TABLE OF CONTENTS

DECLARATION……………………………………………………….. Error! Bookmark not defined.

DEDICATION………………………………………………………………………………………………….. iii

ACKNOWLEDGEMENT…………………………………………………………………………………. iv

TABLE OF CONTENTS……………………………………………………………………………………. v

LIST OF FIGURES…………………………………………………………………………………………… ix

LIST OF TABLES…………………………………………………………………………………………….. x

DEFINITION OF TERMS………………………………………………………………………………… xi

LIST OF ABBREVIATIONS AND ACRONYMS……………………………………………. xiii

ABSTRACT……………………………………………………………………………………………………… xv

CHAPTER 1: INTRODUCTION……………………………………………………………………….. 1

• Background of the Study……………………………………………………………………………… 1
  • Problem Statement……………………………………………………………………………………….. 3
  • Justification of the Study………………………………………………………………………………. 4
  • Research Questions………………………………………………………………………………………. 5
  • Objectives…………………………………………………………………………………………………… 6
    • Broad Objective………………………………………………………………………………………… 6
    • Specific Objectives……………………………………………………………………………………. 6
  • Hypotheses………………………………………………………………………………………………….. 7
  • Significance of the Study……………………………………………………………………………… 7
  • Delimitations and Limitations……………………………………………………………………….. 7
  • Assumptions………………………………………………………………………………………………… 8
  • Conceptual framework……………………………………………………………………………….. 8

CHAPTER 2: LITERATURE REVIEW…………………………………………………………… 10

• Overview of Child Malnutrition…………………………………………………………………… 10
  • Caregiver Demographic, Socio-economic Characteristics and Nutrition Status of children 6-23 months       11
  • Feeding Practices of Children 6-23months…………………………………………………….. 12
    • Continued-breastfeeding beyond Supplementary Feeding Program……………….. 13
    • Complementary feeding beyond Supplementary Feeding Program………………… 14
  • Assessment of Child Nutrition Status…………………………………………………………… 17
  • Childhood Morbidity and Child Nutrition Status after Supplementary Feeding Program          18
    • Acute Respiratory Infections…………………………………………………………………….. 19
    • Diarrheal Disease…………………………………………………………………………………….. 20
    • Malaria…………………………………………………………………………………………………… 21
    • Health Seeking Behaviour for Common Childhood Illnessess……………………….. 21
  • Government Efforts to Curb Under-nutrition………………………………………………… 22
    • Food related interventions in Isiolo County………………………………………………… 23
  • Occurrence of Relapse after Supplementary Feeding Program…………………………. 24
  • Summary of the Literature Review Isolating the Gap……………………………………… 25

CHAPTER 3: MATERIALS AND METHODS…………………………………………………. 26

• Research Design…………………………………………………………………………………………. 26
  • Variables…………………………………………………………………………………………………… 26
    • Independent Variables……………………………………………………………………………… 26
    • Dependent Variable…………………………………………………………………………………. 26
  • Location of Study………………………………………………………………………………………. 26
  • Study Population………………………………………………………………………………………… 27
    • Inclusion Criteria……………………………………………………………………………………… 28
    • Exclusion Criteria…………………………………………………………………………………….. 28
  • Sample size Determination…………………………………………………………………………… 28
  • Sampling Technique……………………………………………………………………………………. 30
  • Data Collection Tools…………………………………………………………………………………. 32
  • Data Collection Procedures…………………………………………………………………………. 33
  • Pre-testing…………………………………………………………………………………………………. 35
    • Validity………………………………………………………………………………………………….. 35
    • Reliability……………………………………………………………………………………………….. 35
  • Data Analysis…………………………………………………………………………………………… 35
  • Logistical and Ethical Considerations………………………………………………………….. 36

CHAPTER 4: RESULTS………………………………………………………………………………….. 38

• Demographic and Socio-economic Characteristics among Caregivers……………….. 38
  • Household Characteristics………………………………………………………………………… 38
  • Maternal Characteristics……………………………………………………………………………. 40
  • Child Characteristics………………………………………………………………………………… 41
    • Time since Discharge from Supplementary Feeding Program………………………… 41
  • Feeding Practices of Study Children after Supplementary Feeding Program Discharge            42
    • Continued Breastfeeding Status of Study Children……………………………………… 42
    • Meal Frequency……………………………………………………………………………………….. 43
    • Minimum Meal Frequency………………………………………………………………………… 43
    • Dietary Diversity……………………………………………………………………………………… 44
    • Minimum Dietary Diversity………………………………………………………………………. 45
    • Minimum Acceptable Diet………………………………………………………………………… 46
  • Nutrition Status of the Study Children………………………………………………………….. 47
    • Acute Malnutrition (Wasting)……………………………………………………………………. 47
    • Chronic Malnutrition (Stunting)…………………………………………………………………. 48
    • Underweight…………………………………………………………………………………………… 49
    • Under-nutrition by Demographic Characteristics, Feeding Practices and Time after discharge from Supplementary Feeding Program……………………………………………………………………….. 50
  • Morbidity Status of the Study Children and Health Seeking Behavior……………… 51
  • Acute Malnutrition Relapse…………………………………………………………………………. 52
  • Associations between Caregiver Demographic, Socio-economic Characteristics, Feeding Practices, Morbidity status and Nutrition Status………………………………………………………………… 53
    • Demographic and Socio-economic Characteristics with Child Nutrition Status 53
    • Feeding Practices and Nutrition Status among Study Children……………………… 54
    • Morbidity status and Nutrition Status of Study Children……………………………… 56
    • Duration after discharge from Supplementary Feeding Program and Nutrition Status                      57

CHAPTER 5: DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS… 58

• Discussion…………………………………………………………………………………………………. 58
  • Caregiver Demographic and Socio-economic Characteristics…………………………. 58
  • Feeding Practices of the Children………………………………………………………………. 59
    • Minimum Dietary Diversity………………………………………………………………………. 60
    • Minimum Meal Frequency………………………………………………………………………… 61
    • Minimum Acceptable Diet………………………………………………………………………… 62
  • Nutrition Status of the Children Aged 6-23 months after Discharge from Supplementary Feeding Program………………………………………………………………………………………………………….. 63
  • Morbidity Status, relapse rate and Nutrition Status of the Children……………….. 64

5.1.6 Summary of Study Findings……………………………………………………………………… 65

• Conclusions……………………………………………………………………………………………….. 66
  • Recommendations………………………………………………………………………………………. 67
    • For Policy and Practice…………………………………………………………………………….. 67
    • For Further Research………………………………………………………………………………… 68

REFERENCES………………………………………………………………………………………………… 69

APPENDICES………………………………………………………………………………………………….. 80

APPENDIX 1: INTRODUCTORY NOTE AND INFORMED CONSENT………….. 80

APPENDIX 2: DATA COLLECTION TOOLS/INSTRUMENTS……………………….. 82

APPENDIX 3: ETHICAL CLEARANCE…………………………………………………………. 91

APPENDIX 4: NACOSTI RESEARCH AUTHORIZATION…………………………….. 92

APPENDIX 5: COUNTY COMMISSIONER CLEARANCE…………………………….. 93

APPENDIX 6: COUNTY EDUCATION CLEARANCE…………………………………… 94

APPENDIX 7: COUNTY PUBLIC HEALTH CLEARANCE……………………………. 95

APPENDIX 8: MAP OF STUDY SITE…………………………………………………………….. 96

LIST OF FIGURES

Figure 1.1: Causes of childhood under-nutrition……………………………………………………….. 9

Figure 4.1: Primary food provider and decision maker in the household…………………….. 40

Figure 4.2: Proportion of study children by breastfeeding status……………………………….. 42

Figure 4.3: Food groups consumed by study children in the preceding 24 hours…………. 45

LIST OF  TABLES

Table 3:1 Distribution of the proportionate sample size for the 13 health facilities……….. 31

Table 4:1: Distribution of household members by demographic and socioeconomic characteristics      39

Table 4:2: Distribution of maternal age, marital status and occupation……………………….. 40

Table 4:3: Distribution of age and sex of the study children……………………………………… 41

Table 4:4: Distribution of time since the children were discharged…………………………….. 41

Table 4:5: Distribution of meals fed to the study children in the preceding 24 hours……. 43

Table 4:6: Distribution of study children who met the minimum meal frequency in the preceding 24 hours…………………………………………………………………………………………………………………………. 44

Table 4:7: Dietary diversity score of food groups consumed in the preceding 24 hours… 44

Table 4:8: Distribution of study children who achieved the minimum dietary diversity on foods consumed in the previous 24 hours…………………………………………………………………………………………… 46

Table 4:9: Distribution of study children who met the minimum acceptable diet based in the previous 24 hours…………………………………………………………………………………………………………………. 46

Table 4:10: Distribution of acute malnutrition (wasting) by sex and age of the study children 48

Table 4:11: Chronic malnutrition (stunting) by sex and age of the study children………… 49

Table 4:12: Underweight by sex and age of the study children…………………………………. 50

Table 4:13: Nutrition status by demographic characteristics, child feeding practices and duration of time after program exit……………………………………………………………………………………………………….. 51

Table 4:14: Morbidity status of study children and health seeking behavior………………… 52

Table    4:15:    Association    between    caregiver    demographic and socio-economic characteristics and nutrition status of the study children       54

Table 4:16: Relationship between number of meals, number of food groups consumed with nutrition status of the study children……………………………………………………………………………………………….. 54

Table 4:17: Relationship between achievement of minimum acceptable diet and nutrition status of the study children……………………………………………………………………………………………………………… 55

Table 4:18: Association between morbidity and nutrition status of the children………….. 56

Table 4:19: Relationship between duration of time post SFP discharge and nutrition status of the children…………………………………………………………………………………………………………………………. 57

DEFINITION OF TERMS

Anthropometric measurements: The body measurements used in this study to assess the nutrition status of an individual; they included the weight, height dimensions and age. Cure rate: the proportion of children who were discharged from the SFP program as cured, from the total SFP program exits. This study used the 75% sphere standard for program performance was used as the reference.

Early life: In this study, it was the period between birth and 24 months of life.

Feeding practices: these were the actions carried out by a caregiver relating to breastfeeding and complementary feeding, solid and semi-solid foods, given to a child (Kamau, 2014). This study dwelt on breastfeeding between 6 and 23 months, frequency of feeding (meal frequency), types of food consumed (dietary diversity) and attainment of acceptable diet.

Global acute malnutrition: this was the accumulated proportion of children who had a weight for length Z-cores of below -2SD

Malnutrition: a state where the bodily functions are weakened affecting adequate maintenance of processes such as growth, disease resistance and subsequent recovery (Kenya MMS and MoH, 2009). While malnutrition portrays as under-nutrition or over- nutrition, this study focused on under-nutrition.

Meal: this entailed the food that was consumed in the previous 24 hours of this study. Moderate Acute Malnutrition: This is the effect of short-term food deprivation, sometimes with infection, characterized by the degree of wasting. The weight and height anthropometric measurements taken in this study were referenced against the WHO 2006 child growth standards for interpretation. Standard deviation of between -3SD and below

-2SD was termed as Moderate Acute Malnutrition (MAM), an entry criteria into Supplementary Feeding Program (SFP).

Nutrition status: This conveyed the condition of the body as revealed by anthropometric measurements referenced against WHO 2006 child growth standards; weight-for-length, length-for-age and ultimately weight-for-age (Ndanu, 2013).

Optimal growth: Desirable increase in size consistent with the WHO 2006 child growth standards.

Primary caregiver: A person who consistently spends most of his or her time caring for a child to include feeding. This study purposed to interview the mother as the primary caregiver.

Relapse: this term represented deterioration of nutrition status after a period of improvement. At the time of this study, sampled children who were found to have a WLZ score of below -2SD (as referenced against WHO 2006 growth charts) were referred to as relapse cases.

Supplementary Feeding Program: nutrition treatment program that offers a dry ration of Corn-Soy Blend (CSB) and vegetable oil, or RUSF (peanut-based paste); and medical provisions of anti-helminthes, micronutrients supplementation (Vitamin A, Iron and Folic acid) and measles immunization to children 6-59 months (Kenya MMS and MoH, 2009). This study centered on those who were 6-23monts.

Under-nutrition: A state arising from insufficient intake or utilization of nutrients in the body. Stunting, wasting and underweight were the focus of this study.

Z-score: This referred to the index used to show how much a value deviated from the median. The weight for length, weight for age and height for age were the focus.

LIST OF ABBREVIATIONS AND ACRONYMS

ASAL             :           Arid and Semi-Arid Land CHW            :                        Community Health Worker CSB            :           Corn Soy Blend

DHIS              :           District Health Information System

ENA               :           Emergency Nutrition Assessment

FEWS NET   :           Famine Early Warning Systems Network

FGD               :           Focus Group Discussion GAM   :                        Global Acute Malnutrition GoK :           Government of Kenya

IEG                 :           Independent evaluation Group

IMAM            :           Integrated Management of Acute Malnutrition IMCI   :                                   Integrated management of childhood illnesses KDHS   :           Kenya Demographic Health Survey

KII                  :           Key Informant Interview

KFSSG           :           Kenya Food Security Steering Group KNBS     :                        Kenya National Bureau of Statistics LAZ          :           Length for Age Z-score

MAM              :           Moderate Acute Malnutrition MDD       :                        Minimum Dietary Diversity MDG          :           Millennium Development Goal MICS           :           Multiple Indicator Cluster Survey MMS              :           Ministry of Medical Services

MoEST           :           Ministry of Education Science and Technology

MoH               :           Ministry of Health

MoPHS           :           Ministry of Public Health and Sanitation

NACOSTI      :           National Commission for Science Technology Innovation

NGO               :           Non-Governmental Organization

OR                  :           Odds ratio

RUSF             :           Ready-to-Use Supplementary Food RUTF        :                        Ready to Use Therapeutic Food SAM    :           Severe Acute Malnutrition

SD                   :           Standard Deviation

SFP                 :           Supplementary Feeding Program

SMART         :           Standardized Monitoring and Assessment of Relief and Transition

SPSS               :           Statistical Package for Social Sciences

UNICEF        :           United Nations International Children Education Fund

WAZ               :           Weight for Age Z-score WHO    :           World Health Organization WLZ          :           Weight for Length Z-score

ABSTRACT

Child under-nutrition is linked to delayed growth milestones and increased severity of otherwise common illnesses. There has been minimal significant change over the years on decline of malnutrition. Although Integrated Management of Acute Malnutrition (IMAM) had been successful in managing acute malnutrition, these children continue to be at risk of illnesses, relapse and ultimate death in the subsequent year after treatment. Children in Isiolo County are at risk of acute malnutrition relapse being prone to frequent dry spells. Still, scientific documentation on their follow-up is scanty and overlooks deteriorating nutrition and health trends. This study purposed to determine the feeding practices and nutrition status of the children aged 6-23 months, following successful discharge from Supplementary Feeding Program (SFP) in Isiolo County. The study used  a cross sectional analytical study design on 204 mother-child pairs. The children were sampled purposively from SFP registers in 13 health facilities in Garbatulla sub-County with their mothers as respondents. Researcher-administered questionnaires, focused group discussion guides (FGDs) and Key Informant Interviews (KIIs) were used to collect and triangulate data. ENA for SMART 2011 and SPSS version 17.0 software packages were used to key in data for analysis. Relationship between variables was determined using Chi-square and Pearson Product Moment Correlation. Three-quarter (74%) of the mothers were aged between 25 years and 34 years while most of them were homemakers (71.1%) with an average household size of 6 members. Most of the households bought their food (90.2%) with some who also waited on food aid (23.5%) to meet the deficit. Under-nutrition by Z-scores was indicated by wasting (14.7%), stunting (33.8%) and underweight (19.1%) while the mean duration of time since the discharge was 5 months. The proportion of children who were breastfed in the 24 hours preceding the study was as follows: 95.0% of 6-11months, 76.6% of 12-17months and 40.2% of 18- 23months. Nearly all children (99.0%) attained their minimum dietary diversity with the most commonly consumed food groups being grains, roots and tubers (100%) then dairy products (80.4%). More than half (59.8%) of the children received their recommended minimum meal frequency. Barely 50.7% of all the children achieved their minimum acceptable diet whereby most of them were being breastfed (71.6%). Maternal age (r=- 0.352; p=0.03) and time since discharge (r=-0.25; p=<0.001) had a significant negative association with wasting. Dietary diversity (r=0.47; p=0.045), meal frequency (r=0.53; p=0.038) and attaining minimum acceptable diet (χ²=45.71; p=<0.001) exhibited a significant relationship with wasting. In conclusion, maternal age, age of the child, breastfeeding status and period of time since SFP discharge are important regarding the child’s nutrition status. The study recommends encouragement of caregivers to continue breastfeeding to at least 2 years with enhanced follow-up after discharge where mothers are advised to visit the clinic consistently for monitoring. Further studies on caloric dietary intake and longitudinal studies are suggested to assess dietary adequacy and determine causality of relapse.

CHAPTER 1: INTRODUCTION

          Background of the Study

Nutrition status of children highly relies on interactions between foods they consume, their general health and the care they receive (KNBS, 2009). Interestingly, there has been a 37% reduction in global underweight levels from the year 1990 to 16% in 2011 (UNICEF, 2013). This progress towards underweight reduction has, however, been considered slow since more than 50% of affected countries failed to achieve the target for underweight reduction that had been set for the year, 2015 (Ainsworth & IEG, 2010). More specifically, acute food scarcity is reported to result in muscle wasting, acknowledged as acute malnutrition, which could be affirmed through the weight and height/length measurements (Park et al., 2012).

The prevalence of wasting is reported to indicate presence and extent of humanitarian crisis in a population (Chowdhury et al., 2012). The 2008 Lancet Series  on  Maternal  and Child under nutrition [as cited by Chowdhury et al., 2012], estimated that 19 million and 55 million children below the age of 5 years had severe and moderate acute malnutrition respectively. In addition, UNICEF (2013) documents an 11% decrease in the wasting levels between the years 1990 and 2011 in the global population of children. In an effort to tackle child related under nutrition, UNICEF (2013) and Eggersdorfer et al. (2013) highlight a shift of focus from reducing underweight prevalence in the population to preventing stunting. Moreover, the first 2 years of life are part of the 1000 days (window of opportunity) said to be critical in reducing the detrimental effects of malnutrition in the population (Eggersdorfer et al., 2013).

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