Upper Tana River Bura District April 2010 Small Scale Survey Report

SUMMARY OF KEY FINDINGS

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With a GAM rate above the WHO emergency threshold of 15%, the nutritional status of Bura District is considered as emergency. More than four-fifth of caretakers (84.8%) reported that their child had been sick in the two weeks preceding the survey date. Malaria, diarrhea and cough appeared to be the top 3 prevalent diseases. The markets remained the main source of food across all sites of Bura district, while individual production remained an important source for the majority of households in the Halo, Buwa, Saka, Nanigi, Bangale and Bura locations. Purchasing food on credit from local vendors, reduction of meal size and skipping meals are the leading coping strategies during the hunger gap. Based on the nutrition, WASH and Food Security results, the nutrition surveillance system needs to be continued in Bura district of Tana River.

1. INTRODUCTION Bura district is comprised of the Bura, Madago and Bangale divsions and was recently fomed as a new dsitrict in the greater Coast province of Kenya. The marginal mixed farming livelihood zone occupies the river line of River Tana in Madogo and parts of Bura, and Bangale divisions. The pastoral zones are mostly situated in parts of Bura and Bangale divisions. The rainfall pattern is bimodal and often erratic. The rainy seasons runs from October to December (short rain) and March to May (long rain) every year. The pastoral and marginal mixed farming livelihood zones rely on long rains while the mixed farming areas are dependent on the short rains 1. The mean annual rainfall ranges between 220 mm and 500 mm except for the southern part which receives rainfall ranging between 750 mm and 1250 mm annually. The district is generally hot and dry with temperatures ranging between 21C and 38C. Agricultural activities depend on rain although there are irrigation schemes in Bura and Hola 2. In order to monitor trends in acute malnutrition and
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TANA RIVER DISTRICT, 2009 Long Rains Assessment, 27th -31st July 2009 Ibid: page 3
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its root causes, ACF-International Network Kenya Mission, in collaboration with the Ministry of Health and the Arid Land Resources Management Project (ALRMP), the Kenya Bureau of National Statistics (KBNS) and International Medical Corps (IMC), has conducted the first round Small Scale Survey in order to set-up baseline values so as to monitor the nutrition and food security situation as well as to identify the most vulnerable communities within Bura District. The first round small scale survey was implemented in 30 clusters randomly selected using ENA/SMART software and the first round of data collection was conducted in April 2010 during the period of the long rain season. 2. METHODOLOGY Nutrition data: A small sample is selected using the SMART methodology. It is rapid, cost-effective and representative methodology. 30 clusters of 10 children between 6 and 59 months are randomly selected. The list of sub-locations was obtained from the Bura District Statistics Office. Food Security, Water & Sanitation data: The Food Security and Water and Sanitation data are collected within the households sampled for the nutrition assessment. Data entry and data analysis was performed with SPSS/PC+ Software Version 13. The results from the first round of surveillance are presented in the following sections. 3. RESULTS OF NUTRITION, HEALTH AND CARE PRACTICES DATA 3.1. Acute Malnutrition Prevalence

The data collection was conducted from April 16th to April 21st, during the long rain season. A total of 365 children (190 boys and 175 girls) aged 6-59 months were assessed in the survey. During the validation process, it appeared that the results provided by one of the 5 teams were not in compliance with standards. The data collected by this team was therefore excluded from the analysis. The present results are issued from the data of 280 children, 53% boys and 47% girls. The overall sex ratio was 1.12, within the acceptable range.

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The prevalence calculated with the ENA software for SMART gives the following results:

Table 1: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by 3 gender WHO references Global Acute Malnutrition (<-2 z-score and/or oedema) Moderate Acute Malnutrition (<-2 and >=-3 z-score and no oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema) 18.9% (13.5-24.3) 15.4 % (10.6-20.1) 3.6% (1.1-6.1) NCHS references 18.9% (13.5-24.3) 17.9% (12.7-23.0) 1.1% (0.0 2.5)

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According to the CDC probability calculator, the surveyed population has 85% probability to reach 16.2% for GAM, and 2.4% of SAM.

Figures in brackets are 95% confidence intervals

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Table 2: GAM and SAM rates with 85% probability threshold Global Acute Malnutrition (<-2 z-score and/or oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema) 16.2% 2.4%

Both indicators show that the nutrition situation in Bura District can be considered above the emergency threshold set-up by WHO for GAM (15%). 3.2. Measles Vaccination and Vitamin A Coverage

Data on measles vaccination and vitamin A coverage were collected based on verification of immunization card and caretakers confirmation. The results indicate that measles immunization coverage is 85% (49.4% confirmed by card, 35.6% according to caretaker). This coverage is satisfactory according to the 80% WHO recommendation to avoid epidemic, if the verbal reports of vaccination without cards are accurate. 73.3% of children had received at least 1 capsule of Vitamin A, which is attributed to availability of immunization centers and outreach services rendered by MOH periodically in all the Bura District.
Table 3: Measles vaccination and Vitamin A coverage Indicator Responses Child vaccination proved by card Measles vaccination (N=263) Child vaccinated according to caretaker Child Not Immunized Vitamin supplementation received at least once Never Received N 130 93 40 % 49.4% (43.4 55.5) 35.4% (29.6-41.1) 15.2% (10.9-19.5) 74.1% (68.9-79.4) 25.9% (20.6-31.1)

Vitamin A (N=263)

195 68

3.3.

Morbidity

Since this survey is considered as a baseline, it reflects the existing situation of local areas during the long raining season. The information was collected through household questionnaires. For this survey no information was collected from the health facilities. More than four-fifth of caretakers (84.8%) reported that their child had been sick in the two weeks preceding the survey date. As per the illnesses reported, the most prevalent was fever with chills like malaria accounting for 47.5%, followed by diarrhoea/vomiting (42%), fever with cough and difficulty in breathing (35%) and skin infections (12.7%). Other diseases like intestinal parasite, measles, and eye and skin infections account for less than 10%. The reported prevalence of diarrhea was 31.7% in Modogo, followed by 20.65% in Bangale and 15.9% in Bura divisions. Fever with chills like malaria and cough each account for more than 40% in the divisions of Bura, Madogo and Bnagale. All of the reported diseases are preventable and are likely related to water, sanitation and hygiene factors. These probable contributing factors could be attributed to the relatively congested living environments of the larger towns, with poor sanitation practices among the local communities.

ACF Kenya - SSS Surveillance - May 2010

Figure 1: Prevalence of Illnesses 2 weeks preceeding the survey 70% 60% 50% 40% 30% 20% 10% 0%

Diarrhea/Vommit

diffcult breathing

Fever with chills

Eye infections

3.4.

Breastfeeding Practices

According to the interviews, only about 65.5% of mothers had initiated breastfeeding within an hour after birth, as recommended by WHO. The timing of introduction of complementary food does not follow WHO recommendations for a majority of interviewees: it is too early (before 4 months) for 44.3% too late (after 6 months) for 37.7% and adequate (between 4 and 6 months) for 18% 3.5. Mosquito Net Coverage

The proportion of households with mosquito nets was about 59.3% in Bura district. The reported mosquito net use among all household members was 51.3%, followed by children under five years of age (6.3%) and others household members (such as children between 5 to 18 years old, adult males and females) each accounting for less than 5%. The way people use mosquito nets should be further investigated and corrected. The promotion of environmental activities such as the destruction of mosquito breeding sites should be strengthened as well in order to reduce malaria prevalence amongst children. 4. RESULTS OF WATER, SANITATION AND HYGIENE PRACTICES DATA 4.1. Water Sources and Use

About 32% of the population has access to safe water, either from a shallow well with hand pump (17%) or from a piped water system (15%). The most common water sources are earth pans or dams (38% of households) while irrigation canals account for 15%, rivers for 6%, unprotected shallow wells for 7% of water sources. It is to be noted that a few respondents cited springs or water trucking as their sources. Most water sources are reliable, delivering water daily in 87% of cases. For safe sources, piped water is 87% reliable and hand pumps are 98% reliable in the survey area. Alternative water sources are unsafe in 99% of cases.

ACF Kenya - SSS Surveillance - May 2010

Fever, cough,

Skin infections

Intestinal

like malaria

ting

parasite

Measles

Other

Figure 4: Households Sourcesof drinking water Figure 4 Household's source of Drinking Water
40% 35% 30% 25% 20% 15% 10% 5% 0%

shallow well

River (i.e.flowing,

Earth pan or dam

system/borehole

Water trucking

Constructed

Other (iirigation

spring source

Public roof rain

Unconstructed

Piped water

to public tank

Piped water

shallow well

traditional

catchment

not dry)

Physical distance (or duration walking) to a water source is one of the determining factors of water access. Household respondents were asked how long it takes them to walk from their home to main water point. 64% of households reported they take 15 minutes or less to the main water point (about 500 m, the SPHERE standard for distance), whereas about 32% take between 15 minutes to an hour and 4% take more than an hour. For alternative water sources, the majority of respondents (53%) reported that they walk more than an hour to fetch drinking water and only 7% walk less than 15 minutes. The average per capita water consumption is 12.6 litres per person per day (l/p/d), which is low compared to other ASAL areas of Kenya. That said, it should be noted that almost 18.3% of household use less than 7.5 litres per day which is at an emergency level, 31% of households use 10 litres per person per day and overall 83.7% do not meet the Sphere indicator of 15 litres per person per day. About 75.7 % of households are below the Kenyan National Standard of 20l/p/d.
Figure 5: Per Capita Water Consumption in Liters Per Day 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 75.7% 63.7%

31.0% 18.3%

Emergency level (< 7.5 l/p/d)

Low (<10 l/p/d)

Less than SPHERE (<15 l/p/d)

Less than National Standard (<20 l/p/d)

4.2.

Hand Washing Practice

Over 95.7% respondents in all clusters reported that household members wash their hands, often citing the appropriate time before cooking (53.3%), after latrine use (47.3%) or before eating (49.7%). More than 56% of households reported that they use only water and less than one-fourth of households use soap.

ACF Kenya - SSS Surveillance - May 2010

canal)
5

Figure 6:6Washing Hands Figure Washing of Hands

60% 50% 40% 30% 20% 10% 0%

After handling

in the shamba

relieving After taking

special time After going to

breastfeeding

hands at any

Before eating

Doesn't wash

children to

Does not wash

4.3.

Latrine Use

More than 78% of households reported defecating in the bush. About 17.1% of households were observed by the survey team to have some type of latrine, which agrees closely with the 17% of households who reported using their own latrine. Sharing latrines between families is uncommon and was reported by only 6% of households. Lack of appropriate waste disposal especially during rainy season and in areas with a more concentrated population, like market centres, predisposes children and adults to diseases potentially leading to malnutrition. The survey result shows that 85.7% of households reporting diarrhea did not use latrines. Thus, improving access to latrines is one of the preventive interventions to diseases and ultimately to alleviate the prevalence of malnutrition among children under five.
Figure 7: Defecation Place Used by HHs

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% In the bushes, open defecation Neighbours latrines My own latrine, but My own latrine for my shared with neighbours family only not shared

5.

RESULTS OF FOOD SECURITY & LIVELIHOODS DATA 5.1. Livestock ownership and milk production

In Bura district, 71% of households reported that they own livestock, of which 43.2% of livestock owners belong to the pastoral zone, and 56.8% reside in the marginal mixed farming zone. (NB. The survey sample comprises 40% from pastoral zones and 60% from marginal mixed farming
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After working

toilet or

the toilet

animals

Before

hands

Abolution

cooking

Before

zones, which has implications for the interpretation of these results). The table below provides a breakdown of livestock ownership by type. Both average and median ownership are provided as average ownership can be skewed by small numbers of households with relatively large herds. Table 5: Household Livestock Ownership by Livestock Type % of HH % of HH Ownership in Ownership Ownership Livestock Type Marginal % of HH in Pastoral Mixed Farming Areas Areas Cattle Camel Goat Sheep Chicken Donkey 19% 3% 58% 25% 32% 9% 45% 70% 43% 40% 38% 46% 55% 30% 57% 60% 62% 54%

Average No. Owned per HH 7 11 10 6 6 3

Median No. Owned per HH 4 5 5 4 5 1

When asked whether they had milked any animal the day before the interview, 77.9% of livestock-owning households reported that they had. The average amount milked per day was 2.12 litres, and the median was 1 litre. 5.2. Crop Cultivation

Farming is not extensively practiced in Bura district, with only 30% of those surveyed reporting that they cultivate crops. The majority of crop production is irrigated and takes place along the Tana River in Saka, Bura, Buwa, Madogo and Chewele. Rain-fed production is limited due to low water availability 4. The table below demonstrates relatively limited crop diversification overall, with maize accounting for the bulk of production. Table 6: Household Crop Production by Type Crop Type Maize Bean Tomato Banana Pawpaw Mango Watermelon Others 5.3. No. of HH 80 2 2 5 1 5 1 7 Sources of Food % of Farming HH 89% 2% 2% 6% 1% 6% 1% 8% Average Production per HH in kg 524 238 757 268 35 334 50 71 Median Production per HH in kg 180 238 757 400 35 100 50 30 Total Production in kg 41885 475 1513 1340 35 1670 50 500

The most significant main source of food reported was market purchase, accounting for 54.7% of the households. Own production (27.7%), food aid (7.0%) and gifts (10.7%) were the other primary food sources.

Tana River 2009 LRA report

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Figure 10: First Most Important of Food for HH 60% 50% 40% 30% 20% 10% 0% Purchase of food Own production Food aid Gift

5.4.

Income and Expenditure

Major sources of income for the 30 days preceding the survey date included sales of livestock and livestock products, daily labour, charcoal production, agricultural sales and remittances. The mean household income for the last 30 days was 5972 Ksh. This is translated to an average daily income of 33 Ksh per person per day, well below the World Bank poverty threshold of 1.25 USD (104 Ksh).
Figure 11: Household Income Sources

45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

Earning from own

Agricultral/hortic

labour/wage

Remittance

Salary

livestock products

ulture products

Livestock and

(petty/small

% of HH

% of Total Income

The average monthly expenditure per household was 6749Ksh. This reveals that the average household is spending approximately 800 Ksh per month more than they receive as income.

ACF Kenya - SSS Surveillance - May 2010

Other (specify)

Sales of bush

Loans/credits

(charcoal,

products

business

sale

sale

Daily

120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0%

Figure 12 : Household Expenditure Patterns

Fuel

Debt payment

Clothing

Food

Transportation

Rent (house or

health (services

Duksi/Madrassa

Medical and

% of HH

% of Total Expenditure

5.5.

Dietary Diversity

Dietary diversity was measured using the Household Dietary Diversity Score (HDDS), measuring the 12 main food groups consumed in the 24 hours prior to the survey. Results show that the average HDDS for Bura District is 3.52. The table below shows the distribution of the households according to HDDS category, revealing that the majority fall within the low dietary diversity group. Table 7: HDDS by Category HDDS Category Low Dietary Diversity (<=3 Food Groups) Moderate Dietary Diversity (4 - 5 Food Groups) High Dietary Diversity (6 + Food Groups) % of HH 55.3% 33.7% 11.0% 95% CI (49.5 - 61.0) (28.3- 39.3) (7.7 - 15.1)

Analysis of the food groups consumed shows the cereals, condiments, sugars, oils and fats and dairy products were the most commonly consumed. By contrast high protein food stuffs including meat, fish and eggs were only eaten by a small minority. Similarly the consumption of vegetables and fruits was very low.
Figure 13: Food Groups Consumed by the Households 120% 100% 80% 60% 40% 20% 0%

cattle, chicken,

rice, bread, or

Milk, yougurt,

with oil, fat,

Vegetables

Sugar or honey

Friuts

Eggs

Fish or dried

Foods made

yams, beets or

Ugali, patsta,

from beans,

Foods made

Meat (camels,

Potartoes,

ACF Kenya - SSS Surveillance - May 2010

cheese, or

condiments
9

Any other

fish

medication

School

Water

Mira

Livestock

land)

fee

5.6.

Coping Strategies

Utilization of coping strategies was revealed to be high amongst the households, indicating that their capacity to access sufficient food is limited. Virtually all households (98%) reported reducing meal sizes, with 74% also skipping meals. Purchase of food on credit (65%) and sale of productive assets (58%), were also strategies employed by a majority of the households. This is concerning as it indicates that households are incurring debt whilst also selling productive assets which is unsustainable in the long term.
Figure 14: Coping Stratgies Used By HHS 100% 80% 60% 40% 20% 0%
Skip meals (exclude ramadan) Reduce meals Eat less Purchase food on local venders Borrow money from relatives Send eat with relatives Sell assets (saling of livestock, farming Other (specify) the size of preferred wild foods) children to productive

foods (eg credit from

6.

CONCLUSION AND RECOMMENDATIONS

The prevalence of Global and Severe acute malnutrition are above the WHO emergency threshold. Breastfeeding and weaning practices are not adequate for an important part of the population, and need reinforcement. More than two-third of the population access unsafe water from a piped water system, earth pans or dams, irrigation canals, unprotected shallow well and springs sources or water trucking. Moreover, the average per capita water consumption is 12.6 litres per person per day (l/p/d), which is low compared to other ASAL areas of Kenya and about 63.7% do not meet the Sphere indicator of 15 litres per person per day. Provision of safe drinking water interventions should be carried out. Most households in the study sites have no access to latrines. More than 78% the respondents relieve themselves in the open field or bush. Therefore, promotion of hygiene and sanitation activities needs to be carried out as priority interventions. The utilisation of coping strategies is generally high, including erosive strategies which can undermine the households asset base and jeopardise longer-term sustainability. This indicates that many households are facing regular and significant food shortages. Market purchase is the main source of food for the majority, with food forming the single largest area of expenditure. Given this context, interventions to increase household income, including through improved income from livestock production and trade, have the potential to help address food insecurity. Agricultural production is relatively limited, with the majority of farmers cultivating only maize. This indicates that there is the potential to boost production through the introduction of more diverse crops, particularly short-cycle and drought-resistant varieties. Household dietary diversity is low, a situation exacerbated by the predominance of cereals, sugars, fats, and condiments and very limited consumption of protein-rich foods, vegetables and fruits. Given this there is a need to provide nutritional education in tandem with interventions to increase the production of fruits and vegetables and promote their consumption at the household level. The surveillance activities will be continued on quarterly basis in Bura district for a follow up of these indicators.
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