WEST POKOT COUNTY

SMART SURVEYPRELIMINARY FINDINGS

MAY,2012

OBJECTIVES OF WEST POKOT SMART SURVEY

OVERAL OBJECTIVE: To determine the rates of acute malnutrition amongst children aged 6-59 months in West Pokot County.

Specific survey objectives Determine the prevalence of acute malnutrition in the children aged 6-59months. Determine the Crude and under five mortality rates of the entire population Determine the morbidity rates in children aged 0-59 months. Estimate the coverage of immunization (measles, OPV1&3), and micronutrient

supplementation amongst children aged 0-59 months. Estimate the coverage of women supplemented with iron folate for 90 days in their last

pregnancy Assess household food security, Maternal Child Health care and WASH practices. To develop capacity amongst focal government ministries and community members on

how to undertake SMART surveys

SURVEY AREA COVERED

The survey was conducted in 3 districts and 14 divisions across the county:

DISTRICTS: West Pokot, Central Pokot, and Pokot North DIVISIONS: Kapenguria, Kongelai, Sook, Chepararia, Lelan, Sigor, Tapach, Chesegon, Alale, Kacheliba, Kasei, Konyao, Kiwawa, & Batei

The identified areas had slight difference in their livelihood zones as follows;• West Pokot- Mixed Farming• Central Pokot- Agro-Pastoral• Pokot North- Pastoral

SURVEY FINDINGS: 39 villages were randomly sampled based on PPS. However, 10.0% of these were inaccessible prompting the team to move into the RC’s (4) as per SMART methodology guidelines. Design effect of 1.21 unveiled

SAMPLING DESIGN

TWO STAGE CLUSTER SAMPLING (PPS)

FIRST STAGE: Clusters selected using PPS sampling methodology Obtain population of the survey sites was obtained to the smallest geographical unit,

being a village. Enter data into the ENA software alongside the planning information. Based on the

desired precision, prevalence and design effect Cluster assignment proportion to population size.

SECOND STAGE-households/children: (12HH/cluster)through simple random sampling Obtain a list of HH from village elder Randomly select 12 households through simple random sampling

PLAUSIBILITY CHECK

INDICATOR SURVEY VALUE ACCEPTABLE VALUE/RANGE COMMENT

Digit preference - WEIGHT 2 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Good

Digit preference - HEIGHT 7 Acceptable

Design Effect W/H 1.21

Design effect Mortality1.0

WHZ ( Standard Deviation) 0.99 0.8 – 1.2 Good

WHZ (SKEWNESS)

0.09 If between minus 1 and plus 1, the distribution can be considered

symmetrical.

Symmetrical

WHZ (KURTOSIS)

- 0.20 If less than an absolute value of 1 the distribution can be considered as normal.

Normal distribution

PERCENTAGE OF FLAGS

WHZ: 0.2%, HAZ: 3.0 %, WAZ: 0.7 %

Less than 3% - 5% of the entire sample Acceptable range

AGE DISTRIBUTION (%)

Group 1: 06-17 months 24.8% 20% - 25% Within acceptable ranges. Recall (calendar of event) was used in 32.4% of the cases to estimate ages of

children

Group 2: 18-29 months 23.8% 20% - 25% Group 3: 30-41 months 22.3% 20% - 25% Group 4: 42-53 months 20.3% 20% - 25%

Group 5: 54-59 months 8.8% 10.0%

Plausibility check continued…. INDICATOR SURVEY VALUE ACCEPTABLE VALUE/RANGE INTERPRETATION/

COMMENT

Age ratio: (6-29): (30-59) MONTHS

0.95 The value should be around 1.0 Acceptable

SEX RATIO 1.17 0.8 – 1.2 ACCEPTABLE

SEX RATIO p VALUEp-value = 0.077 BOYS and GIRLS are equally

represented

OVERAL SURVEY QUALITY5.0 % 0-5 = Excellent; 5-10= Good EXCELLENT

POISSON DISTRIBUTION

GAM: ID=1.43

(p=0.041) SAM:

ID=1.43 (p=0.042

If the p value is between 0.05 and 0.95 the cases appear to be randomly distributed among the clusters, if ID is higher than 1

and p is less than 0.05 the cases are aggregated into certain cluster (there

appear to be pockets of cases). If this is the case for Oedema but not for WHZ then

aggregation of GAM and SAM cases is likely due to inclusion of oedematous cases in

GAM and SAM estimates.

Aggregation of GAM and SAM cases is likely due to inclusion of oedematous cases in GAM and SAM

estimates.

One confirmed oedema case reported in Naruoro, Alale. Case referred.

DEMOGRAPHIC CHARACTERISTICS

Demographic characteristics nTotal number of HH 459

Total household sample 2884

Total under five sample 616

Males 1461

Females 1443

Sex Ratio 1:1

PLW 276

MALNUTRITION RATE TRENDS

INDEX INDICATOR 2011 2012 Statistical significance

WHO 2006

GAM: W/H < -2 z and/or Oedema14.9%

(13.5 – 18.8)12.3 %

(9.3- 16.0) p =0.144

SAM: W/H < -3 z and/or Oedema2.3%

(1.3 – 4.2)1.5 %

(0.7 – 3.2)p =0.325

Prevalence of stunting: H/A <-2 37.5%(33.0 – 42.3)

43.2 %

(38.5 - 48.0)

p =0.086

Prevalence of underweight: W/A <-230.4%

(26.3- 34.9)36.1%

(31.6 – 40.9)

p =0.071

No statistical significance in malnutrition rates above when compared to 2011

NUTRITION STATUS BY MUAC

NUTRITIONAL STATUS BY MUAC2011

%2012

%

Prevalence Severe Acute Malnutrition (SAM): MUAC < 11.5 CM and/or Oedema

0.6 (0.1 - 2.5)

Prevalence Moderate Acute Malnutrition (MAM): MUAC ≥11.5 CM and <12.5CM

3.4 (1.8 - 6.2)

Prevalence of Global Acute Malnutrition (GAM): MUAC < 12.5 cm or edema

3.9 (2.2 - 6.8)

At risk MUAC ≥12.5 and <13.5 cm n=88 14.3 16.40

Nutrition Status of caregivers of <5 year old children

% of PLW n=237 70.1% of women with MUAC <21 cm n=17 7.2%of PLW with MUAC <21 cm n=15 6.3

NUTRITIONAL STATUS OF CAREGIVERS OF <5S

MORTALITY RESULTS

MORTALITY RATES WEST POKOT COUNTY

2010 2011 2012

Total CRUDE MORTALITY RATE (Number/10,000/day)

1.17( 0.5 – 1.79)

1.66 (0.9 – 3.04)

0.23%(0.11-0.49)

UNDER FIVE MORTALITY RATE (Number/10,000/day)

0.99 (0.7 – 1.28)

1.30 (0.84 – 1.98)

0.58%(0.19-1.78)

CAUSES OF DEATH IN 2012:

Main causes of death amongst adults: poisoning, mental problems, fever, cough, ARI

Main causes of death amongst children under five: fever, ARI, death at birth

GENERAL FINDINGS:Only 3 facilities (Kacheliba, Kapenguria and Sigor facilities have documented deaths)Deaths outside facility are rarely reported

Main cause of deaths in 2011 as per Nutrition survey were malaria, diarrhea and vomiting

MORBIDITY RATES AMONGST 0-59MONTHS; 2011-2012

72.1% of HH had children who had been sick two weeks to the survey

Short Rain Assessment 2012: West Pokot reported an increase in diarrhea and dysentery cases among children under five attributable to poor hygienic practices

Management of Diarrhea Disease (%)

21.5

1.5

6.2

1.5

30.8

36.7

18.4

0

5

10

15

20

25

30

35

40

ORS Home-made Sugar /Salt Soln

Home-made liquids

Zinc Others

2012

2011

Shortage in suppliesKEMSA kit

2011%

2012%

OPV 1: CARD 61.8 71.5

OPV 1: RECAL 31.1 24.9

OPV 3: CARD 57.4 64.4

OPV 3: RECAL 29.7 23.6

Immunization and Vitamin A supplementation coverage

AGE GROUP NO.OF TIMES RESULT 2012 (%)

6-11 (n=63) ONCE 41.2

12-59 (n=474)

ONCE 39.2

TWICE 27.0

THRICE 5.1

Defaulter rates seem to increase as the children grow older.

Vitamin A supplementation below target with most cases being reported in places like Naruoro, Narochichi, Chesikiro, Kamayech and Katuda villages

Issues reported during Malezi bora:

Planting season; Mothers have competing activities hindering attendance to medical services

Had to reach areas because of terrain and heavy rains

Poor documentation at facility level reported during brainstorming sessions

Attributed to supplementation during illness

MEASLES IMMUNIZATION COVERAGE

53.0 54.0

29.0 24.8

18.0 21.2

0%

20%

40%

60%

80%

100%

2011 2012

Comparison in Measles immunization status; 2011 and 2012

Not immunized Recal Card

No statistical difference

High Impact Nutrition Intervention INDICATORS

HINI INDICATORS2011

%2012

% % 2-5 years old children de-wormed twice a year 40.3 10.3 %<5s supplemented with zinc last time they had diarrhea 0.0 1.5 %of women supplemented with iron for 90 days in their last pregnancy 84.2 47.8

Iron out of stock for quite sometime, only folic availableCombined iron folate brought in February 2012DHIS record indicate a 1.0% coverage in iron supplementation in MAY 2012, documentation????

Not comparable as

indicator for last year was based on 1

year old

INFANT AND YOUNG CHILD FEEDING PRACTICES

INFANT AND YOUNG CHILD NUTRITION n 2012BREASTFEEDING PRACTICES

Early initiation of breastfeeding (within an hour) 21584.0

%

Exclusive breastfeeding rates (0-5 months) 2136.2

%MINIMUM DIETARY DIVERSITY

Proportion of infants aged 12-15 months fed on breast milk 4391.5

%

Proportion of infants aged 6-8 months receiving solid, semi solid or soft foods 28

87.5%

Proportion of breastfed children 6-23 months consuming ≥3 food groups 54

36.5%

Proportion of non breastfed children 6-23 months consuming ≥4 food groups 4

10.5%

Proportion of both breastfed and non breastfed children 6-23 months consuming ≥ 3 or ≥ 4 food groups respectively 56

23.9%

EBF & Dietary diversity score below target

IYCN Continued............

MINIMUM MEAL FREQUENCY

Proportion of breastfed children 6-8months and 6- 23 months having at least 2 meals and ≥ 3 meals a day respectively 13 7.2%

Proportion of non breastfed children 6-23 months having ≥4 meals a day 9 24.3%

Proportion of breastfed children 6-8 months, 6-23 months and non breastfed 6-23 months having ≥2, ≥3 and≥4 meals a day respectively 161 73.9%

SOURCES OF DRINKING WATER (%)SOURCES OF DRINKING WATER (%)

WASH

22.6

8.1

3.7

48.5

2.4

2.6

7.4

3.9

0 10 20 30 40 50 60

Tap water

Protected borehole

Protected spring

River

Unprotected borehole

Dam

Laga

Unprotected spring

Safe Sources

Unsafe (Majority)

WATER TREATMENT

31.5% Safe sources; 68.5% Unsafe sources

81.6

138.1

1.10

10

20

30

40

50

60

70

80

90

Don’t Treat Boiling Chemicals Other

31.5% Safe sources; 68.5% Unsafe sources

59.9

7.9

21.7

3.9 6.6

70.8

0

10

20

30

40

50

60

70

80

In the bushes,open defeacation

Neighbour or shared traditional

latrine

Own traditional pit latrine

Neghbours or shared ventilated

improved pit latrine

Own ventilated improved pit

latrine

2012

2011

ACCESS TO LATRINE

42 ODF VillagesCLTS trainings

HAND WASHING AT CRITICAL TIMES

53.5

62.9

95.4

66.2

0 20 40 60 80 100 120

After toilet

Before cooking

Before Eating

After taking children to the toilet

GENERAL HAND WASHING PRACTICES (%)

0 5 10 15 20 25 30 35 40 45

Only water

Soap

Inconsistent use of soap

Lopotwa/Siang (traditional herb)

Ashes

39

43.4

17

0.2

0.4

Households Mosquito bed net ownership and utilization

BEDNET OWNERSHIP 2011 (%) 2012 (%)

Households owning Mosquito nets 38.9 86

Households without Mosquito nets 61 14

BEDNET UTILIZATION 2011 (%)

2012 (%)

<5 Children 60.2 43.9

Adult Females 40.8

High ownership attributed to mass distribution in Sep-Oct 2011

High bed net ownership but low utilization. Observations during survey indicate that bed nets

•Used in grain store•Used to cage chicken from eating flowering beans/legumes•Making children’s undergarments

FSL: MAIN SOURCES OF LIVELIHOOD

83.3% of households own Livestock

18.4

43.4

7.4

12.7

8.3

4.4

5.6

0 10 20 30 40 50

Livestock herding

Crop production

Employed(salaried)

Daily /Wage labour

Small business/petty trade

Firewood /Charcoal

Other

HOUSEHOLD FOOD SOURCES

0 10 20 30 40 50 60 70 80 90

Own farm production

Own livestock products (milk,eggs)

Own livestock products (meat)

Purchase

Credit

Food Aid

Gift

Others

57.9

67.4

40.8

89.9

40.1

29.8

20

3.3

HOUSEHOLD DIETARY DIVERSITY SCORE (HDDS)

DIET DIVERSITY GROUPS 2012 (%)

Low Dietary Diversity (3 Food Groups) 45.2

Medium Dietary Diversity (4-5 Food Groups) 27.9

High Dietary Diversity (>6 Food groups) 27

Household Dietary Diversity by Food Groups

0

10

20

30

40

50

60

70

80

90

100 95

10

85.9

6.9 9.13.9 0.7

19.7

68.276.3

61.7

92.697.8

7

90

12.6 9.5 11.26.6

23.6

46

37.2 41.248.7

2011

2012

SUMMARY OF GENERAL FINDINGS

There is no significant difference in GAM 12.3 % (9.3-16.0) and SAM 1.5% (0.1-3.2) rates

There is no significant difference in the stunting 43.2% (38.5-48.0) and wasting levels 36.1% (31.6-40.9) amongst children aged 6-59 months .

There is a significant drop in mortality levels i.e. both crude rates 0.23 %(0.11-0.49) and amongst under-fives 0.58% (0.19-1.78)

There is a significant increase in diarrhoeal incidences (51.3%) Exclusive breast- feeding rates (36.2%) are below national target of 50

%. There is a slight increase in Zinc supplementation (1.5%) but below

national target of 50%. (KDHS Report 2008-9-0.0%) Iron supplementation amongst pregnant women (47.8%) noted a

significant decrease below national targets of 50%. Low Household Dietary Diversity (45.2%)

RECOMMENDATIONS FOR DISCUSSION

Finding Possible Causes Possible SolutionsNUTRITION

Stunting (43.2%) Low IYCN Practices (Low EBF rates & DDS)

Further investigations on IYCN practices,Strengthen the Community units, Support and strengthen MTMSGs

Low Vitamin A coverage (32.1%) Numerous hard to reach areas

Enhance social mobilization, support outreach servicesStrengthen the PULL system and facility systems

Zinc supplementation (1.5%) Erratic supplies,Iron-Folate supplementation (47.8%)

Erratic supplies, numerous hard to reach areas

Low Deworming (10.3%) Numerous hard to reach areas

Enhance social mobilization, support outreach services

Low Immunization Coverage (OPV 3 64.4%, Measles 54%)

Few refrigerators,Hard to reach areas

Enhance mass social mobilization, support outreach servicesprovide storage equipment(Cool boxes and refrigerators ) for facilities

Increase in Malaria incidences (31.5%)

Inappropriate use of mosquito nets, inadequate knowledge among community members

Increase awareness in order to change attitudes and practices

WASH Open defecation still predominant (59.9%)

Inadequate knowledgeLow latrine coverage

Strengthen CLTSUtilization of the community strategy to increase community awareness on hygiene practices

Increase in Diarrhoea Disease (51.3%)

Unsafe water sources, no treatment of water before use,open defecation,Inadequate knowledge on hygiene practices

FSL

Low HDDS (45.2%)

Poor quality seeds-poor harvest, fertilizer, Lack of appropriate storage practices

Provide agricultural extension services (appropriate farming techniques)

RECOMMENDATIONS Cont.........

LETS DISCUSS…………

.