or difficult breathing; diarrhoea; and fever with chills like malaria with no significant change from the January surveillance result. Based on the 12 food groups the mean diet diversity score was 6.4 in January and 6.3 in April with very low proportion of households consuming eggs, fish and meat, respectively about 8%, 17% and 21% in January and 9%, 21% and 18% in April. 1. INTRODUCTION An estimated 5.7 million or about 48% of the 12 million urban population of Kenya is believed to reside in slums or informal settlements 1. Urban food insecurity has become a growing humanitarian problem requiring close monitoring. Building on the experience it has developed since 2005 in monitoring the nutritional and food security situation in the North Eastern Province through annual nutritional surveys, ACF is implementing Food Security and Nutrition Surveillance system in Mathare, the second biggest slum in Nairobi. With the existing level of poverty and food price increase witnessed since late 2007, acute malnutrition amongst children is expected to be a growing problem requiring close monitoring of nutritional status of children and key food security indicators in the slums. To monitor trends in malnutrition and its underlying causes, ACF with the Ministry of Health and Nairobi City Council implemented an integrated surveillance based on the Lot Quality Assurance Sampling (LQAS) methodology. The Mathare slum sentinel site was chosen as representative of the poorest urban areas of Nairobi and the second round of data collection was conducted from April 20-24, 2009. 2. METHODOLOGY The surveillance was conducted using Lot Quality Assurance Sampling (LQAS) with 33x6 design two-stage cluster sampling where Probability Proportional to population Size (PPS) was applied for cluster selection using ENA for SMART software and at the second stage compounds and households were selected using a modified system of EPI random walk method. The sample included 198 children and 198 households 2. Data on anthropometrics measurements of children 6-59 months of age as well as additional household level data on health, water, sanitation, hygiene, food security and livelihood information were collected. The results from the second round of the surveillance are presented in the following sections. 1 Kenya Food Security Update, GFSSG, January 2009 2 All children aged 6 to 59 months were measured in each of the surveyed household. Extra children were excluded randomly in the analysis to keep the 33x6 LQAS design 1
3. CHILD NUTRITIONAL STATUS The anthropometric data was analyzed using ENA for SMART and LQAS decision rule. The findings were then expressed in point estimates. The comparisons of the main indicators GAM and SAM of the January and April 09 results showed no significant difference as highlighted in the table below. For a threshold of GAM 1, the decision rule of 13 in LQAS methodology the site showed less than 13 children with WHZ -2 Z scores indicating that a 9 probability for the GAM rates are less than 1 which is significantly lower than WHO emergency threshold of 15% GAM Rate Table 1: Mathare Malnutrition Rates 3 Z-Score-NCHS January-09 4.0 % (0.9-7.1 C.I.) Apr-09 4.5% (1.6-7.5 C.I.) # of Children <-2 Z-Score 6 9 Decision Rule 1 1 SAM Rate 1.0 % (0.0-2.4 C.I.) 2. (0.1-3.9 C.I.) An estimated population of 118,000 people were covered in the sentinel site. With traditionally accepted ratio of of population being less than 5 years of age, 23,600 children are estimated to be living within Mathare sentinel site geographical area. When considering that moderate acute malnutrition increases the risk of death by a factor of 4, and severe acute malnutrition by a factor 10 4, it appears urgent to ensure a proper access to treatment for all acutely malnourished children. Factors related to poor child feeding and weaning practices, high levels of morbidity associated with poor environmental hygiene and inadequate hygiene practices compounded with low incomes could be some of the potential contributing factors to changes in GAM and SAM rate. 4. CHILD FEEDING AND HEALTH PRACTICES 4.1. Child Morbidity The percentage of caretakers whose children had been sick for the two weeks prior to the survey date was 5 and 49% for January and April respectively. Generally the top three diseases in order of prevalence include diarrhoea, fever cough or difficulty in breathing and fever with chills like malaria. Overall, there was a noticeable increase in April in the prevalence of diarrhoeal diseases which could be linked to poor hygiene and sanitation practices that was observed during the field data collection. Further analysis on health seeking behaviour, 79% and 75% of sampled households with sick child sought treatment in January and April respectively with majority from either private or public clinic. With more than 5 of the sampled households without mosquito nets in the two periods, this may explain the high prevalence of fever with chills like malaria coupled with poor environmental hygiene. 3 Results in brackets are point estimates at 95% confidence level 4 C. Prudhon, A. Briend, D. Laurier, M. H. N. Golden and J. Y. Mary, Comparison of Weight- and Height-based Indices for Assessing the Risk of Death in Severely Malnourished Children http://aje.oxfordjournals.org/cgi/content/abstract/144/2/116 2
Figure 1: Major Childhood Illnesses in the two-week before the survey % of households with sick child 35. 30. 25. 20. 15. 10. 5. 0. Jan09 April 09 Diarrhea Fever with chills like malaria Fever, cough, difficult in breathing 4.2. Exclusive Breastfeeding Exclusive breastfeeding during the first 6 months is very rare, reported by less than 1 of the sampled households. The initiation of breastfeeding practice was fairly good with majority of the mothers, 58% in January and 51% in April, with children less than 2 years reporting initiating within the first hour after delivery. Early introduction of complementary feeding is attributed to most of the mothers working all the day away from their children. The poor result on exclusive breastfeeding highlights the need for extended health promotion activities in the communities, with a special focus on care and IYCF practices. Shorter periods of exclusive breastfeeding and inadequate weaning practices are, indeed, recognised as significant factors contributing to morbidity and acute malnutrition amongst children. Figure 2: Introduction to complementary feeding 10 9 8 7 5 3 1 Jan-09 Apr-09 After six months 4-6 Months Less than four months 4.3. Measles Vaccination and Vitamin A Coverage Measles vaccination coverage is estimated at more than 8 verified by either a vaccination card or mother s recall. 7 of the children had received vitamin A supplements either once or more 3
in the last one year for both January and April 09. Although these rates are high, efforts still need to be made to ensure coverage of 9 (SPHERE standards) of measles vaccination, as it poses a risk of high mortality in cases of outbreak due to overcrowding in the slum area. Potential contributory factors to the inadequate coverage are poor health infrastructures in the slum, as well as high levels of migration in the population. Table 2: Measles vaccination and Vitamin A Coverage January-09 April-09 Measles Vaccination # % # % By card 84 45.4 78 39.4 According to Mother/Caretaker 81 43.8 84 42.4 Not Immunized 20 10.8 36 18.2 Total 185 100.0 198 100.0 January-09 April-09 Vitamin A # % # % Never Received 46 23.2 61 30.8 Once or more 152 76.8 137 69.2 Total 198 100.0 198 100.0 5. Water, Sanitation and Hygiene Practices 5.1. Water Sources and Use Sources of water for domestic use remained the same during the two periods with majority, over 9, accessing water from city council pipes. Normally, piped water from city council is chlorinated hence considered safe. The high rates of diarrhoea and vomiting in the slums can be associated with post contamination of water after fetching during storage and handling. The average per capita water consumption per day was 21.7 5 [20.2-23.3] and 19.9 [17.8-22.0] in January and April, respectively. It is generally above the 15 litres/person/day SPHERE standards. Concerning treatment of water before drinking, a majority of households, 66% and 67% in January and April respectively, reported nothing done to the water. Less than 3 of the households in both January and April reported boiling the water before drinking. Considering that the majority of households did nothing to the water before drinking and the predominantly unhygienic environment in the slum area, cross contamination of water after drawing from the pipes can be considered a significant risk factor for high prevalence of diarrhoeal diseases. 5.2. Hand Washing Practice An overwhelming majority, 97%, reported washing hands; after toilet about 77% and 96% and before eating about 82% and 94% in January and April, respectively. When asked about use of soap 76% and 67% of caretakers reported using soap when they wash their hands in January and April, respectively. There is a need for concerted efforts to reach 10 use of soap in hand washing for better hygiene practices. 5 Figures in bracket are 95% C.I. 4
Figure 3:% of households using soap for hand washing 10 9 8 7 5 3 1 Jan-09 Apr-09 Soap Soap when I can afford it Only water 5.3. Latrine Use Analysis of use of latrine facilities indicates that about 59% in January and 51% in April used neighbours or shared pit latrines, followed by public toilets, 34% and 41% in the same order. On the cleanliness of the toilet facilities, based on physical observation by the interviewers, about 55% in January and 46% in April were judged unclean based on presence of faeces on the slab. To improve on excreta disposal, behaviour change communication on proper human waste disposal should be strengthened. 5.4. Garbage disposal Data on garbage disposal was collected in April only and the result reveals that the majority of households (53 %) reported throwing their household garbage to the river, followed by throwing their garbage in an open field (28%). Figure 4: Propotion of households by different waste disposal methods 28% 4% 12% 3% 53% Nairobi city council Thrown into garbage pit Thrown in the open field Private firm/youth group Thrown into the river 5
6. Food Security 6.1. Sources of Food Purchase of food Items were main source of food in the slums. There is no significant change compare to the findings of January and March. Other important sources of food include food aid, gift and own production for a minority of households (Figure 5). Given the total dependence on markets, an increase in food prices or reduction in market supply of food commodities is likely to have a major impact on access to food. Figure 5 : First important source of food for households for the 30 days before the survey 10 8 Jan 09 April 09 Purchase Others 6.2. Income and Expenditure The three important sources of income in Mathare include daily labour/wage, own business and salary for 49%, 25% and 14%, respectively in April. There was no major difference in terms of sources of income between the two periods. Figure 6: Proportion of Households by Main Sources of Income 10 9 8 7 5 3 1 Others Salary Own Business Daily Labour/Wage Jan 09 April 09 6
The mean monthly income for the reference period was KSH 7,108 in January and 9,494 in April. This is translated to an average daily per capita income 6 of 54 KSH and 81KSH in that order, which was higher than normally expected in the slum. In order to see the income distribution, the data was analyzed by quartiles. The top 25% of the households accounted to close to 5 of the income while the bottom 25% of the households accounted to just 1 or less of the total income (Figure 6). It can be argued that the bottom 5 of the households constitutes the most vulnerable group. Figure 7: Share of Monthly Per Capita Income (PCI) by Quartile 60. 50. % of total PCI 40. 30. 20. Jan 09 April 09 10. 0. Q1 Q2 Q3 Q4 Income Quartile The average per capita daily expenditure was KSH 63 and 65 in January and April, respectively. In January expenditure was higher than income while in April the reverse was true. This could be due to the fact that the January data collection was right after Christmas when expenditures could have been higher than normal times such as in April. In terms of proportion, the three most important sources of expenditure include food, house rent and cooking fuel, accounting to 43%, 13% and 11% in January and 48%, 12% and 8.5% in April. 6.3. Dietary Diversity The dietary diversity was measured using the 12 main food groups consumed using 24 hours recall period. The mean dietary diversity score can be considered as medium, with a mean score of 6.4 food groups in January and 6.3 in April. The main food groups consumed by most households included cereals, sugar, fat/oil and vegetables. The consumption of eggs, fish and meat was low (Table 3). Table 3: Proportion of Households by Food Group Consumed January 09 (N=198) April 09 (N=198) Food Group N % N % Cereals 196 99.0 198 100.0 Roots or tubers 44 22.2 20 10.1 Any vegetables 167 84.3 169 85.4 Fruits 74 37.4 45 22.7 Eggs 15 7.6 18 9.1 6 The per capita income is estimated based on family size only and not converted into adult equivalent since no detailed demographic data were collected 7
Meat 41 20.7 35 17.7 Fish 34 17.2 42 21.2 Beans, peas, lentils, or nuts 57 28.8 60 30.3 Milk or milk product 133 67.2 91 46.0 Fat or oil 158 79.8 182 91.9 Sugar or honey 175 88.4 192 97.0 Other condiments (e.g. coffee, tea) 169 85.4 188 94.9 Mean Diversity Score 6.4 6.3 6.4. Use of Coping Strategies The three most commonly used coping strategies include reducing the size of the meals, purchasing food on credit from local vendors and skipping meals. There was no change in the use of the different coping strategies from January (Figure 8). However, these three coping mechanisms used by over 65% of the households indicate vulnerability of households to food insecurity and lower intakes of food. Figure 8: Household coping strategies for the 30 days before survey 10 8 Jan 09 April 09 Skipping meals Purchase food on credit Send children to eat with relatives Reducing meal size Borrow money from relatives Sale of productive assets 7. CONCLUSION AND RECOMMENDATIONS The GAM rate based on the LQAS decision rule and point estimate showed lower than 1 in both January and April. Such results were expected, as the access to health, safe water or diversified food being higher in Nairobi than in remote or rural regions. However, translated into a potential caseload of acutely malnourished children, it appears that the rates measured in Mathare are high enough to justify the development of an extended access to the treatment of acute malnutrition. Such access is not yet available. It also appears that hygiene and sanitation are largely inadequate in the slum and be a potential source for high levels of child morbidity. Such rates of morbidity could lead to high rates of acute malnutrition unless proper preventive measures are implemented. Immunization and access to health services also needs to be strengthened, as well as the provision of mosquito nets. 8
To address the escalating cost of food prices especially leafy vegetables in the urban slums, establishment of urban gardening to ease the burden will go long way in ensuring not only food security but also good nutritional status. Based on the results of January and April round of surveillance, the nutritional situation in Mathare slum was not yet alarming, but most indicators already show a concerning situation. Any deterioration, for instance, induced by food price increase could have a dramatic impact on the health status of the population, particularly on children. 9