West Pokot Survey Report

41 Pages·2012·1.72 MB·English

MAY 2012

Integrated Nutrition, Food Security and
Retrospective Mortality Survey

West Pokot County
Kenya

Funded by

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
TABLE OF CONTENTS
LIST OF TABLES ...................................................................................................................................................... 3
LIST OF FIGURES ..................................................................................................................................................... 3
ACKNOWLEDGEMENT ............................................................................................................................................ 4
LIST OF ABBREVIATIONS AND ACRONYMS ............................................................................................................. 5
1 EXECUTIVE SUMMARY ................................................................................................................................... 6
1 INTRODUCTION ............................................................................................................................................. 7
2 METHODOLOGY ............................................................................................................................................ 7
2.1 TYPE OF SURVEY ............................................................................................................................................... 7
2.2 SURVEY OBJECTIVES........................................................................................................................................... 7
2.3 SOURCES OF SURVEY DATA ................................................................................................................................. 8
2.4 SAMPLING METHODOLOGY ................................................................................................................................. 8
2.4.1 First Stage ................................................................................................................................................ 8
2.4.2 Second Stage ............................................................................................................................................ 9
2.4.3 Survey Schedule and Training .................................................................................................................. 9
2.4.4 Field Work ................................................................................................................................................ 9
2.4.5 Data entry, cleaning, and analysis ........................................................................................................... 9
2.5 INDICATORS USED ........................................................................................................................................ 9
2.5.1 Anthropometric survey ............................................................................................................................ 9
2.5.2 Mortality survey: .................................................................................................................................... 10
2.5.3 Health, WASH and Food Security& Livelihoods: ..................................................................................... 10
2.6 DATA QUALITY CONTROL AND ASSURANCE ............................................................................................... 10
3 SURVEY LIMITATIONS/CONSTRAINTS .......................................................................................................... 11
4 SURVEY RESULTS ........................................................................................................................................ 11
4.1 ANTHROPOMETRIC SURVEY ....................................................................................................................... 11
4.1.1 Distribution by age and sex .................................................................................................................... 11
4.1.2 Distribution of Acute Malnutrition in Z-score, WHO 2006 standards .................................................... 12
4.1.3 Distribution of Middle Upper Arm Circumference.................................................................................. 14
4.2 RETROSPECTIVE MORTALITY SURVEY ......................................................................................................... 14
4.3 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS ............................................................ 15
4.4 HEALTH AND NUTRITION ............................................................................................................................ 15
4.5 WATER SANITATION AND HYGIENE ............................................................................................................ 19
4.6 FOOD SECURITY AND LIVELIHOODS............................................................................................................ 22
5 DISCUSSION AND CONCLUSIONS ................................................................................................................. 28
6 RECOMMENDATIONS .................................................................................................................................. 29
APPENDIX 1: SUMMARY OF KEY FINDINGS .............................................................................................................. 31
APPENDIX 2: SURVEY PLAUSIBILITY REPORT SUMMARY,MAY 2012 .................................................................................... 33
APPENDIX 3: MAP OF WEST POKOT COUNTY ................................................................................................................. 34
APPENDIX 4: SAMPLED VILLAGES ................................................................................................................................. 35
APPENDIX 5: HOUSEHOLD MORTALITY DATA FORM (ONE SHEET PER HOUSEHOLD) ................................................................ 36
APPENDIX 6: CLUSTER MORTALITY QUESTIONNAIRE (ONE SHEET/CLUSTER) ................................................................ 37
APPENDIX 7: ANTHROPOMETRIC QUESTIONNAIRE ................................................................................................. 38
APPENDIX 8: IYCN QUESTIONNAIRE ........................................................................................................................ 39

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
LIST OF TABLES
TABLE 1: SURVEY PLANNING DETAILS ......................................................................................................................................................... 8
TABLE 2: DISTRIBUTION OF AGE AND SEX OF SAMPLE .................................................................................................................................... 11
TABLE 3: PREVALENCE OF ACUTE MALNUTRITION BY AGE BASED ON WHZ-SCORES AND/OR OEDEMA, WHO 2006 REFERENCES................................... 12
TABLE 4: DISTRIBUTION OF ACUTE MALNUTRITION AND OEDEMA BASED ON WEIGHT-FOR-HEIGHT Z-SCORES ............................................................. 12
TABLE 5: SEASONAL COMPARISON IN MALNUTRITION RATES .......................................................................................................................... 14
TABLE 6: MUAC DISTRIBUTION .............................................................................................................................................................. 14
TABLE 7: SUMMARY OF MORTALITY DATA ................................................................................................................................................. 14
TABLE 8: MORTALITY RATES ................................................................................................................................................................... 14
TABLE 9: VITAMIN A SUPPLEMENTATION ................................................................................................................................................... 17
TABLE 10: OPV VACCINATION ................................................................................................................................................................ 17
TABLE 11: IYCN INDICATORS ................................................................................................................................................................. 18
TABLE 12: WATER STORAGE CONTAINERS .................................................................................................................................................. 21
TABLE 14: APPROPRIATE HAND WASHING PRACTICES.................................................................................................................................... 22
TABLE 14: HOUSEHOLD HARVEST ............................................................................................................................................................ 23
TABLE 15: HOUSEHOLD LIVESTOCK OWNERSHIP .......................................................................................................................................... 24
TABLE 16: HOUSEHOLD DIETARY DIVERSITY SCORE ..................................................................................................................................... 25
TABLE 17: STRESSORS EXPERIENCED......................................................................................................................................................... 27
TABLE 18:DIARRHOEA INCIDENCES VS. WASH ........................................................................................................................................... 28
TABLE19: SUMMARY OF KEY FINDINGS, POSSIBLE CAUSES AND RECOMMENDATIONS ................................................................. 29

LIST OF FIGURES
FIGURE 1: DISTRIBUTION OF SEX BY AGE GROUP ..................................................................................................................... 12
FIGURE 2: WEIGHT FOR HEIGHT DISTRIBUTION IN Z-SCORE COMPARED TO THE WHO STANDARD .................................................... 13
FIGURE 3:WEIGHT FOR HEIGHT Z-SCORES BASED ON GENDER (WHO STANDARDS) ...................................................................... 13
FIGURE 4:HEIGHT FOR AGE COMPARED TO WHO STANDARDS .................................................................................................. 13
FIGURE 5: MAIN SOURCE OF LIVELIHOOD .............................................................................................................................. 15
FIGURE 6: MORBIDITY RATES .............................................................................................................................................. 15
FIGURE7: DIARRHOEA MANAGEMENT .................................................................................................................................. 16
FIGURE 8: HEALTH SEEKING BEHAVIOR .................................................................................................................................. 16
FIGURE 9: TRENDS IN MOSQUITO NET OWNERSHIP AND USAGE ................................................................................................. 17
FIGURE 10: MEASLES VACCINATION COVERAGE ..................................................................................................................... 18
FIGURE 11: WATER ACCESSIBILITY ....................................................................................................................................... 19
FIGURE 12:QUEUING TIME AT WATER SOURCE ....................................................................................................................... 20
FIGURE 13: RELIEVING POINTS IN WEST POKOT COUNTY ......................................................................................................... 20
FIGURE 14: WATER TREATMENT PRACTICES .......................................................................................................................... 21
FIGURE 15: CRITICAL HAND WASHING TIMES ......................................................................................................................... 21
FIGURE 16: PROPORTION OF HOUSEHOLDS WHO PLANTED CROPS ............................................................................................. 22
FIGURE 17: REASONS FOR INCREASE OR DECREASE IN MOST RECENT HARVEST .............................................................................. 23
FIGURE 18: DURATION OF THE RECENT HARVEST FOR HOUSEHOLD CONSUMPTION ........................................................................ 23
FIGURE 19: HOW THE MOST RECENT HARVEST WAS USED ......................................................................................................... 24
FIGURE 20: CONSUMED FOOD GROUPS ................................................................................................................................ 25
FIGURE 21: HOUSEHOLD FOOD SOURCES .............................................................................................................................. 26
FIGURE 22: SOURCES OF HOUSEHOLD INCOME ....................................................................................................................... 26
FIGURE 23: HOUSEHOLD EXPENDITURE................................................................................................................................. 27

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
ACKNOWLEDGEMENT
Action Against Hunger is indebted to all the parties for their contribution and profound support during the survey
exercise. The survey wouldn’t have been possible without the active participation of the actors who included and
were not limited to:
 UNICEF for financial support
 ACF Kenya Nairobi and West Pokot teams for their technical and logistical support throughout the survey
process
 The relevant government ministries (Ministry of Health/Public Health, Arid Lands and Resource Management
Project, Local authorities, Ministry of Agriculture)for provision of relevant background information and playing
an active role during data collection as team leaders
 All the data collection teams for their diligent effort in gathering reliable and quality data
 The community and caretakers of sampled households for taking their time out of their busy schedule to
provide the much needed valuable information

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
LIST OF ABBREVIATIONS AND ACRONYMS
ACF-USA Action Contre la Faim- USA (Action Against Hunger-USA)
ALRMP Arid Lands Resource Management Project
ASAL Arid and Semi-Arid Land
CLTS Community Led Total Sanitation
CMR Crude Mortality Rate
DHIS District Health Information System
DHMT District Health Management Team
EBF Exclusive Breastfeeding
ENA Emergency Nutrition Assessment
EPI Expanded Program on Immunization
GAM Global Acute Malnutrition
GFD General Food Distribution
GOK Government of Kenya
HINI High Impact Nutrition Interventions
HDDS Household Dietary Diversity Score
IMAM Integrated Management of Acute Malnutrition
NGO Non-Governmental Organization
IYCN Infant and Young Child Nutrition
KEMSA Kenya Medical Supply Agency
KDHS Kenya Demographic Health Survey
MAM Moderate Acute Malnutrition
MOMS Ministry of Medical Services
MOPHS Ministry of Public Health and Sanitation
MUAC Mid Upper Arm Circumference
NCHS National Centre for Health Statistics
OPV Oral Polio Vaccine
OTP Outpatient Therapeutic Program
PPS Population Proportion to Size
RC Reserve Cluster
SAM Severe Acute Malnutrition
SFP Supplementary Feeding Program
SMART Standardized Monitoring and Assessment of Relief and Transitions
U5MR Under Five Mortality Rate
UNICEF United Nations Children’s Fund
W/H Weight for Height
WFP World Food Program
WHO World Health Organization

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
1 EXECUTIVE SUMMARY
An integrated nutrition, food security and retrospective mortality survey was undertaken by the Ministry of Health
and ACF during the rainy season (May 2012) in West Pokot County. The overall survey objective was to determine
the rates of acute malnutrition amongst children aged 6-59 months and the population’s mortality rates1 in West
Pokot County.

SMART2 methodology was utilized in the implementation of the survey. Adequate and prior planning were crucial
in actualization of the survey objectives despite heavy rains in the area that constrained access to part of the
sampled clusters; a challenge that was tackled by accessing replacement clusters.

Findings from this study revealed critical global acute malnutrition (GAM) rates of 12.3% (9.4 – 16.0) and severe
acute malnutrition (SAM) rates of 1.5% (0.7 – 3.2). These findings show no significant difference with the 2011
malnutrition rates recorded during a similar period. Crude and under five mortality rates of 0.22% (0.09 – 0.57)
and 0.87%(0.28 – 2.70) respectively were obtained. These lie below the WHO alert and emergency mortality
thresholds. Additional information was gathered to provide more insight into factors underlying the acute
malnutrition mortality rates (See appendix 1: Summary of Key findings). In summary, high disease incidence, poor
infant and young child nutrition, increased distance to facilities that inhibit prompt health care seeking behavior,
limited access to safe water, low latrine coverage/ usage and compromised food security are some of the
contributing factors to the prevailing malnutrition rates.

The above findings indicate the need for an integrated and concerted effort in tackling the probable determinants
of malnutrition in West Pokot.

1Crude and Under five Mortality rates
2 Standardized Monitoring and Assessment in Relief and Transitions

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
1 INTRODUCTION
West Pokot County is an ASAL3 area located in Rift Valley Province. It borders Uganda to the West, Trans-Nzoia and
Marakwet to the South and Turkana to the East. The County covers a surface area of 9100 square km with an
estimated population of 512,6904 and an annual population growth rate of 3.1%.

The county is composed of 3 main districts namely West, Central, and North Pokot. These districts consequently
form the 3 major livelihood zones of pastoralism, agro-pastoral, and mixed farming for North, Central and West
Pokot districts respectively.

The food security situation in the county was reported to be critical especially in the North and moderate in some
areas in May 20115. Analysis of secondary data indicates that stressed levels have been consistent in the agro
pastoral zone, while the mixed farming livelihood zone has improved from stressed to no food insecurity in
relation to previous assessments6. Despite the food security situation being expected to improve; a number of
challenges such as endemic livestock diseases7, high food prices, recurrent droughts, insecurity, and cattle rustling
especially in the North and Central Pokot are inevitable.

2 METHODOLOGY
2.1 Type of Survey
An integrated nutrition and food security survey was conducted in West Pokot County in May 2012. This was
exactly a year since the last one conducted by Samaritan’s Purse in 2011.The survey applied Standardized
Monitoring and Assessment of Relief and Transition (SMART) methodology with all the tools tailored as per the
MOPHS8 and MOMS9 recommendations for anthropometric and retrospective mortality survey.

Additional household data was collected using structured questionnaires, adjusted to meet the survey objectives in
regard to dynamics of the county. The key information collected included WASH10, food security and health/ health
care practices.
2.2 Survey Objectives
The overall survey objective was to determine the rates of acute malnutrition amongst children aged 6-59 months
and the population’s mortality rates11 in West Pokot County.

Specific survey objectives were to;
1. Determine the prevalence of acute malnutrition in the children aged 6-59months.
2. Determine the Crude and under five mortality rates of the entire population
3. Determine the morbidity rates in children aged 0-59 months.

3 Arid and Semi-Arid lands
4KNBS4 2009 Census Report,
5Integrated SMART survey conducted in West Pokot County by Samaritans Purse
6West Pokot 2012 Short Rains Assessment Report
7Peste des Petits Ruminants (PPR) and Contagious Caprine Pleural Pneumonia (CCPP) in goats and East Coast Fever
(ECF) in cattle
8Ministry of Public Health and Sanitation
9Ministry of Medical Services
10Water, Sanitation and Hygiene
11Crude and Under five Mortality rates

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
4. Estimate the coverage of immunization (measles, OPV1&3), and micronutrient supplementation amongst
children aged 0-59 months.
5. Estimate the coverage of women supplemented with iron folic acid for 90 days in their last pregnancy
6. Assess household food security, Maternal and Child Health care practices, and water sanitation and hygiene
practices.
7. Develop capacity amongst focal government ministries and community members in undertaking integrated
nutritional surveys
2.3 Sources of Survey Data
The survey data was derived from both primary and secondary sources for both quantitative and qualitative forms.
Some of the primary data gathered included anthropometry, mortality, IYCN, WASH, FSL and market prices. These
were gathered through administration of structured questionnaires at household levels. Secondary data was also
obtained from various sources such as MOPHS/MOMS, NDMA12, past survey reports and Yanga’t13 so as to
triangulate findings from primary data sets.
2.4 Sampling Methodology
2.4.1 First Stage
A two stage sampling methodology was applied for the survey using ENA for SMART November 2011software. The
county population was obtained from the 2009 Census report [The smallest sampling unit (village)].Sample size
was then determined by entering the design effect, prevalence rates, desired precision, average household size,
and non-response rate into the ENA for SMART planning phase as shown in the table below.

Table 1:Survey Planning Details
Anthropometric RATIONALE
Data entered on ENA software
Survey
Estimated prevalence of GAM 18.2 Highest GAM C.I in May 2011 survey
Desired precision 4.7 The higher the malnutrition prevalence, the lower the
precision as well as objectives
Design effect 2.0 Slight difference in livelihood zones
Average household size 6.8 May 2011 Survey
Percent of under five children 20 Population estimate from DHIS and Census report 2009
Percent of non-respondent 5 Based on vastness of the area as well as cater for any
unforeseen circumstances
Households to be included 465
Data entered on ENA Software Mortality Survey
Estimated death rate per 1.98 Highest Crude mortality rate C.I in May 2011 survey
10000/day
Desired precision 0.8
Design Effect 2.0 Slight difference in livelihood zones
Recall period 90days
Average Household size 6.8 As per May 2011 Survey
Non-Response 5
Households to be included 445

12National Drought Management Authority
13 Community Based Organization that deals with Water Sanitation and Hygiene and Girl Child Education in West
Pokot County.

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
Based on probability to population size (PPS), 39 clusters were randomly selected comprising of 12 households per
cluster for data collection. It is however important to note that 10% of the clusters could not be accessed due to
heavy rains that flooded and cut off roads. The team thus assessed all the replacement clusters as per SMART
methodology guidelines.
2.4.2 Second Stage
The second stage involved obtaining 12 households per cluster during data collection process.
A list of all existing households was obtained per cluster with the help of respective village elders and 12
households selected through simple random sampling. Relevant data was then gathered from each of the twelve
sampled households.
The anthropometric survey targeted all children aged 6-59 months in the sampled households whereas the
mortality survey targeted all sampled households irrespective of whether they had a child under five years of age
or not. Sampled households whose occupants (child and/or caregiver) were not available at the time of the data
collection were revisited later during the day.
2.4.3 Survey Schedule and Training
The training of the survey teams (6 team leaders, 2 data entry clerks, 24 enumerators, and 3 ACF staff) was
scheduled and conducted from 14th to 18th May 2012 in Kapenguria. The training covered all the important
components of the SMART survey. These included the survey objectives, administration of questionnaires in the
local language, anthropometric measurements, use of survey tools, interview techniques and how to record the
responses during data collection exercise in the household. The primary data collection exercise was planned for
19th to 25th May 2012 for the entire West Pokot County; however, this had to be extended by two days to the 27th
May 2012. The extension was mainly due to inaccessibility of 10% of the sampled clusters compelling the exercise
to cover the 4 RCs (Reserve Clusters).
2.4.4 Field Work
The field work was mainly data collection, a rigorous exercise aimed at gathering primary data from the sampled
villages to make inferences with regard to the survey objectives. It was conducted by 6 teams, each constituted of
4 enumerators (2 data measures and 2 data collectors) and 1 team leader from the Ministry of Health.
Coordination and supervision of the entire process was done by ACF Staff.
2.4.5 Data entry, cleaning, and analysis
ENA for SMART software November 2011 version, SPSS version 18, and Microsoft Excel were used for data
analysis. Anthropometric data was entered into ENA software on daily basis to determine the quality of gathered
data for close monitoring, supervision, and provision of feedback to the teams before going to the field.
Household database was made through SPSS exportation into Excel upon entering household questionnaire
information into the SPSS for windows version 18. The collected data was subsequently imported into SPSS for
correlation and analysis.
2.5 INDICATORS USED
2.5.1 Anthropometric survey
All children aged 6-59 months were targeted in the entire sampled household for anthropometric survey. The
anthropometric data was collected using the anthropometric questionnaire. The information gathered using this
tool includes:

Age: Birth certificates, baptism cards as well as birth notifications were used to determine the children’s ages.
However, a local events calendar was used in absence of the above documents.

Sex: The child’s sex was documented as Male (M) or Female (F)
Weight: Children’s weight was taken in their undressed state using a 25 kg hanging spring Salter scale to the
nearest 100g (recorded to 1 decimal place)

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012
Height/Length: Recumbent length was taken for children less than 85 cm or less than 2 years of age while those
greater or equal to 85 cm or more than 2 years of age were measured standing up.

MUAC: Mid Upper Circumference (MUAC) was measured on the left arm with no clothes on the arm, at the middle
point between the elbow and the shoulder, while the arm was relaxed and hanging by the body’s side. MUAC was
measured to the nearest mm. In the event of a disability the right arm was used or for those who are left-handed,
MUAC was taken on the right arm.

Bilateral Oedema: This was assessed by the application of moderate thumb pressure for at least 3 seconds on both
feet. Only children with bilateral Oedema were recorded as having nutritional Oedema.

Measles vaccination: Vaccination cards were used to establish measles vaccination status for children aged 9-59
months. Lack of immunization card at the time of the survey prompted the enumerators to probe the caretaker
further 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 “1” (Card) otherwise as “0” (No). Oral confirmation from
the caretaker without confirmation by card was recorded as “2” (caretaker’s verification). All children less than 9
months old were excluded from measles analysis.

Oral Polio Vaccination: The vaccine cards were used to establish if the child had received OPV. However, where
there was no card the caretakers were asked to give a recall confirmation if the child had received the oral polio
vaccine.

De-worming: The caretakers were probed to determine if children between 2 and 5 years had been de-wormed
twice annually.

Vitamin A coverage: This was established by the number of times vitamin A was administered to the eligible child
in the past one year. The answer was further probed and subsequently recorded in the anthropometric
questionnaire and analyzed based on the recommended two age group categories

2.5.2 Mortality survey:
Pertinent mortality data was recorded in all the 12 sampled households per cluster by use of a standard mortality
questionnaire. In case of absence of members of a sampled household or empty households, the teams constantly
inquired about their location from the neighbors and came back later before leaving the village. Sampled
households were not replaced during the exercise.

2.5.3 Health, WASH and Food Security& Livelihoods:
A structured household questionnaire was used to obtain the above data from all the sampled households.

2.6 DATA QUALITY CONTROL AND ASSURANCE

The entire survey team was trained for five days (to include standardization and pilot tests) prior to the data
collection exercise. The training content was tailored to focus on study objectives and methodology. Emphasis was
placed on accuracy and precision in taking anthropometric measurements, data collection tools and appropriate
administration of the questionnaires to the respondents in the local language. Each of the six survey teams had a
team leader from the MOH to oversee the data collection exercise.

ACF-USA / West Pokot SMART Survey-Kenya/ May 2012