1. MAKUENI COUNTY SMART SURVEY March,2012

2. Objective of MAKUENI SMART SURVEY  Determine the prevalence of acute malnutrition in children aged 6-59 months.  Determine the Crude and under five mortality rates amongst the population.  Determine the coverage of specific immunization and micronutrient supplementation amongst targeted groups.  To determine possible immediate and underlying causes of malnutrition to include health, food security and livelihood

3. Survey areas covered The survey covered three districts and five divisions namely: Kibwezi, Makindu, Kathonzweni districts and Kalawa, Nguu, Mulala, Malili, Kiou Divisions. These areas were identified based on similarity of livelihood zones (Marginalized mixed farming)

4. Map of the study area

5. 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 (11HH/cluster)- selected through simple random sampling  Obtain a list of HH from village elder  Identify sampling interval  Randomly select a starting point  Select 11 households through simple random sampling

6. PLAUSIBILITY CHECK INDICATORSURVEY VALUEACCEPTABLE VALUE/RANGEINTERPRETATION/ COMMENT Digit preference - WEIGHT 4(0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable) EXCELLENT Digit preference - HEIGHT 4EXCELLENT WHZ ( Standard Deviation) 0.980.8 – 1.2ACCEPTABLE WHZ (SKEWNESS) - 0.14If between minus 1 and plus 1, the distribution can be considered symmetrical. Symmetrical WHZ (KURTOSIS) - 0.18If less than an absolute value of 1 the distribution can be considered as normal. Normal distribution PERCENTAGE OF FLAGS WHZ: 0.6 %, HAZ: 2.0 %, WAZ: 0.6 % Less than 3% - 5% of the entire sampleAcceptable range AGE DISTRIBUTION (%) Group 1: 6-18 months 28.120% - 25% (Slight over representation )Recall (calendar of event) was used in some instances to estimate the ages of children 19.2% of ages were by recall Group 2: 19-29 months 19.920% - 25% Group 3: 30-41 months 21.720% - 25% Group 4: 42-53 months 21.320% - 25% Group 5: 54-59 months 9.0 10.0% Age ratio of 6-29 MONTHS to 30-59 MONTHS 0.92The value should be around 1.0ACCEPTABLE

7. Plausibility check continued…. INDICATORSURVEY VALUEACCEPTABLE VALUE/RANGEINTERPRETATION/ COMMENT SEX RATIO 1.080.8 – 1.2ACCEPTABLE SEX RATIO p VALUE p-value = 0.372BOYS and GIRLS are equally represented OVERAL SURVEY QUALITY 3.0 %0-5 = Excellent; 5-10= GoodEXCELLENT POISSON DISTRIBUTION GAM: ID=1.53 (p=0.020) SAM: ID=1.00 (p=0.469 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. Severe cases seem to be randomly distributed amongst clusters while there seems to be pockets of moderately malnourished cases

8. Demographic Characteristics Demographic characteristicsn Total number of HH 432 Total household sample 2806 Total under five sample 562

9. MALNUTRITION RATE TRENDS INDEXINDICATOR20122011Statistical significance WHO n= 498 GAM: W/H < -2 z and/or Oedema 6.6% (4.3 - 10.2) 5.1 % (3.3 - 7.7) p=0.27 SAM: W/H < -3 z and/or Oedema 0.2% (0.0 - 1.5) 0.2 % (0.0 - 1.3) P=1 Prevalence of stunting: H/A <-2 40.9% (35.4 - 46.7) 33.5% (29.1 - 38.2) P=0.04 (p<0.05 thus significant) Prevalence of underweight: W/A <-2 23.1% (19.4 - 27.3) 18.0 % (14.7 - 21.8 ) P=0.09 MUAC < 11.5 CM &/or Oedema (SAM) 0.2% (0.0 - 1.5) 0.2% ( 0.0 - 1.3 ) p=1.0 MUAC: ≥11.5 CM & <12.5CM (MAM) 2.8% (1.7 - 4.6) 1.7% ( 0.9 - 3.4) p=0.33 MUAC ≥12.5 & <13.5CM(At Risk) 15.3 % 14.8%p=0.8

10. MAKUENI MARCH 2012: NUTRITION STATUS WHO 2006 ALL n = 498 BOYS n = 258 GIRLS n = 240 Prevalence of GAM (<-2 z-score and/or oedema) ( 33) 6.6% ( 4.3-10.2 95% CI) ( 21) 8.1% ( 4.6-14.0 95% CI) ( 12) 5.0% ( 3.0- 8.2 95% CI) Prevalence of MAM ( =-3 z-score, no oedema) ( 32) 6.4% ( 4.2- 9.8 95% CI) ( 21) 8.1% ( 4.6-14.0 95% CI) ( 11) 4.6% ( 2.7- 7.8 95% CI) Prevalence of SAM (<-3 z-score and/or oedema) (1) 0.2% ( 0.0- 1.5 95% CI) ( 0) 0.0% ( 0.0- 0.0 95% CI) ( 1) 0.4% ( 0.1- 3.1 95% CI) STATISTICAL SIGNIFICANCE in GAM and SAM levels between boys and girls: (GAM p value 0.2773 and SAM p value 0.44. These are GREATER than 0.05 and thus no statistical significance)

11. RESULTS MORTALITY Results 2012 Results 2011 Total CRUDE MORTALITY RATE (Number/10,000/day) 0.15% (0.05 – 0.39) 0.17 (0.06 – 0.48) UNDER FIVE MORTALITY RATE (Number/10,000/day) 0.0% (0.00-0.00) 0.35 (0.09 – 1.38) No statistical significance as p value >0.05

12. Measles Immunization Coverage Results 2012 (%) Results 2011 (%) Measles immunization coverage (>=9 months old) (n=472) Not Immunized7.843.3 By card77.1274.0 Recall16.7422.7 No significant difference IRON SUPPLEMENTATION  Proportion of women supplemented with iron in the last pregnancy; 80.1%

13. OPV 1OPV 3 No5.3710.56 CARD80.8875.7 RECALL13.75 Immunization and Vitamin A supplementation coverage VITAMIN A SUPPLEMENTATION AGE GROUP NO.OF TIMES RESULT 2012 (%) RESULT 2011 (%) 6-11ONCE 69.8 78.2 12-59ONCE 40.9 TWICE 24.5 40.0 THRICE 2.5  Negligible percentage  Third dose in most cases was given during illness to boost a child’s immunity.  ?? Possible impact of Malezi bora Percentage of 2-5 years old de-wormed in the last 6 months  37.0%

14. Infant and Young child feeding practices INFANT AND YOUNG CHILD NUTRITION INDICATORS% BREASTFEEDING PRACTISES Early initiation of breastfeeding (within an hour; n=315)88.2 Exclusive breastfeeding rates (n (0-<6months); n=8051.3 DIETARY DIVERSITY Proportion of breastfed children 6-23 months consuming ≥3 food groups (n=83) 52.2 Proportion of non breastfed children 6-23 months consuming ≥4 food groups (n=7) 0.2 Proportion of both breastfed and non breastfed children 6-23 months consuming ≥ 3 or ≥ 4 food groups respectively (n=90) 46.4 Even though triangulation of this was done, results are above the national target of 50.0% and believed to be more of knowledge rather than practice

15. MINIMUM MEAL TIMES Proportion of breastfed children 6-8 months and 6- 23 months having at least 2 meals and ≥ 3 meals a day respectively (n=176) 93.6 % Proportion of non breastfed children 6-23 months having ≥4 meals a day (n=24) 64.9 % 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 (n=200) 88.9 % IYCN Continued............

16. Morbidity rates Among Children 0-59 months old sick preceding two week survey dates Others include skin infection, chicken pox, swollen neck Significant Increase

17. General hand washing Practices Even though high (99.3%) proportion wash hand, appropriate hand washing at critical times to break contamination route was wanting as illustrated 2012 (%) 2011 (%) Water Only18.1 29.7 Water & Soap38.2 42.1 Soap when I can afford it43.7 27.3 Water & Ashes0 0.9

18. HAND WASHING TIMES COMMENT: Significant difference probably contributing to increase in diarrheal incidences

19. Distance to water source

20. Water treatment

21. Households Mosquito bed net ownership and utilization BEDNET OWNERSHIPResults 2012 (%) Results 2011 (%) Households Owning Mosquito Nets 83.371.1 Households without Mosquito Nets16.718.9 BEDNET UTILIZATION (reporting done only for the vulnerable group) 2012 (%) 2011 (%) Children < 5Years old 64.267.5 Adult Females 56.668.9

22. Household Dietary Diversity Score (HDDS) DIET DIVERSITY GROUPS March 2011 MARCH 2012 n%n% Low Dietary Diversity (= 3 Food Groups) 6611.5 8419.8 Medium Dietary Diversity (4 – 5 Food Groups) 11720.3 14032.9 High Dietary Diversity (6+ Food Groups) 39268.2 20147.3

23. HOUSEHOLD FOOD SOURCES MAIN FOOD SOURCE

24. Summary of general findings  No significant increase or decrease in GAM and SAM  Significant increase in levels of stunting; long term indicator of malnutrition  Significant increase in diarrhoeal incidence; probably attributed to a significant decrease at specific hand washing times specifically before breastfeeding  Main source of food being purchase against a background of high food prices  WASH: General increase in queue times, distance to water sources leading to subsequent decline in per capita water consumption  RAINFALL PATTERNS: During the last survey period, the rains had begun and were evident during the survey. However, only scattered rains were seen  HARVEST:

25. Possible recommendations for discussion Nutrition  Strengthen linkages with other sectors such as WASH to help improve nutrition outcomes that contribute to long term malnutrition (high stunting levels) Food Security & livelihood  Promoting high value traditional crops and timely supply of certified seeds (GOK)  Market linkage and value addition should be entrenched in a cottage industry in the village for economic growth and income generation  The water resources (permanent rivers) need to be tapped for irrigation farming (GOK) Water sanitation & Hygiene  Strengthen public health promotion on appropriate hand washing and water treatment practices (GOK)

26. Recommendations cont...... Water sanitation & Hygiene  Strngthen public health promotion on appropriate hand washing and water treatment practices (GOK)

27. Any questions/queries/ inputs?