Kenya (Kukamega country) - Multiple Indicator Cluster Survey - 2013

Publication date: 2013

Kakamega County, Kenya Multiple Indicator Cluster Survey 2013/14 Final Report February, 2016 Kakamega County MICS 2013/14 P a g e | ii The Kakamega County Multiple Indicator Cluster Survey (MICS) was carried out in 2013/14 by by the Population Studies and Research Institute, University of Nairobi, in collaboration with Kenya National Bureau of Statistics, as part of the global MICS programme. Technical support was provided by the United Nations Children’s Fund (UNICEF). UNICEF provided financial support. UNICEF also provided financial support. The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Suggested citation: Kenya National Bureau of Statistics, Population Studies and Research Institute and United Nations Children’s Fund. 2016. Kakamega County Multiple Indicator Cluster Survey 2013/14, Final Report. Nairobi, Kenya: Kenya National Bureau of Statistics, Population Studies and Research Institute and United Nations Children’s Fund. Kakamega County MICS 2013/14 P a g e | iii Summary Table of Survey Implementation and the Survey Population, Kakamega County MICS, 2013/14 Survey implementation Sample frame Updated National Sample Survey and Evaluation Programme V (NASSEP V) November 2013 Questionnaires Household Women (age 15-49) Children under-five Interviewer training October 2013 Fieldwork November 2013 to January 2014 Survey sample Households Sampled Occupied Interviewed Response rate (Percent) 1,500 1,335 1,221 91.5 Children under-five Eligible Mothers/caretakers interviewed Response rate (Percent) 828 806 97.3 Women Eligible for interviews Interviewed Response rate (Percent) 1,225 998 81.5 Survey population Average household size 4.6 Percentage of population living in Urban areas Rural areas 46.8 53.2 Percentage of population under: Age 5 Age 18 14.9 53.8 Percentage of women age 15-49 years with at least one live birth in the last 2 years 30.6 Housing characteristics Household or personal assets Percentage of households with Electricity Finished floor Finished roofing Finished walls 17.6 32.2 91.4 28.6 Percentage of households that own A television A refrigerator Agricultural land Farm animals/livestock 27.6 3.9 79.7 72.4 Mean number of persons per room used for sleeping 2.73 Percentage of households where at least a member has or owns a Mobile phone Car or truck 87.2 3.9 Kakamega County MICS 2013/14 P a g e | iv Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Kakamega County, 2013/14 NUTRITION Breastfeeding and infant feeding MICS Indicator Indicator Description Value 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 97.5 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 30.1 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 34.7 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 61.0 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day (74.7) 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 35.5 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 19.8 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 59.5 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day (91.8) 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 27.0 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non- breastfed children) the minimum number of times or more during the previous day 68.9 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 38.6 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 22.9 12.6 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 7.2 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate 94.9 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 6.7 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 55.5 1 See Appendix G for a detailed description of MICS indicators Kakamega County MICS 2013/14 P a g e | v CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 98.2 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 92.4 3.3 Diphtheria, pertussis and tetanus (DPT) immunization coverage Percentage of children age 12-23 months who received the third dose of DPT vaccine (DPT3) by their first birthday 93.3 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 86.3 3.5 Hepatitis B immunization coverage Percentage of children age 12-23 months who received the third dose of Hepatitis B vaccine (HepB3) by their first birthday 93.7 3.6 Haemophilus influenzae type B (Hib) immunization coverage Percentage of children age 12-23 months who received the third dose of Hib vaccine (Hib3) by their first birthday 91.9 3.8 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 78.2 Tetanus toxoid 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 72.2 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 17.8 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 39.9 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 16.4 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 56.5 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 5.0 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider (59.2) 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics (67.8) Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 95.0 Kakamega County MICS 2013/14 P a g e | vi Malaria / Fever MICS Indicator Indicator Description Value - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 27.4 3.16a 3.16b Household availability of insecticide-treated nets (ITNs) Percentage of households with (a) at least one ITN (b) at least one ITN for every two people 77.3 44.6 3.17a 3.17b Household vector control Percentage of households (a) with at least one ITN or that have been sprayed by IRS in the last 12 months (b) with at least one ITN for every two people or that have been sprayed by IRS in the last 12 months 78.3 46.6 3.18 MDG 6.7 Children under age 5 who slept under an ITN Percentage of children under age 5 who slept under an ITN the previous night 70.5 3.19 Population that slept under an ITN Percentage of household members who slept under an ITN the previous night 61.6 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 49.7 3.21 Malaria diagnostics usage Percentage of children under age 5 with fever in the last 2 weeks who had a finger or heel stick for malaria testing 23.9 3.22 MDG 6.8 Anti-malarial treatment of children under age 5 Percentage of children under age 5 with fever in the last 2 weeks who received any antimalarial treatment 45.0 3.23 Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti- malarial treatment Percentage of children under age 5 with fever in the last 2 weeks who received ACT (or other first-line treatment according to national policy) 27.5 3.24 Pregnant women who slept under an ITN Percentage of pregnant women who slept under an ITN the previous night 79.5 3.25 Intermittent preventive treatment for malaria during pregnancy Percentage of women age 15-49 years who received three or more doses of SP/Fansidar, at least one of which was received during an ANC visit, to prevent malaria during their last pregnancy that led to a live birth in the last 2 years 24.9 WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 79.4 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 56.0 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 42.3 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 85.6 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 5.0 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 75.5 Kakamega County MICS 2013/14 P a g e | vii REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women age 15-49 years 4.7 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 93 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 28.2 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 61.5 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 22.2 Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 95.3 38.6 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 70.2 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 53.4 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 51.6 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 5.8 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 66.9 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 67.5 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 60.4 CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 40.0 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 63.3 Kakamega County MICS 2013/14 P a g e | viii CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 2.6 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 16.1 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 3.7 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 69.3 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 40.1 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social- emotional, and learning 72.0 LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young women Percentage of young women age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 86.3 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 60.3 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 60.6 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 89.4 7.S1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary (primary 1-8; national) or secondary school 91.2 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 55.6 7.S2 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school (national) or higher 33.5 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 99.1 7.S3 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade (primary 8; national) 90.0 7.7 Primary completion rate Percentage of children attending the last grade of primary school (excluding repeaters) 128.1 7.S4 Primary completion rate Percentage of children attending the last grade of primary school (excluding repeaters) (national) 80.0 7.8 Transition rate to secondary school Percentage of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year 92.7 Kakamega County MICS 2013/14 P a g e | ix 7.S5 Transition rate to secondary school Percentage of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year (national) 35.6 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 1.10 7.S6 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys (national) 1.07 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.28 7.S7 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys (national) 1.23 CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 49.6 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 44.9 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 81.7 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of women age 15-49 years who were first married or in union before age 15 5.6 8.5 Marriage before age 18 Percentage of women age 20-49 years who were first married or in union before age 18 29.8 8.6 Young women age 15-19 years currently married or in union Percentage of young women age 15-19 years who are married or in union 13.8 8.7 Polygyny Percentage of women age 15-49 years who are in a polygynous union 16.3 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years (*) 16.4 Female genital mutilation/cutting 8.9 Approval for female genital mutilation/cutting (FGM/C) Percentage of women age 15-49 years who state that FGM/C should be continued 2.8 8.10 Prevalence of FGM/C among women Percentage of women age 15-49 years who report to have undergone any form of FGM/C 1.2 8.11 Prevalence of FGM/C among girls Percentage of daughters age 0-14 years who have undergone any form of FGM/C, as reported by mothers age 15-49 years 0.1 Kakamega County MICS 2013/14 P a g e | x Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of women age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 57.4 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 18.2 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 9.9 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 0.1 HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of women age 15-49 years who have heard of AIDS 99.9 9.1 MDG 6.3 Knowledge about HIV prevention among young people Percentage of young women age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 45.5 9.2 Knowledge of mother-to- child transmission of HIV Percentage of women age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV 46.5 9.3 Accepting attitudes towards people living with HIV Percentage of women age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 33.6 HIV testing 9.4 People who know where to be tested for HIV Percentage of women age 15-49 years who state knowledge of a place to be tested for HIV 95.3 9.5 People who have been tested for HIV and know the results Percentage of women age 15-49 years who have been tested for HIV in the last 12 months and who know their results 45.4 9.6 Sexually active young people who have been tested for HIV and know the results Percentage of young women age 15-24 years who have had sex in the last 12 months, who have been tested for HIV in the last 12 months and who know their results 58.0 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 65.1 9.8 HIV testing during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 81.1 Sexual behaviour 9.9 Young people who have never had sex Percentage of never married young women age 15-24 years who have never had sex 61.9 9.10 Sex before age 15 among young people Percentage of young women age 15-24 years who had sexual intercourse before age 15 5.6 Kakamega County MICS 2013/14 P a g e | xi 9.11 Age-mixing among sexual partners Percentage of women age 15-24 years who had sex in the last 12 months with a partner who was 10 or more years older 12.9 9.12 Multiple sexual partnerships Percentage of women age 15-49 years who had sexual intercourse with more than one partner in the last 12 months 1.7 9.13 Condom use at last sex among people with multiple sexual partnerships Percentage of women age 15-49 years who report having had more than one sexual partner in the last 12 months who also reported that a condom was used the last time they had sex (*) 9.14 Sex with non-regular partners Percentage of sexually active young women age 15-24 years who had sex with a non-marital, non-cohabitating partner in the last 12 months 15.9 9.15 MDG 6.2 Condom use with non- regular partners Percentage of young women age 15-24 years reporting the use of a condom during the last sexual intercourse with a non-marital, non-cohabiting sex partner in the last 12 months 65.2 Orphans 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non-orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents (0.90) ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 Exposure to mass media Percentage of women age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 7.1 Use of information/communication technology 10.2 Use of computers Percentage of young women age 15-24 years who used a computer during the last 12 months 15.1 10.3 Use of internet Percentage of young women age 15-24 years who used the internet during the last 12 months 15.2 SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.1 Life satisfaction Percentage of young women age 15-24 years who are very or somewhat satisfied with their life, overall 81.7 11.2 Happiness Percentage of young women age 15-24 years who are very or somewhat happy 79.9 11.3 Perception of a better life Percentage of young women age 15-24 years whose life improved during the last one year, and who expect that their life will be better after one year 56.2 TOBACCO AND ALCOHOL USE Tobacco use MICS Indicator Indicator Description Value 12.1 Tobacco use Percentage of women age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month 0.3 Kakamega County MICS 2013/14 P a g e | xii 12.2 Smoking before age 15 Percentage of women age 15-49 years who smoked a whole cigarette before age 15 0.1 Alcohol use 12.3 Use of alcohol Percentage of women age 15-49 years who had at least one alcoholic drink at any time during the last one month 4.9 12.4 Use of alcohol before age 15 Percentage of women age 15-49 years who had at least one alcoholic drink before age 15 2.8 Kakamega County MICS 2013/14 P a g e | xiii Table of Contents Summary Table of Survey Implementation and the Survey Population, Kakamega County MICS, 2013/14 . iii Summary Table of Findings . iv Table of Contents. xiii List of Tables . xvi List of Figures . xx List of Abbreviations . xxi Foreword . xxiii Acknowledgements . xxv Executive Summary . xxvi 1. Introduction . 1 1.1 Background . 1 1.2 Survey Objectives. 3 2. Sample and Survey Methodology . 4 2.1 Sample Design . 4 2.2 Questionnaires . 4 2.3 Training and Fieldwork . 6 2.4 Data Processing . 6 3. Sample Coverage and the Characteristics of Households and Respondents. 7 3.1 Sample Coverage . 7 3.2 Characteristics of Households . 8 3.3 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Years . 11 3.4 Housing characteristics, asset ownership, and wealth quintiles . 14 4. Nutrition. 18 4.1 Birth Weight. 18 4.2 Breastfeeding and Infant and Young Child Feeding . 20 4.3 Salt Iodization . 30 5. Child Health . 32 5.1 Vaccinations . 32 5.2 Neonatal Tetanus Protection . 38 5.3 Care of Illness . 39 5.3.1 Diarrhoea . 41 Kakamega County MICS 2013/14 P a g e | xiv 5.3.2 Acute Respiratory Infections . 51 5.3.3 Solid Fuel Use . 52 5.3.4 Malaria/Fever . 55 6. Water and Sanitation . 76 6.1 Use of Improved Water Sources . 76 6.2 Use of Improved Sanitation . 82 6.3 Handwashing . 92 7. Reproductive Health . 96 7.1 Fertility . 96 7.2 Contraception . 101 7.3 Unmet Need . 104 7.4 Antenatal Care (ANC) . 107 7.5 Assistance at Delivery . 110 7.6 Place of Delivery . 114 7.7 Post-natal Health Checks . 115 8. Early Childhood Development . 122 8.1 Early Childhood Care and Education . 122 8.2 Quality of Care . 123 8.3 Developmental Status of Children . 130 9. Literacy and Education . 132 9.1 Literacy among Young Women . 132 9.2 School Readiness . 133 9.3 Primary and Secondary School Participation . 134 10. Child Protection . 148 10.1 Birth Registration . 148 10.2 Child Labour . 151 10.3 Child Discipline . 156 10.4 Early Marriage and Polygyny . 159 10.5 Female Genital Mutilation/Cutting. 164 10.6 Attitudes toward Domestic Violence . 167 10.7 Children’s Living Arrangements . 169 11. HIV/AIDS and Sexual Behaviour . 172 11.1 Knowledge about HIV Transmission and Misconceptions about HIV . 172 11.2 Knowledge of mother-to-child HIV transmission (MTCT) . 176 11.3 Accepting Attitudes toward People Living with HIV . 178 11.4 Knowledge of a Place for HIV Counselling and Testing during Antenatal Care. 179 Kakamega County MICS 2013/14 P a g e | xv 11.5 Sexual Behaviour Related to HIV Transmission . 182 11.6 HIV Indicators for Young Women . 184 12.7 Orphans . 190 12. Access to Mass Media and Use of Information/Communication Technology. 192 12.1 Access to Mass Media . 192 12.2 Use of Information/Communication Technology . 193 13. Subjective well-being . 195 14. Tobacco and Alcohol Use . 201 14.1 Tobacco Use . 201 14.2 Alcohol Use . 203 Appendix A. Documents Reviewed . 205 Appendix B. Education ISCED Tables . 212 Appendix C. Sample Design . 218 Appendix D. Estimates of Sampling Errors . 222 Appendix E. List of Personnel Involved in the Survey . 227 Appendix F. Data Quality Tables . 229 Appendix G. Kakamega County MICS5 Indicators: Numerators and Denominators . 245 Appendix H. Kakamega County MICS Questionnaires . 258 Kakamega County MICS 2013/14 P a g e | xvi List of Tables Table HH.1: Results of household, women's, men's and under-5 interviews . 7 Table HH.2: Household age distribution by sex . 8 Table HH.3: Household composition . 10 Table HH.4: Women's background characteristics . 12 Table HH.5: Under-5's background characteristics. 13 Table HH.6: Housing characteristics . 14 Table HH.7: Household and personal assets . 15 Table HH.8: Wealth quintiles . 16 Table NU.1: Low birth weight infants . 19 Table NU.2: Guiding Principles for Feeding children age 6-23 months . 20 Table NU.3: Initial breastfeeding . 21 Table NU.4: Breastfeeding . 23 Table NU.5: Duration of breastfeeding . 23 Table NU.6: Age-appropriate breastfeeding . 24 Table NU.7: Infant and young child feeding (IYCF) practices . 26 Table NU.8: Bottle feeding . 28 Table NU.9: Iodized salt consumption . 29 Table CH.1: Vaccinations in the first years of life . 33 Table CH.2: Vaccinations by background characteristics . 35 Table CH.3: Neonatal tetanus protection . 37 Table CH.4: Reported disease episodes . 39 Table CH.5: Care-seeking during diarrhoea . 40 Table CH.6: Feeding practices during diarrhoea . 42 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 44 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 46 Table CH.9: Source of ORS and zinc . 48 Table CH.10: Knowledge of the two danger signs of pneumonia . 49 Table CH.11: Solid fuel use . 51 Table CH.12: Solid fuel use by place of cooking . 52 Table CH.13: Household availability of insecticide treated nets and protection by a vector control method . 55 Table CH.14: Access to an insecticide treated net (ITN) - number of household members . 57 Table CH.15: Access to an insecticide treated net (ITN) - background characteristics . 57 Table CH.16: Use of ITNs . 58 Table CH.17: Children sleeping under mosquito nets . 59 Table CH.18: Use of mosquito nets by the household population. 61 Table CH.19: Care-seeking during fever . 62 Table CH.20: Treatment of children with fever . 64 Table CH.21: Diagnostics and anti-malarial treatment of children . 66 Table CH.22: Source of anti-malarial . 68 Table CH.23: Pregnant women sleeping under mosquito nets . 70 Table CH.24: Intermittent preventive treatment for malaria . 71 Table WS.1: Use of improved water sources . 74 Table WS.2: Household water treatment . 76 Table WS.3: Time to source of drinking water . 77 Kakamega County MICS 2013/14 P a g e | xvii Table WS.4: Person collecting water . 78 Table WS.5: Types of sanitation facilities . 80 Table WS.6: Use and sharing of sanitation facilities . 82 Table WS.7: Drinking water and sanitation ladders . 86 Table WS.8: Disposal of child's faeces . 88 Table WS.9: Water and soap at place for handwashing . 90 Table WS.10: Availability of soap or other cleansing agent . 91 Table RH.1: Fertility rates . 93 Table RH.2: Adolescent birth rate and total fertility rate . 94 Table RH.3: Early childbearing . 94 Table RH.4: Trends in early childbearing . 96 Table RH.5: Use of contraception . 98 Table RH.6: Unmet need for contraception . 102 Table RH.7: Antenatal care coverage . 104 Table RH.8: Number of antenatal care visits and timing of first visit . 105 Table RH.9: Content of antenatal care . 106 Table RH.10: Assistance during delivery and caesarean section . 108 Table RH.11: Place of delivery . 110 Table RH.12: Post-partum stay in health facility . 111 Table RH.13: Post-natal health checks for newborns . 113 Table RH.14: Post-natal health checks for mothers . 114 Table RH.15: Post-natal health checks for mothers and newborns . 115 Table CD.1: Early childhood education. 118 Table CD.2: Support for learning . 120 Table CD.3: Learning materials . 123 Table CD.4: Inadequate care . 124 Table CD.5: Early child development index . 126 Table ED.1: Literacy (young women). 128 Table ED.2: School readiness . 129 Table ED.3: Primary school entry . 130 Table ED.4: Primary school attendance and out of school children . 131 Table ED.5: Secondary school attendance and out of school children . 134 Table ED.6: Children reaching last grade of primary school . 137 Table ED.7: Primary school completion and transition to secondary school. 138 Table ED.8: Education gender parity . 139 Table ED.9: Out of school gender parity . 140 Table ED.10: Summary of education indicators (ISCED) . 142 Table CP.1: Birth registration . 145 Table CP.2: Children's involvement in economic activities . 148 Table CP.3: Children's involvement in household chores . 149 Table CP.4: Child labour . 150 Table CP.5: Child discipline . 152 Table CP.6: Attitudes toward physical punishment . 153 Table CP.7: Early marriage and polygyny (women) . 155 Table CP.8: Trends in early marriage (women) . 157 Table CP.9: Spousal age difference . 158 Table CP.10: Female genital mutilation/cutting (FGM/C) among women . 159 Kakamega County MICS 2013/14 P a g e | xviii Table CP.11: Female genital mutilation/cutting (FGM/C) among girls . 160 Table CP.12: Approval of female genital mutilation/cutting (FGM/C) . 161 Table CP.13: Attitudes toward domestic violence (women) . 162 Table CP.14: Children's living arrangements and orphanhood . 164 Table CP.15: Children with parents living abroad . 165 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women) . 168 Table HA.2: Knowledge of mother-to-child HIV transmission (women) . 171 Table HA.3: Accepting attitudes toward people living with HIV (women) . 172 Table HA.4: Knowledge of a place for HIV testing (women) . 174 Table HA.5: HIV counselling and testing during antenatal care . 175 Table HA.6: Sex with multiple partners (women) . 176 Table HA.7: Key HIV and AIDS indicators (young women) . 178 Table HA.8: Key sexual behaviour indicators (young women) . 181 Table HA.9: School attendants of orphans and non-orphans . 184 Table MT.1: Exposure to mass media (women) . 186 Table MT.2: Use of computers and internet (women) . 187 Table SW.1: Domains of life satisfaction (women) . 189 Table SW.2: Overall life satisfaction and happiness (women) . 191 Table SW.3: Perception of a better life (women) . 192 Table TA.1: Current and ever use of tobacco (women) . 195 Table TA.2: Age at first use of cigarettes and frequency of use (women) . 196 Table TA.3: Use of alcohol (women) . 197 Appendices: Table ED.4: Primary school attendance and out of school children (ISCED). 205 Table ED.5: Secondary school attendance and out of school children (ISCED) . 206 Table ED.7: Primary school completion and transition to secondary school (ISCED) . 208 Table ED.8: Education gender parity (ISCED) . 208 Table ED.9: Out of school gender parity (ISCED) . 210 Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata . 212 Table SE.1: Indicators selected for sampling error calculations . 216 Table SE.2: Sampling errors: Total sample . 217 Table SE.3: Sampling errors: Urban . 218 Table SE.4: Sampling errors: Rural . 219 Table DQ.1: Age distribution of household population . 222 Table DQ.2: Age distribution of eligible and interviewed women . 223 Table DQ.4: Age distribution of children in household and under-5 questionnaires . 224 Table DQ.5: Birth date reporting: Household population . 224 Table DQ.6: Birth date and age reporting: Women . 225 Table DQ.8: Birth date and age reporting: Under-5s . 225 Table DQ.9: Birth date reporting: Children, adolescents and young people . 225 Table DQ.10: Birth date reporting: First and last births. 226 Kakamega County MICS 2013/14 P a g e | xix Table DQ.11: Completeness of reporting . 226 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . 227 Table DQ.13: Completeness of information for anthropometric indicators: Stunting . 227 Table DQ.14: Completeness of information for anthropometric indicators: Wasting . 228 Table DQ.15: Heaping in anthropometric measurements . 228 Table DQ.16: Observation of birth certificates . 229 Table DQ.17: Observation of vaccination cards . 230 Table DQ.18: Observation of women's health cards . 230 Table DQ.19: Observation of bednets and places for handwashing . 231 Table DQ.20: Presence of mother in the household and the person interviewed for the under-5 questionnaire . 231 Table DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 232 Table DQ.22: School attendance by single age . 233 Table DQ.23: Sex ratio at birth among children ever born and living . 234 Table DQ.24: Births in years preceding the survey . 235 Table DQ.25: Reporting of age at death in days . 236 Table DQ.26: Reporting of age at death in months . 237 Kakamega County MICS 2013/14 P a g e | xx List of Figures Figure WS.1: Percent distribution of household members by source of drinking water . 75 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities . 83 Figure WS.3: Use of improved drinking water sources and improved sanitation facilities by household members . 86 Figure WS.4: Use of Improved water and sanitation in urban and rural areas . 87 Figure RH.1: Differentials in contraceptive use . 100 Figure RH.2: Person assisting at delivery . 110 Figure RH.3: Place of delivery and post-natal health checks . 116 Figure ED.1: Education indicators by sex . 141 Figure CP.1: Children under-5 whose births are registered . 146 Figure CP.2: Child disciplining methods, children age 1-14 years . 153 Figure CP.3: Early marriage among women . 158 Figure HA.1: Women with comprehensive knowledge of HIV transmission . 170 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . 173 Figure HA.3: Sexual behaviour that increases the risk of HIV infection, young people age 15-24 years . 183 Appendix: Figure DQ.1: Number of household population by single ages . 223 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points. 229 Kakamega County MICS 2013/14 P a g e | xxi List of Abbreviations ACRWC African Charter on the Rights and Welfare of the Child ACT Artemisinin-based Combination therapy AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ARI Acute Respiratory Infection ART Anti‐retroviral Therapy ASFRs Age-specific Fertility Rates BCC Behaviour Change Communication BCG Bacillus Calmette-Guérin (Tuberculosis) CARMMA Campaign on Accelerated Reduction of Maternal Mortality in Africa CBR Crude Birth Rate CEDAW Convention on the Elimination of all forms of Discrimination Against Women CRC Convention on the rights of the Child CSP Country Strategy Paper CSPro Census and Survey Processing System DOMC Division of Malaria Control DPT Diphtheria Pertussis Tetanus DVI Division of Vaccine and Immunisation EA Enumeration area ECD Early Childhood Development ECDE Early Childhood Development and Education ECDI Early Child Development Index EFA Education for All EHP Essential Health Package EMTCT Elimination of Mother-to-Child Transmission of HIV EPI Expanded Programme on Immunization FCTC Framework Convention on Tobacco Control FGM/C Female genital mutilation/cutting FNSP Food and Nutrition Security Policy GAPPD Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea GARPR Global AIDS Response Progress Reporting GFR General Fertility Rate GIPA Greater Involvement of People Living with HIV and AIDS GMAP Global Malaria Action Plan GPI Gender Parity Index GVAP Global Vaccine Action Plan HIV Human Immunodeficiency Virus ICPD International Conference on Population and Development ICT Information and Communications Technology IDD Iodine Deficiency Disorders ILO International Labour Organization IPT Intermittent Preventive Treatment IPTp Intermittent Preventive Treatment of Pregnant women IRS Indoor Residual Spraying ITN Insecticide Treated Net IUD Intrauterine Device JMP Joint Monitoring Programme KASF Kenya AIDS Strategic Framework Kakamega County MICS 2013/14 P a g e | xxii KCPE Kenya Certificate of Primary Education KCSE Kenya Certificate of Secondary Education KDHS Kenya Demographic and Health Survey KEBS Kenya Bureau of Standards KEPI Kenya Expanded Programme on Immunization KHPF Kenya Health Policy Framework KNASP Kenya National AIDS Strategic Plan KNBS Kenya National Bureau of Statistics LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MoH Ministry of Health MTP Medium Term Plans NAR Net Attendance Rate NASSEP V National Sample Survey and Evaluation Programme V NHSSP II National Health Sector Strategic Plan II NNAP National Nutrition Action Plan NTFIC National Tobacco Free Initiative Committee ORS Oral Rehydration Salts ORT Oral rehydration treatment PMI Presidents Malaria Initiative PMTC Prevention of Mother to Child Transmission PNC Post-natal Care PNHC Post-natal Health Checks PPM Parts Per Million PSRI Population Studies and Research Institute, University of Nairobi RHF Recommended Home Fluid SP Sulfadoxine-Pyrimethamine SPSS Statistical Package for Social Sciences STIs Sexually Transmitted Infections SUN Scaling Up Nutrition TFR Total Fertility Rate UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization Kakamega County MICS 2013/14 P a g e | xxiii Foreword The 2013/14 Multiple Indicator Cluster Survey (MICS5) covering Bungoma, Kakamega and Turkana Counties are part of the fifth global round of Multiple Indicator Cluster Survey series conducted worldwide to provide up-to-date information on the situation of children and women. This survey was conducted in collaboration with the Population Studies and Research Institute (PSRI) of the University of Nairobi, the Kenya National Bureau of Statistics (KNBS) and United Nations Children’s Fund (UNICEF). The results of this survey provide requisite baseline information that can be used to facilitate evidence-based planning, budgeting and programming by policymakers and stakeholders at the county levels. The reports will go a long way in encouraging increased demand for use of statistics by policy makers at devolved levels; ensure that resources at both county and national levels are used most effectively through well-planned projects/programmes that will benefit especially the women and children of the three counties. MICS5 was conducted at county level to provide comprehensive and disaggregated data to partly fill the existing data gaps at this level. This survey is the second of its kind to be conducted at the devolved level after MICS4 was conducted in the six counties of the Nyanza region in 2011. MICS3 was conducted in all the 13 districts of the then Eastern Province in 2008. The MICS5 results are critical in gauging milestones achieved in the field of education, nutrition, child development, and health for women and children in the three counties and in evaluating the various health based policies that the Government has formulated over the years towards achieving the national welfare objectives. More specifically, the 2013/14 MICS5 data is critical in informing the future planning for the three counties, especially in view of the new constitutional dispensation and Vision 2030. It is anticipated that MICS5 will supplement the data collected during 2014 Kenya Demographic and Health Survey (KDHS). In addition, the information collected will inform strategic communication for social and behaviour change interventions by Government and partners including UNICEF. Furthermore, the data will contribute to the improvement of data and monitoring systems in the three counties. The survey laid emphasis on quality in every step of the process, right from the design of the tools, training of interviewers, monitoring of data collection, and the whole process of data processing. The MICS5 has much to offer to the health and family planning professionals, government planners, NGOs, researchers, and gender specialists. The potential users are numerous. It is, therefore, our appeal that the findings of MICS5 be put into good use so as to improve the well-being of people in the counties; to prepare reasonable and realistic objectives for county projects; to draw attention to critical problems and inequities; and to determine budgetary priorities. This report is a culmination of concerted efforts of various organizations and individuals. I have the greatest pleasure to give credit to the technical and financial assistance from UNICEF. I wish to appreciate the organizations, especially Population Studies and Research Institute of the University of Nairobi, that have contributed so much time, energy, and expertise to providing these findings and results. In addition I commend the hard work and dedication of Kenya National Bureau of Statistics (KNBS) staff in assisting to plan and implement this Survey. I thank the interviewers, editors, supervisors, who traversed the three counties, knocking on doors and spending hours talking to household respondents to generate the data. They faced a variety of challenges from occasional vehicle breakdowns, bad terrains, changing weather to basic accommodation. I wish to thank the Kakamega County MICS 2013/14 P a g e | xxiv respondents who generously and voluntarily provided the information. Without them, there would have been no report to talk about. Much gratitude goes to the data processing specialists and data editors for dedicating their time and expertise to put together quality data. All of them did a tremendous job. Zachary Mwangi Director General, Kenya National Bureau of Statistics Kakamega County MICS 2013/14 P a g e | xxv Acknowledgements Kenya implemented the Multiple Indicator Cluster Survey (MICS5) in 2013/2014 in the three counties of Bungoma, Kakamega and Turkana as part of Global MICS round five. MICS is an international household survey programme developed by UNICEF. MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. In Kenya, this information is important to guide the planning and implementation of new development plans targeting the new administrative County -levels of governance. The successful implementation of the MICS5 was due to the great support and dedication of the partners. Kenya would like to thank the following collaborating organizations:  United Nations Children’s Fund  Kenya National Bureau of Statistics We do appreciate the financial support provided by the United Nations Children’s Fund. Special thanks go to the technical experts from the Kenya National Bureau of Statistics and Population Studies and Research Institute (PSRI) who ensured that the survey was implemented efficiently and effectively to produce quality results. These experts included officers from the collaborating institutions. They exhibited high degree of professionalism during the preparatory work prior and during the implementation stage as well as during the data analysis and report writing. We also thank the UNICEF Regional Office for East and Southern Africa and UNICEF Kenya Country Office for the technical support provided to Kenya during MICS5. We especially recognize and appreciate the support of Dr. Paul Mpuga, Dr. Monica Chizororo, Mr. Nicholas Oloo, Dr. Robert Ndugwa, Dr John Ndegwa Wagai and Dr. Nyasha Madzingira. Our deepest gratitude goes to the Kenyan Core Technical team responsible for implementing the MICS5. The team consisted of technical staff from the PSRI lead by Prof. Lawrence Ikamari supported by Mr. Ben Obonyo, Dr. Wanjiru, Dr. Samuel Wakibi, Dr Andew Mutuku and Dr. Odipo. The survey could not have been such a success without the guidance and expertise of the Kenya National Bureau of Statistics. In particular, the immeasurable support, advice and guidance of Mr. Zachary Mwangi – Director General, KNBS, Mr Macdonald Obutho – Director Population and Social Statistics, Mr. Robert Buluma, Mr. James Ng’ang’a and Bernard Obasi. This core team effectively implemented the entire MICS5 household survey. Finally, the most heartfelt gratitude goes to the County Statistical Officers in Bungoma, Kakamega and Turkana; Supervisors, KNBS enumerators, Research Assistants, the Village Elders and all the respondents who participated in the generation of data that made this survey successful. Prof. Murungaru Kimani Director Population Studies and Research Institute University of Nairobi Kakamega County MICS 2013/14 P a g e | xxvi Executive Summary The Kakamega County Multiple Indicator Survey (MICS) is a representative sample survey designed to provide estimates for a large number of indicators on the situation of children and women at the county level, for urban and rural areas. The survey used two-stage stratified cluster sampling where the first stage selected 50 clusters from the KNBS fifth National Sample Survey and Evaluation Program (NASSEP V) household-based master sampling frame using equal probability selection method (EPSEM). The second stage randomly selected a uniform sample of 30 households in each cluster from a list of households in the cluster using systematic random sampling method. The survey was implemented by the University of Nairobi through Population studies and Research Institute in collaboration with Kenya National Bureau of Statistics (KNBS) with support from UNICEF Kenya. Information was collected from a total of 1,221 households representing 92 percent response rate. The composition of these households was 5,666 household members comprising 2,752 males and 2,914 females. The mean household size was 4.6 persons. About 46 percent of the sampled households’ population is below 15 years, 50 percent are age 15-64 years, and four percent are age 65 years and above. Due to data quality issues, data relating to mortality and anthropometric measures were not analyzed and reported. Anthropometric data suffered from digit preference for both weight and height, while for mortality, deaths especially among under-5 years old were under reported. KDHS 2014 had similar shortcomings. Nutrition Weight at birth is a good indicator not only of a mother's health and nutritional status but also the new-born’s chances for survival, growth, long-term health and psychosocial development. The survey findings show that 56 percent of births were weighed at birth and approximately seven percent of infants weighed less than 2,500 grams at birth. Ninety-eight percent of the children were ever breastfed and only 30 percent of babies were breastfed for the first time within one hour of birth. Approximately 35 percent of children age less than six months were exclusively breastfed. By age 12- 15 months (75 percent) and 20-23 months (36 percent) were still being breastfed. Among children under age 3 years, the median duration of any breastfeeding was 20 months. Percentage of children age who were age appropriately breastfed during the previous day of the survey was 60 percent for 0-23 months. The overall assessment using the indicator of minimum acceptable diet revealed that only 20 percent of children age 6-23 months were benefitting from a diet sufficient in both diversity and frequency. Seven percent of children under 6 months were fed using a bottle with a nipple during the previous day of the survey. In 95 percent of households, salt was found to contain at least 15 parts per million (ppm) or more of iodine. Child Health Immunization plays a key part in reducing preventable child diseases and mortality. The percentage of children who were fully vaccinated by their first birthday is 67 percent. Overall, 77 percent of children age12-23 months were fully vaccinated against vaccine preventable childhood diseases while 96 percent were vaccinated against measles. About 18 percent of children under-5 years were reported to have had diarrhoea in the two weeks preceding the survey, five percent symptoms of ARI, and 27 percent an episode of fever. Overall, a health facility or provider was seen in 40 percent of cases among children with diarrhoea. Eighty-nine percent of the children with diarrhoea received one Kakamega County MICS 2013/14 P a g e | xxvii or more of the recommended home treatments (i.e. were treated with ORS or any recommended homemade fluid), while 22 percent received zinc. In addition, 16 percent received ORS and zinc. Seventy-seven percent of households had at least one insecticide treated net and 71 percent slept children under-five years slept under an ITN the night preceding the survey. Advice was sought from a health facility or a qualified health care provider for half (50 percent) of the children with fever and was higher among males (54 percent) compared with females (46 percent). Overall, 24 percent of children with a fever in the previous two weeks had blood taken from a finger or heel for testing. Thirty-two percent of males and 17 percent of females had their blood taken for testing. Eighty percent slept under an Insecticide Treated Net, the night prior to the survey. Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant determinant of diseases such as cholera, typhoid, and schistosomiasis. Drinking water can also be contaminated with chemical and physical contaminants with harmful effects on human health. In addition to preventing disease, improved access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. In Kakamega, 79 percent of the population use an improved source of drinking water. Fifty-six percent of household members in households using unimproved drinking water sources are using an appropriate water treatment method. For a quarter of the household population, it takes the household member 30 minutes or more to get to the water source and bring water from an improved water source. In the majority of households (78 percent), an adult female usually collects drinking water when the source was not on the premises. Twenty-three percent of households use an improved toilet facility that is public or shared with other households. In Kakamega County, the percentage of households where a place for hand washing was observed is 10 percent. Ninety percent of the households had no specific place for hand washing in the dwelling, yard, or plot. Reproductive Health Empowering women and adolescent girls to exercise their sexual and reproductive health rights is a necessary condition for sustainable development. The findings show that age specific fertility rate and birth rate for the three years preceding the survey fertility is 93 births per 1,000 women among adolescents age 15-19 years. Sixteen percent of women age 15-19 years had already had a birth, three percent were pregnant with their first child. Four percent of women age 15-49 years have had a live birth before age 15. The proportion of women with a live birth before age 15 is four percent in urban areas and five percent in rural areas. Contraception by women currently married or in union is 62 percent and one in three married women use injectables. Total unmet need for family planning is 22 percent. Ninety-five percent of the women received ANC from a skilled health provider. Among those women who had a live birth during the last two years preceding the survey, 70 percent had blood pressure checked, urine and blood samples taken. More than half of births occurring in the two years preceding the MICS were delivered by skilled personnel. About 52 percent of births were delivered in a health facility. Overall, 67 percent of women who gave birth in a health facility stayed 12 hours or more in the facility after delivery. Sixty-five percent of newborns received a health check following birth while in a health facility or at home and 59 percent of mothers received a health check following birth while in a health facility or at home. Kakamega County MICS 2013/14 P a g e | xxviii Early Childhood Development In Kakamega County, about 40 percent of children age 36-59 months are attending an organised early childhood education programme. Sixty-three percent of children age 36-59 months have an adult household member engaged in four or more activities that promote learning and school readiness. The father’s involvement in such activities was low, with only three percent of children age 36-59 months with fathers involved in four or more activities. Mother’s engagement in four or more activities that promote learning during the three days preceding the survey was higher at 16 percent. Availability of children’s books for those age 0-59 months was low, with only four percent of children living in households where at least 3 children’s books were present. Sixty-nine percent of children age 0-59 months had two or more types of playthings to play with in their homes. A total of 40 percent of children were left with inadequate care, either by being left alone or in the care of another child. Child development index is calculated as the percentage of children who are developmentally on target in at least three of the four component domains such as language- cognitive, physical, social-emotional, and approaches to learning. In Kakamega County, 72 percent of children age 36-59 months are developmentally on track. Literacy and Education Youth Literacy Rate as a measure of the effectiveness of the primary education system is often seen as a proxy measure of social progress and economic achievement. Sixty percent of children who were attending the first grade of primary school at the time of the survey were attending pre-primary school the previous year. About 86 percent of young women age 15-24 years were literate. Among those with primary school as their highest level of education, 76 percent were able to read the statement shown to them. Nine percent of children age 6-13 years were out of school, with a low attendance rate of 65 percent for children age 6, who appeared to be starting late in school. Twenty percent of the children of secondary school age were out of school. The majority of all children starting grade 1 were expected to reach grade 8 (90 percent). The gender parity index (GPI) for primary school was 1.07, suggesting boys and girls of primary school age attended primary education at the same rate. The GPI for secondary education was 1.23, indicating a higher secondary school attendance rate among girls of secondary age than among boys of the same age. Child Protection A name and nationality is every child’s right, enshrined in the Convention on the Rights of the Child (CRC) and other international treaties. The findings show that the births of 50 percent of children under-five years are registered. Male children (54 percent) are more likely to have their births registered than female children (46 percent). The percentage of children age 12-14 years involved in economic activities for 14 hours or more is 19 percent, while two percent of children age 15-17 years were involved in economic activities for 43 hours or more. About 82 percent of children age 1-14 years were subjected to at least one form of psychological aggression or physical punishment by household members during the past month. Among women age 15-49 years, 6 percent were married before age 15 and, among women age 20-49 years, 11 percent were married before age 15 while 32 percent were married before age 18. Among currently married/in union women age 20-24 years, about 16 percent are married/in union to a man who is older by ten years or more. Kakamega County MICS 2013/14 P a g e | xxix About one percent of women in Kakamega County have some form of female genital mutilation. Three percent of women believe FGM should be continued while 92 percent believe it should be discontinued. Overall, 57 percent of women feel that a husband/partner is justified in hitting or beating his wife in at least one of the five situations (if she goes out without telling her husband, neglects children, argues with husband, if the wife refuses to have sex with the husband if she burns the food). Nearly 18 percent of children live with neither of their biological parents and the proportion is higher in rural areas (21 percent) than urban areas (15 percent). HIV/AIDS and Sexual Behaviour Almost all women age 15-49 years (99.9 percent) in Kakamega County have knowledge of AIDS. Seventy-two percent know of the two main ways of preventing HIV transmission, with 84 percent knowing having only one faithful uninfected partner and 85 percent know using a condom every time as main ways of preventing HIV transmission. Overall, 47 percent of women have comprehensive knowledge of HIV prevention methods and transmission which is higher in urban (50 percent) than rural areas (44 percent) and also varies with education and wealth status. In total, 61 percent of women rejected the two most common misconceptions that HIV can be transmitted through mosquito bites (78 percent) and by sharing food with someone with HIV (90 percent) and know that a healthy-looking person (84 percent) can be HIV-positive. About 91 percent and 78 percent of women know that supernatural means and mosquito bites cannot transmit HIV, respectively. Ninety-seven percent of women age 15-49 years know that HIV can be transmitted from mother to child by at least one of the three means; during pregnancy, delivery and breastfeeding while 47 percent of women know all three ways of mother-to-child transmission. Ninety-nine percent of women age 15-49 years who have heard of AIDS agreed with at least one accepting statement. The most common accepting attitude is willingness to care for a family member with AIDS in own home (96 percent). More educated women tend to have a more accepting attitude than those with no education. Ninety-five percent of women age 15-49 years know of a place where to be tested, while 83 percent have been tested. Fifty-two percent of women know the result of their most recent test. The proportion of women age 15-49 years that had been tested within the last 12 months preceding the survey is 52 percent, while those who had been tested within the last 12 months and know the result is 45 percent. Sixty-five percent of women age 15-49 years with a live birth in the last two years preceding the survey received HIV counselling during ANC, 83 percent were offered an HIV test and were tested for HIV; and 81 percent received HIV counselling, were offered an HIV test, accepted and received the results. Two percent of women 15-49 years of age reported that they had sex with more than one partner in the last 12 months with a mean number of lifetime sexual partners as 2.1. Forty-six percent of young women have comprehensive knowledge. Young women who know of three means of HIV transmission from mother-to-child are 43 percent and 92percent have knowledge of a place to get tested. About 58 percent of young women age 15-24 years, who were sexually active, had been tested for HIV in the last 12 months and know the result. The proportion is high among young women with secondary/higher education (62 percent) compared with those with primary education (54 percent). Overall, 6percent of young women age 15-24 years reported ever having sex before age 15. Further, one percent of young women had sex with more than one partner in the last 12 months preceding the survey. Only 65 percent of women used a condom the last time they had sex. About 13 percent of Kakamega County MICS 2013/14 P a g e | xxx women age 15-24 years who had sex in the last 12 months before the survey, had sex with a man 10 or more years older. Access to Mass Media and Use of Information/Communication Technology About 16 percent of women in Kakamega County read a newspaper or magazine, 75 percent listen to the radio, and 29 percent watch television at least once a week. Overall, 19 percent do not have regular exposure to any of the three media, while 80 percent are exposed to at least one and seven percent to all the three types of media on a weekly basis. Women with higher education are more likely to have been exposed to all three types of media (16 percent) than women with primary education (2 percent). Similarly, women from the richest households are more likely to have been exposed to all three types of media (21 percent) than women from the poorest households (1 percent). Overall, 18 percent of young women age 15-24 years ever used the internet, while 15 percent used the internet during the last 12 months. The proportion of young women who used the internet more frequently, at least once a week during the last month, was 11 percent. Both computer and internet use during the last 12 months were more widespread among the 20-24 year old women. Use of a computer and the internet is also strongly associated with area and education. Only about 3 percent of women with primary education reported using a computer during the last 12 months, while about a third of the women with higher education used a computer. Similarly, higher utilisation of the internet is observed among young women in urban areas (20 percent) compared with 10 percent in rural areas. Subjective Well-being Young women are the most satisfied with the way they look 93 percent, their health (87 percent), and their family life (83 percent). The percentage of women age 15-24 years who are very or somewhat satisfied; with school is 95 percent, with their job is 78 percent, and with their income is 64 percent. In Kakamega County, 82 percent of women age 15-24 years are satisfied with their life. The proportion of women who are satisfied with life is somewhat higher in rural areas (88 percent) than in urban areas (75 percent). About 80 percent of women age 15-24 years are very or somewhat happy. The proportion of women age 15-24 years who think that their lives improved during the last one year and who expect that their lives would get better after one year, is 56 percent. Differences in the perception of a better life can be observed by wealth quintiles: 39 percent of young women who live in households in the poorest wealth quintile think that their lives improved during the last one year and expect that it would get better after one year, while the corresponding proportion for young women who live in households in the richest wealth quintile is 63 percent. Tobacco and Alcohol Use In Kakamega County MICS, ever use of any tobacco products among women is two percent, while less than one percent smoke cigarettes, or used smoked or smokeless tobacco products on one or more days during the last one month prior to the survey. Only about one woman age 15-49 years in a thousand smoked a cigarette for the first time before age 15. Kakamega County MICS 2013/14 P a g e | xxxi About five percent of women age 15-49 years had at least one drink of alcohol on one or more days during the last one month preceding the survey while three percent have had at least one alcoholic drink before the age of 15 years. The proportion who had an alcoholic drink in the last month preceding the survey ranged between two percent and nine percent by age while for women who had at least one alcoholic drink before age 15 was between one percent and five percent, with no clear pattern from one age group to the other. Women age 15-49 years in urban areas in Kakamega county are twice (4 percent) as likely to have had at least one alcoholic drink before age 15 than their rural counterparts (2 percent). The results further indicate that women age 15-49 years in Kakamega county who reside in urban areas are twice (7 percent) more likely to have had at least one alcoholic drink at any time during the last one month than those in the rural areas (3 percent). Kakamega County MICS 2013/14 P a g e | 1 1. Introduction Kakamega County is one of the 47 counties in Kenya. Kakamega County is located in the Western part of Kenya and constitutes 12 constituencies (Malava, Lugari, Mumias West, Mumias East, Matungu, Lurambi, Shinyalu, Ikolomani, Butere, Navakholo, Likuyani, and Khwisero). The county has an estimated population of 1,660,651 people.2 1.1 Background This report is based on the Kakamega County Multiple Indicator Cluster Survey (MICS), conducted in 2013/14 by the Population Studies and Research Institute, University of Nairobi, in collaboration with Kenya National Bureau of Statistics, as part of the global MICS programme. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action (2002)3, the goals of the United Nations General Assembly Special Session on HIV/AIDS (2001)4, the Education for All Declaration (2000)5 and the Millennium Development Goals (MDGs) 2000.5 A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child- focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” 2Kenya National Bureau of Statistics, 2013. Statistical Abstract 2013 3A World Fit for Children. Resolution adopted by the United Nations General Assembly 10 May 2002. 4United Nations General AssemblySpecial Session on HIV/AIDS 2001. Summary of the Declaration of Commitment on HIV/AIDS25-27 June 2001, New York 5http://www.unesco.org/new/en/education/themes/leading-the-international-agenda/education-for-all/ Kakamega County MICS 2013/14 P a g e | 2 Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” Kenya’s GDP has grown by an annual average of 4 percent in the past five years. In 2013, Kenya adopted its second five-year Medium Term Plan (MTP II 2013-17) to implement its ‘Vision 2030’, which represents a solid strategic framework to transform Kenya into a newly industrializing, middle-income country by 2030.6 The African Development Bank’s Country Strategy Paper (CSP) 2014-18 for Kenya supports the country’s ambitions and addresses its main developmental challenges by promoting job creation as the overarching objective. The Kakamega County MICS results are expected to form part of the baseline data for the post-2015 era. The survey findings are also expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed6, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health.7 This final report presents the results of the indicators and topics covered in the survey. There are 14 chapters presented as follows: Chapter 1: An introductory note to the Kakamega County MICS Report Chapter 2: Sample and survey methodology Chapter 3: Sample coverage and characteristics of households and respondents Chapter 4: Child nutrition Chapter 5: Child health Chapter 6: Water and sanitation Chapter 7: Reproductive health Chapter 8: Early childhood development Chapter 9: Literacy and education Chapter 10: Child protection Chapter 11: HIV, AIDS and sexual behaviour Chapter 12: Mass Media, Information, and Communication Technology (ICT) Chapter 13: Subjective well-being Chapter 14: Tobacco and alcohol use 6United Nations Children’s Fund (UNICEF), September 2014. Committing to Child Survival: A Promise Renewed - Progress Report 2014. 7WHO. 2014. Implementing the Commission on Information and Accountability Recommendations2014: Progress Report Accountability for Women’s and Children’s Health. Kakamega County MICS 2013/14 P a g e | 3 1.2 Survey Objectives The 2013/14 Kakamega County MICS has as its primary objectives to:  Provide up-to-date information for assessing the situation of children and women in Kakamega County;  Generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention;  Furnish data needed for monitoring progress toward goals established in the Millennium Declaration, and other internationally agreed upon goals, as a basis for future action;  Collect disaggregated data for the identification of disparities, to allow for evidence based policy- making aimed at social inclusion of the most vulnerable;  Contribute to the generation of baseline data for the post-2015 agenda;  Validate data from other sources and the results of focused interventions; and  Contribute to the improvement of data and monitoring systems in Kenya and to strengthen technical expertise in the design, implementation, and analysis of such systems. Kakamega County MICS 2013/14 P a g e | 4 2. Sample and Survey Methodology Chapter Two presents the survey sample design and methodology, content for the three questionnaires used in the survey, the interviewer training process, fieldwork, and data management and processing. 2.1 Sample Design The sample for the Kakamega County MICS, 2013/14 was designed to provide estimates for a large number of indicators on the situation of children and women at the county level. The urban and rural areas within the county were the main sampling strata. The sample was selected in two stages: cluster and household. The survey utilized the fifth National Sample Survey and Evaluation Program (NASSEP V) household-based master sampling frame which is created and maintained by the Kenya National Bureau of Statistics (KNBS). The primary sampling unit for the frame is a cluster, which constitutes one or more EAs, with an average of 100 households. For the NASSEP V master sample the EAs were selected within each stratum using systematic sampling with probabilities proportion to size (PPS). For the MICS, within each stratum a specified number of census enumeration areas was selected from the master sample using an equal probability selection method (EPSEM). After a household listing was carried out in the selected clusters, a systematic sample of 30 households was drawn in each sampled cluster. In total, 50 clusters were selected for the survey in Kakamega County. The sample was stratified by urban and rural areas, and was not self- weighting. All selected clusters were visited during fieldwork. For reporting county level results, sample weights are used. A more detailed description of the sample design is provided in Appendix C. 2.2 Questionnaires A set of three questionnaires was used in the survey: 1) a household questionnaire which was administered to the household head or any other responsible member of the household; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; 3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under-5 years living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: o List of Household Members o Education o Child Labour o Child Discipline o Household Characteristics o Insecticide Treated Nets o Indoor Residual Spraying o Water and Sanitation o Handwashing Kakamega County MICS 2013/14 P a g e | 5 o Salt Iodization The Questionnaire for Individual Women age 15-49 years included the following modules: o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility/Birth History o Desire for Last Birth o Maternal and Newborn Health o Post-natal Health Checks o Illness Symptoms o Contraception o Unmet Need o Female Genital Mutilation/Cutting o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Tobacco and Alcohol Use o Life Satisfaction The Questionnaire for Children Under5 was administered to mothers (or caretakers) of children under 5 years of age8 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Immunization o Breastfeeding and Dietary Intake o Care of Illness o Anthropometry Due to data quality issues, data relating to mortality and anthropometric measures were not analyzed and reported. Anthropometric data suffered digit preference for both weight and height, while for mortality, deaths especially among children under-five years were under reported. The recommendation to remove the Mortality Chapter and the anthropometric measures section from the Nutrition Chapter was adopted at the final reports validation workshop organized by KNBS, PSRI and UNICEF. KDHS 2014 had similar shortcomings. The DQ tables are included in the report for reference. The MICS data set can be accessed and evaluated by researchers for further analysis. The survey team, KNBS and the Population Studies and Research Institute will review the data in detail to identify challenges encountered and to address them before the next round of surveys. The questionnaires are based on the MICS5 model questionnaire.9 From the MICS5 model English version, the questionnaires were customised and translated into Kiswahili and Luhya sub dialect and 8 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. 9 The model MICS5 questionnaires can be found at http://www.childinfo.org/mics5_questionnaire.html Kakamega County MICS 2013/14 P a g e | 6 were pre-tested in four clusters (rural and urban) in Trans Nzoia County. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Kakamega County MICS questionnaires is provided in Appendix F. In addition to administering of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine, observed the place for handwashing, and measured the weights and heights of children under-5 years of age. Details and findings of these observations and measurements are provided in the respective sections of the report. 2.3 Training and Fieldwork Training for the fieldwork was conducted in Kitale town for 14 days from 24th October to 6th November, 2013. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Facilitators used a variety of methods which included PowerPoint presentations, illustrations on flip charts, question and answer, case studies, group work and group discussions. Towards the end of the training period, trainees spent two days practising the research tools by interviewing respondents in selected urban and rural clusters in Trans Nzoia County. Fieldwork began in November 2013 and concluded in February 2014. The survey team was divided into two groups. Each group comprised of 5 interviewers, one driver, one editor, one measurer and a supervisor. 2.4 Data Processing CSPro software, Version 5.0 running on desktop computers was used for data entry. Data entry was done by a trained team of 14 data entry operators, one Archivist/System administrator and one data entry supervisor. For quality assurance purposes, all questionnaires were double-entered and internal consistency checks performed. Procedures and standard programs developed under the global MICS programme and adapted to the Kakamega County MICS questionnaire were used throughout. Data processing began simultaneously with data collection in November 2013 and was completed in February 2014. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version 21. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. Kakamega County MICS 2013/14 P a g e | 7 3. Sample Coverage and the Characteristics of Households and Respondents Chapter Three presents results on sample coverage and the characteristics of households, female respondents age 15-49 years and children under-five years of age. The chapter also discusses housing characteristics, asset ownership and household wealth quintiles. 3.1 Sample Coverage Table HH.1 presents results of household, women’s and under-5 interviews for Kakamega County. A total of 1,500 households were selected for the sample out of which 1,335 were occupied. Of these, 1,221 were successfully interviewed giving a response rate of 92 percent. In the interviewed households, 1,225 eligible women age 15-49 years were identified. Of these, 998 women were successfully interviewed, yielding a response rate of 82 percent. The survey listed 828 eligible children under-five years. Questionnaires were completed by mothers/caretakers for 806 of these children, which corresponds to a response rate of 97 percent. The response rate at the household level; and for women age 15-49 years and children under-five years of age was higher in rural areas than urban areas. Overall response rates of 75 percent and 89 percent were calculated for the individual interviews of women, and under-5s, respectively (Table HH.1). Low overall response rates of women are observed, more particularly in urban areas (66 percent) compared to rural areas (80 percent). Data quality Table DQ.2 indicates that a large proportion of unsuccessful interviews was with respect to younger women age 15-24 years. Table HH.1: Results of household, women's, men's and under-5 interviews Number of households, women, men, and children under 5 by interview results, and household, women's, men's and under-5's response rates, Kakamega County MICS, 2013/14 Total Area Urban Rural Households Sampled 1,500 570 930 Occupied 1,335 510 825 Interviewed 1,221 430 791 Household response rate 91.5 84.3 95.9 Women Eligible 1,225 433 792 Interviewed 998 341 657 Women's response rate 81.5 78.8 83.0 Women's overall response rate 74.5 66.4 79.5 Children under 5 Eligible 828 281 547 Mothers/caretakers interviewed 806 273 533 Under-5's response rate 97.3 97.2 97.4 Under-5's overall response rate 89.0 81.9 93.4 Kakamega County MICS 2013/14 P a g e | 8 3.2 Characteristics of Households The weighted age and sex distribution of the survey population are provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. Data by single year age distribution of the population is presented in Appendix F, Table DQ.1. In the 1,221 households successfully interviewed in the survey, a total of 5,666 household members were listed. Of these, 2,752 (49 percent) are males, and 2,914 (51 percent) are females. Table HH.2: Age distribution of household population by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Kakamega County MICS, 2013/14 Total Males Females Number Percent Number Percent Number Percent Total 5,666 100.0 2,752 100.0 2,914 100.0 Age 0-4 842 14.9 407 14.8 435 14.9 5-9 969 17.1 500 18.2 468 16.1 10-14 801 14.1 394 14.3 407 14.0 15-19 672 11.9 348 12.6 325 11.1 20-24 413 7.3 195 7.1 218 7.5 25-29 386 6.8 169 6.1 217 7.4 30-34 267 4.7 130 4.7 137 4.7 35-39 285 5.0 121 4.4 164 5.6 40-44 196 3.5 95 3.4 101 3.5 45-49 170 3.0 94 3.4 76 2.6 50-54 192 3.4 78 2.8 114 3.9 55-59 170 3.0 78 2.8 91 3.1 60-64 96 1.7 48 1.7 48 1.7 65-69 77 1.4 31 1.1 46 1.6 70-74 65 1.1 35 1.3 30 1.0 75-79 28 0.5 12 0.4 16 0.6 80-84 20 0.4 8 0.3 12 0.4 85+ 13 0.2 6 0.2 7 0.2 Missing/DK 4 0.1 3 0.1 2 0.1 Dependency age groups 0-14 2,612 46.1 1,301 47.3 1,311 45.0 15-64 2,846 50.2 1,356 49.3 1,490 51.1 65+ 204 3.6 92 3.4 111 3.8 Missing/DK 4 0.1 3 0.1 2 0.1 Child and adult populations Children age 0-17 years 3,047 53.8 1,519 55.2 1,528 52.5 Adults age 18+ years 2,614 46.1 1,230 44.7 1,384 47.5 Missing/DK 4 0.1 3 0.1 2 0.1 The population pyramid (Figure HH.1) is broad based, similar in many respects to the national population pyramid but with some notable differences. The pyramid indicates that a high proportion of the population (46 percent) is below 15 years of age (Table HH.2). Half of the population is in the age group 15 to 64 years (population that is depended on). Similarly, the dependency population is 50 percent (4 percent are 65 years and above while 46 percent are below age 15 years). About 54 percent Kakamega County MICS 2013/14 P a g e | 9 of the population is under the age of 18. The percentage of males under the age of 18 years is 55 percent while that of females is 53 percent. The population pyramid shows that children age 0-5 year are lower than those in the age group 5-9 years. The national population pyramid from the 2009 census is smooth and shows a higher percentage of the population in the 0-4 year age group than in the 5-9 year age group, which is what is expected. The MICS pyramid picture for the 0-4 and 5-9 age groups could be attributed to interviewers’ bias (out transference) in order to reduce the number of under-five questionnaires to administer. There is also a noticeable drop in the age group 20-24 years, which may be an indication of out-migration of the population from the county to other areas either for further education, employment opportunities or other reasons. Figure HH.1: Age and sex d istr ibut ion of household populat ion , Kakamega Count y MICS, 2013/14 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15- 49, and children under-5 years. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provide background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.10 Table HH.3 provides percent and frequency distribution by selected characteristics such as sex of the household head, area, number of household members, education of household head, and ethnicity of the household head. These background characteristics are used in subsequent tables in this report. 10 See Appendix C: Sample Design, for more details on sample weights. 10 8 6 4 2 0 2 4 6 8 10 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Percent Age Males Females Note: 5 household members with missing age and/or sex are excluded Kakamega County MICS 2013/14 P a g e | 10 The figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted total number of households are equal, since sample weights were normalized.10 The table also shows the weighted mean estimated household size of 4.6 persons. The data indicates that 65 percent of the households are male headed while 35 percent are headed by women. The households were equally distributed between urban and rural areas. About 29 percent of the households have household sizes of 4-5 persons, 22 percent have 2-3 persons, and another 22 percent have 6-7 persons, 14 percent have one person, nine percent have 8-9 persons and four percent have 10 or more persons. Most heads of households have either primary education (53 percent) or secondary/higher education (34 percent). Only 12 percent of households are headed by people who have no education. Most of the heads of households (90 percent) are of the Luhya ethnic group. Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Kakamega County MICS, 2013/14 Weighted percent Number of households Weighted Unweighted Total 100.0 1,221 1,221 Sex of household head Male 65.3 798 770 Female 34.7 423 451 Area Urban 50.3 614 430 Rural 49.7 607 791 Number of household members 1 13.8 168 155 2 9.5 116 116 3 12.6 154 158 4 15.6 191 190 5 13.2 161 157 6 13.3 163 167 7 8.8 107 117 8 6.1 75 72 9 3.1 38 39 10+ 4.1 50 50 Education of household head None 12.3 150 159 Primary 52.7 644 662 Secondary+ 34.1 416 391 Missing/DK 0.9 11 9 Ethnicity of household head Luhya 90.1 1,101 1,107 Other ethnic group 9.9 120 114 Mean household size 4.6 1,221 1,221 Kakamega County MICS 2013/14 P a g e | 11 3.3 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Years Tables HH.4 and HH.5 provide information on the background characteristics of female respondents age 15-49 years and children under age 5 years. In all these tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized).10 In addition to providing useful information on the background characteristics of women, and children under age five, the tables also show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to area, age, marital/union status, motherhood status, births in last two years, education11, wealth index quintiles12, 13, and ethnicity of the household head. The results show that women age 15-49 years were equally distributed between urban and rural areas. Disaggregation of the data by the age of the woman shows that 21 percent of the women are age 15-19 years, 17 percent are 20-24 years, and 19 percent are in the 25-29 years category. Sixty-six percent of the women interviewed are currently married/in union, while 27 percent have never married. Of all women age 15-49 years in Kakamega County, three quarters have ever gave birth, including 31 percent who gave birth in the two years preceding the survey and 44 percent who never gave birth in the last two years. The majority (96 percent) of women have either primary education (60 percent) 11 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 12 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In Kakamega County MICS, the following assets were used in these calculations: radio, television, non-mobile telephone, refrigerator, agricultural land, farm animals/livestock, watch, mobile telephone, bicycle, motorcycle or scooter, animal- drawn cart, car or truck, boat with a motor, and ownership of dwelling. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D and Pritchett, L. 2001. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India. Demography 38(1): 115-132; Rutstein, SO and Johnson, K. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6; and Rutstein, SO. 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. 13 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest population quintile”, which is used interchangeably with “women in the wealthiest survey population”, “women living in households in the richest population wealth quintile”, and similar. Kakamega County MICS 2013/14 P a g e | 12 while 36 percent have secondary/higher education. Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Kakamega County MICS, 2013/14 Weighted percent Number of women Weighted Unweighted Total 100.0 998 998 Area Urban 50.3 502 341 Rural 49.7 496 657 Age 15-19 21.1 210 213 20-24 17.1 170 169 25-29 19.2 192 188 30-34 11.9 119 119 35-39 15.2 152 146 40-44 8.7 87 93 45-49 6.9 69 70 Marital/Union status Currently married/in union 66.0 659 648 Widowed 3.1 31 35 Divorced 0.6 6 7 Separated 3.2 32 33 Never married/in union 27.1 270 275 Motherhood and recent births Never gave birth 25.0 249 255 Ever gave birth 75.0 749 743 Gave birth in last two years 30.6 306 295 No birth in last two years 44.4 443 448 Education None 4.2 42 42 Primary 59.7 595 615 Secondary+ 36.1 360 341 Wealth index quintile Poorest 18.2 181 197 Second 20.3 203 214 Middle 19.7 196 194 Fourth 20.3 203 209 Richest 21.5 215 184 Ethnicity of household head Luhya 91.9 918 920 Other ethnic group 8.1 80 78 Background characteristics of children under-5 years are presented in Table HH.5. These include the distribution of children by several attributes: sex, area, age in months, respondent type (mother’s or caretaker’s), mother’s education, wealth indices, and ethnicity of household head. Kakamega County MICS 2013/14 P a g e | 13 The proportion of male children under-5 years is 48 percent while females are 52 percent. About a quarter (25 percent) of the children are age 36-47 months. Majority of the women who responded to the questions about the child under-5 years are mothers of the children (85 percent) compared to 15 percent of caretakers. Most mothers (65 percent) have primary level of education while 28 percent have secondary and above level of education. A quarter (26 percent) of the children are in the poorest wealth quintile while 22 percent are in the second poorest quintile. Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Kakamega County MICS, 2013/14 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 806 806 Sex Male 48.1 388 384 Female 51.9 418 422 Area Urban 50.2 405 273 Rural 49.8 401 533 Age 0-5 months 8.7 70 68 6-11 months 10.0 81 82 12-23 months 19.9 161 159 24-35 months 18.6 150 152 36-47 months 25.4 205 197 48-59 months 17.3 140 148 Respondent to the under-5 questionnaire Mother 85.1 686 685 Other primary caretaker 14.9 120 121 Mother’s educationa None 7.7 62 59 Primary 64.8 522 535 Secondary+ 27.5 222 212 Wealth index quintile Poorest 25.7 207 218 Second 21.9 176 176 Middle 19.1 154 163 Fourth 19.6 158 151 Richest 13.7 111 98 Ethnicity of household head Luhya 94.8 764 764 Other ethnic group 5.2 42 42 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. Kakamega County MICS 2013/14 P a g e | 14 3.4 Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide results on household characteristics and assets in connection to household wealth. Table HH.6 presents characteristics of housing, disaggregated by area, distributed by connection of electricity in the dwelling; and the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. About 18 percent of the households have electricity (29 percent urban and 6 percent rural areas). Most of the houses have natural flooring14 (68 percent) while 32 percent have finished floors15, with 91 percent of the houses having finished roofing. For walls to their houses, 59 percent have rudimentary exterior walls, 29 percent have finished walls16 and 11 percent have natural walls.17 Data was also collected on the number of sleeping rooms and number of persons sleeping in one room. The mean number of persons per sleeping room is 2.7 persons. 14 Natural flooring – earth/sand or dung 15 Finished floor - Parquet or polished wood, vinyl or asphalt strips, ceramic tiles, cement or carpet 16 Finished walls – Cement, stone with lime / cement, bricks, cement blocks, covered adobe or wood planks / shingles 17 Natural walls - No walls, cane /palm / trunks or dirt. Additional definitions for housing characteristics (Table HH.6) are in Appendix G Kakamega County MICS 2013/14 P a g e | 15 Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Kakamega County MICS, 2013/14 Total Area Urban Rural Electricity Yes 17.6 29.2 5.8 No 82.4 70.8 94.2 Flooring Natural floor 67.7 53.6 81.9 Rudimentary floor 0.0 0.0 0.0 Finished floor 32.2 46.2 18.1 Other 0.1 0.2 0.0 Roof Natural roofing 8.5 4.6 12.3 Rudimentary roofing 0.0 0.0 0.0 Finished roofing 91.4 95.1 87.7 Other 0.1 0.2 0.0 Exterior walls Natural walls 10.8 10.0 11.6 Rudimentary walls 58.6 46.0 71.4 Finished walls 28.6 41.5 15.5 Other 1.9 2.3 1.5 Missing/DK 0.1 0.2 0.0 Rooms used for sleeping 1 40.0 44.9 35.0 2 37.7 35.7 39.7 3 or more 21.2 18.5 23.8 Missing/DK 1.1 0.8 1.4 Total 100.0 100.0 100.0 Number of households 1,221 614 607 Mean number of persons per room used for sleeping 2.73 2.62 2.84 In Table HH.7, households are distributed according to ownership of assets, including dwelling units, by households and by individual household members. The results show that 73 percent of the households own a radio (73 percent in both urban and rural areas) while 28 percent own a television set. About 80 percent of households own agricultural land while 72 percent own farm animals/livestock. The data further indicate that 87 percent of household members own a mobile phone, 39 percent a bicycle, 38 percent a bank account, while 21 percent own a watch. More than three quarters of the dwelling units are owned by a household member. Ownership of dwelling unit is higher in rural areas (96 percent) than urban areas (61 percent). About 35 percent of the rented dwelling units are situated in urban areas compared to only three percent in rural areas. Kakamega County MICS 2013/14 P a g e | 16 Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Kakamega County MICS, 2013/14 Total Area Urban Rural Percentage of households that own a Radio 73.0 73.3 72.7 Television 27.6 35.7 19.4 Non-mobile telephone 1.6 1.4 1.8 Refrigerator 3.9 6.8 0.9 Solar Panel 1.9 1.9 1.9 Chair 1.1 1.1 1.1 Sofa Set 1.6 1.5 1.6 Table 1.0 1.1 1.0 Cupboard 1.5 1.5 1.5 Bed 1.1 1.1 1.0 Clock 1.8 1.8 1.8 Camera 2.0 2.0 2.0 Computer 2.0 1.9 2.0 Percentage of households that own Agricultural land 79.7 70.4 89.1 Farm animals/Livestock 72.4 62.2 82.6 Percentage of households where at least one member owns or has a Watch 21.2 23.6 18.9 Mobile telephone 87.2 89.4 85.0 Bicycle 39.3 33.4 45.3 Motorcycle or scooter 9.2 9.0 9.4 Animal-drawn cart 0.5 0.3 0.8 Car or truck 3.9 5.9 1.9 Boat with a motor 0.0 0.0 0.0 Bank account 37.9 46.8 28.9 Ownership of dwelling Owned by a household member 78.3 61.2 95.5 Not owned 21.7 38.8 4.3 Rented 18.8 34.5 2.9 Other 2.9 4.3 1.5 Missing/DK 0.1 0.0 0.1 Total 100.0 100.0 100.0 Number of households 1,221 614 607 Table HH.8 shows how the household populations in urban and rural areas are distributed according to household wealth quintiles. Forty-nine percent of the households in urban areas are in the poorest to middle wealth quintiles compared to those in rural areas (69 percent). Kakamega County MICS 2013/14 P a g e | 17 Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintile, according to area of residence and regions, Kakamega County MICS, 2013/14 Wealth index quintile Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 5,666 Area Urban 15.5 16.4 17.4 18.5 32.2 100.0 2,653 Rural 23.9 23.1 22.2 21.4 9.3 100.0 3,013 Kakamega County MICS 2013/14 P a g e | 18 4. Nutrition About half of Kenya’s estimated 38.5 million people are poor, and some 7.5 million people live in extreme poverty, while over 10 million people suffer from chronic food insecurity and poor nutrition. Children are undernourished and micronutrient deficiencies are widespread.18, 19 The Government of Kenya is strongly committed to reducing hunger and malnutrition. Policies and strategies were developed to guide the nutrition interventions and activities in the country. These include the Food and Nutrition Security Policy (FNSP) 2011, National Nutrition Action Plan (NNAP) 2012-2017 and Kenya Health Strategic Plan 2008-2012. Most of these interventions were part of Scaling Up Nutrition (SUN) actions that were implemented globally to accelerate efforts towards achieving MDG 4 and 5. The NNAP is aligned to the government’s Medium Term Plans (MTPs) to enable mainstreaming of the nutrition budgeting process into national development plans, and facilitate allocation of resources to nutrition programmes. Chapter Four presents the results on birth weight; breastfeeding, and infant and young child feeding practices; and use of iodized salt at household.20 4.1 Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. 18 Government of Kenya, 2011. National Food and Nutrition Security Policy. 19 The Partnership for Maternal, Newborn and Child Health, 2012. Maternal and Child Health: Kenya 20 A section on anthropometric indicators was excluded from the report due to data quality issues. Kakamega County MICS 2013/14 P a g e | 19 One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in health facilities, and those who are, represent only a sample of all births. Since many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.21 In Kakamega County, 56 percent of births were weighed at birth and approximately seven percent of infants weighed less than 2,500 grams at birth (Table NU.1). A larger proportion of babies in urban areas were weighed (60 percent) compared to only half of the babies in rural areas. Babies from households in the richest wealth quintile were more likely to be weighed at birth than babies in the poorest wealth quintile. 21 For a detailed description of the methodology, see Boerma, JT et al. 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization 74(2): 209-16. Kakamega County MICS 2013/14 P a g e | 20 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Kakamega County MICS, 2013/14 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live- born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 1.8 10.4 63.5 22.6 1.6 100.0 6.7 55.5 306 Mother's age at birth Less than 20 years (4.3) (9.9) (55.6) (28.3) (1.9) 100.0 (8.2) (59.4) 45 20-34 years 1.2 11.2 66.5 19.3 1.8 100.0 6.5 55.7 223 35-49 years (2.7) (6.6) (55.1) (35.6) (0.0) 100.0 (5.9) (49.7) 39 Birth order 1 5.5 4.0 68.2 21.1 1.2 100.0 7.9 74.5 71 2-3 0.0 14.9 66.0 19.1 0.0 100.0 6.5 53.9 111 4-5 1.0 9.6 63.7 23.9 1.9 100.0 5.8 58.9 68 6+ 1.9 10.9 52.1 30.3 4.8 100.0 6.8 29.8 55 Area Urban 3.0 10.9 64.1 20.8 1.2 100.0 7.8 60.4 168 Rural 0.5 9.8 62.8 24.9 2.0 100.0 5.4 49.5 138 Mother’s education None (*) (*) (*) (*) (*) 100.0 (*) (*) 12 Primary 1.9 12.8 57.4 25.9 2.0 100.0 7.3 46.1 195 Secondary+ 2.0 6.3 75.9 14.9 0.9 100.0 5.9 73.7 99 Wealth index quintile Poorest 4.6 13.1 64.7 17.0 0.6 100.0 9.7 33.2 79 Second 0.0 14.7 60.5 20.7 4.2 100.0 6.6 49.2 69 Middle 3.5 15.3 54.1 24.5 2.6 100.0 9.3 56.8 58 Fourth 0.0 4.6 64.2 31.1 0.0 100.0 3.4 71.3 57 Richest (0.0) (0.0) (77.5) (22.5) (0.0) 100.0 (2.4) (83.8) 43 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases 4.2 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to two years of age. Breastfeeding for the first two years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient deficiency. In addition, it can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 Kakamega County MICS 2013/14 P a g e | 21 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.22 UNICEF and WHO recommend that infants be initiated to breastfeeding within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.23 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.24 A summary of key guiding principles25, 26 for feeding 6-23 month olds is provided in the Table NU.2 below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).27 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; (ii) food items from at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). 22 Bhuta, Z. et al. 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 23 WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February, 2003. 24 WHO. 2003. Global Strategy for Infant and Young Child Feeding. 25 PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. 26 WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age. 27 WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. Kakamega County MICS 2013/14 P a g e | 22 Table NU.2: Guiding Principles for Feeding children age 6 – 23 months Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups28 eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na Table NU.3 and Figure NU. 1 are based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.29 Ninety-eight percent of the children were ever breastfed (Table NU.3). However, although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 30 percent of babies were breastfed for the first time within one hour of birth and 82 percent of newborns in Kakamega County started breastfeeding within one day of birth. Babies delivered in a health facility were more likely to be breastfed within one hour of delivery or within one day of birth compared to those delivered at home, (36 percent and 25 percent, respectively. About one in five babies received prelacteal feed. Babies were more likely to receive prelacteal feed when delivered in a rural area, delivered by a traditional birth attendant, or delivered at home. The findings are presented in Figure NU.1 by urban/rural areas. 28 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. 29 Prelacteal feed refers to the provision of any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). Kakamega County MICS 2013/14 P a g e | 23 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a prelacteal feed, Kakamega County MICS, 2013/14 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live-born children in the last two years Within one hour of birth2 Within one day of birth Total 97.5 30.1 81.7 19.3 306 Area Urban 98.0 29.7 85.1 13.9 168 Rural 96.9 30.6 77.4 25.9 138 Months since last birth 0-11 months 98.6 30.6 80.9 22.2 152 12-23 months 96.4 29.6 82.4 16.4 154 Assistance at delivery Skilled attendant 98.2 35.4 84.2 14.1 159 Traditional birth attendant 100.0 27.1 82.7 25.1 90 Other (97.4) (15.1) (75.5) (29.7) 32 Place of delivery Home 100.0 25.4 80.9 26.3 140 Health facility 98.2 35.8 84.5 14.0 158 Public 99.3 39.3 87.5 15.5 121 Private (94.7) (24.1) (74.2) (9.1) 36 Mother’s education None (*) (*) (*) (*) 12 Primary 97.6 28.2 81.1 21.7 195 Secondary+ 97.0 33.8 80.5 13.3 99 Wealth index quintile Poorest 98.6 29.6 82.3 27.8 79 Second 94.6 37.5 83.3 15.5 69 Middle 95.2 22.2 70.5 20.2 58 Fourth 100.0 22.0 85.6 17.1 57 Richest (100.0) (40.7) (87.6) (11.5) 43 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 24 F i g u r e N U . 1 : I n i t i a t i o n o f b r e a s t f e e d i n g , K a k a m e g a C o u n t y M I C S , 2 0 1 3 / 1 4 The set of Infant and Young Child Feeding indicators reported in Tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some related to the mother’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed; referring to infants age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately 35 percent of children age less than six months were exclusively breastfed (Table NU.4).30 With 61 percent predominantly breastfed, it is evident that water-based liquids are displacing feeding of breastmilk to the greatest degree. By age 12-15 months, 75 percent of children were breastfed and by age 20-23 months, 36 percent were breastfed. 30 Background characteristics variables are not included in Table NU.4 due to insufficient sample size. 85 77 82 30 31 30 0 20 40 60 80 100 Urban Rural Kakamega County P er ce n t Within one day Within one hour Kakamega County MICS 2013/14 P a g e | 25 Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Kakamega County MICS, 2013/14 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Total 34.7 61.0 70 (74.7) 49 35.5 62 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.8 - Predominant breastfeeding under 6 months 3 MICS indicator 2.9 - Continued breastfeeding at 1 year 4 MICS indicator 2.10 - Continued breastfeeding at 2 years ( ) Figures that are based on 25-49 unweighted cases Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3 years, the median duration is 20 months for ever breastfeeding, about one month for exclusive breastfeeding, and three months for predominant breastfeeding. There are minimal variations according to background characteristics. Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Kakamega County MICS, 2013/14 Median duration (in months) of: Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median 19.8 0.7 3.3 462 Sex Male 20.7 0.6 2.4 216 Female 19.3 1.9 4.0 246 Area Urban 20.2 1.1 2.8 224 Rural 19.7 0.6 3.8 238 Mother’s education None (16.1) (2.5) (2.5) 29 Primary 20.0 0.6 2.7 302 Secondary+ 21.0 1.4 4.5 131 Wealth index quintile Poorest 21.5 1.2 3.0 123 Second 16.2 0.5 2.3 102 Middle 21.0 1.6 3.6 86 Fourth 15.5 2.2 4.3 85 Richest 17.6 3.1 3.8 66 Mean 19.2 1.9 3.7 462 1 MICS indicator 2.11 - Duration of breastfeeding ( ) Figures that are based on 25-49 unweighted cases Kakamega County MICS 2013/14 P a g e | 26 The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breastmilk and solid, semi-solid or soft food. The results in Table NU 6 show that 67 percent of children age 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children age 0-23 months drops to 60 percent. Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Kakamega County MICS, 2013/14 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Total 34.7 70 66.6 242 59.5 312 Sex Male (21.1) 31 64.3 118 55.4 148 Female (45.4) 39 68.8 124 63.2 163 Area Urban (30.5) 38 68.8 126 59.9 163 Rural (39.5) 32 64.3 116 59.0 148 Mother’s education None (*) 3 (*) 12 (*) 15 Primary (28.1) 44 67.7 153 58.9 197 Secondary+ (*) 23 67.2 77 62.2 100 Wealth index quintile Poorest (*) 21 83.3 61 66.8 82 Second (*) 23 (63.9) 42 50.0 65 Middle (*) 13 (75.5) 41 68.6 54 Fourth (*) 10 53.5 53 55.5 63 Richest (*) 4 (53.9) 45 (*) 48 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Overall, (92)31 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day (data not shown). The same percentage received solid, semi-solid, or soft foods among currently breastfeeding infants. About two-thirds of the children age 6-23 months (69 percent) were receiving solid, semi-solid and soft foods the minimum number of times (Table NU.7). The proportion of children receiving the minimum dietary diversity, or foods from at least four food groups, was much lower than that for the minimum meal frequency, indicating the need to focus on improving diet quality and nutrient intake among this vulnerable group. The overall assessment using the indicator of minimum acceptable diet 31 Note that the percentage above is in parentheses because the finding is based on less than 50 cases. Kakamega County MICS 2013/14 P a g e | 27 revealed that only 20 percent of children age 6-23 months were benefitting from a diet sufficient in both diversity and frequency. Kakamega County MICS 2013/14 P a g e | 28 Table NU.7: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Kakamega County MICS, 2013/14 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6- 23 months Percent of children who received: Number of children age 6- 23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Total 34.3 68.6 22.9 167 47.4 69.8 12.6 27.0 70 38.6 68.9 19.9 242 Sex Male 34.9 70.8 23.9 79 (38.3) (70.1) (10.2) (22.8) 34 36.3 70.6 19.8 118 Female 33.8 66.6 22.0 87 (56.0) (69.4) (14.9) (31.0) 36 40.7 67.4 19.9 124 Age 6-8 months (17.5) (80.4) (17.5) 44 - - - - 0 (16.7) (80.4) (17.5) 46 9-11 months (25.4) (64.3) (17.9) 33 (*) (*) (*) (*) 1 (25.6) (63.1) (18.4) 35 12-17 months (46.2) (69.6) (32.2) 49 (63.1) (88.9) (20.5) (38.5) 24 51.8 76.0 28.3 73 18-23 months (45.5) (57.9) (21.6) 40 (39.3) (60.4) (7.8) (20.6) 44 44.2 59.2 14.4 88 Area Urban 37.9 63.5 25.3 89 (*) (*) (*) (*) 35 39.1 66.2 21.2 126 Rural 30.1 74.4 20.1 77 (51.3) (66.6) (14.3) (29.3) 35 38.0 72.0 18.3 116 Mother’s education None (*) (*) (*) 6 (*) (*) (*) (*) 6 (*) (*) (*) 12 Primary 25.8 70.1 18.9 107 (50.3) (67.0) (8.0) (22.7) 42 33.1 69.2 15.8 153 Secondary+ (50.9) (63.7) (29.4) 54 (*) (*) (*) (*) 22 51.8 68.2 28.1 77 1 MICS indicator 2.17a - Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 - Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 - Minimum dietary diversity 5 MICS indicator 2.15 - Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. Kakamega County MICS 2013/14 P a g e | 29 b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds. ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 30 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle-feeding is practiced in Kakamega County. The findings indicate that seven percent of children under 6 months were fed using a bottle with a nipple. Table NU.8: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Kakamega County MICS, 2013/14 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Total 7.2 312 Sex Male 5.4 148 Female 8.8 163 Age 0-5 months 6.7 70 6-11 months 8.7 81 12-23 months 6.7 161 Area Urban 6.1 163 Rural 8.4 148 Mother’s education None (*) 15 Primary 4.9 197 Secondary+ 12.8 100 Wealth index quintile Poorest 1.0 82 Second 8.3 65 Middle 8.6 54 Fourth 8.7 63 Richest (12.6) 48 1 MICS indicator 2.18 - Bottle feeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases 4.3 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Kakamega County MICS 2013/14 P a g e | 31 The IDD legislation, (Kenya Public Health Act [Chapter 242] of 1986 (revised in 2012)), covers all salt produced for human consumption. Specifications for edible salt are reviewed regularly (latest revision was in September 2000) by the Kenya Bureau of Standards. Iodization of salt is mandatory. The mandated level of iodization is 168.5 mg/kg of salt, or 100ppm.32 The Ministry of Health monitors IDD in the country. In 96 percent of households in Kakamega, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate content. Table NU.9 shows that in two percent of households, there was no salt available. These households were included in the denominator of the indicator. In 95 percent of households, salt was found to contain at least 15 parts per million (ppm) or more of iodine. Use of adequately iodized salt is over ninety percent in both urban and rural areas (97 percent and 93 percent, respectively). There are no meaningful variations between the richest and poorest households in terms of iodized salt consumption. Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Kakamega County MICS, 2013/14 Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt >0 and <15 PPM 15+ PPM1 Total 95.5 1,221 2.3 2.8 94.9 100.0 1,193 Area Urban 95.5 614 1.8 0.9 97.2 100.0 597 Rural 95.5 607 2.8 4.7 92.5 100.0 596 Wealth index quintile Poorest 94.5 246 4.2 2.2 93.5 100.0 243 Second 98.6 218 0.6 4.1 95.2 100.0 216 Middle 94.4 232 2.8 3.6 93.7 100.0 225 Fourth 95.4 234 2.2 2.3 95.5 100.0 228 Richest 94.9 292 1.6 2.2 96.2 100.0 282 1 MICS indicator 2.19 - Iodized salt consumption 32 http://www.tulane.edu/~internut/Countries/Kenya/kenyaiodine.html Kakamega County MICS 2013/14 P a g e | 32 5. Child Health Kenya has acceded and ratified a number of major international and regional conventions some of which aim at ensuring child survival, growth and development. In 1990, Kenya ratified the United Nations Convention on the rights of the Child (CRC).33, 34 Article 6 of the CRC refers to the right to life, survival and development. The term ‘development’ in this context refers to physical, mental, emotional, cognitive, social and cultural development. Further, Article 24 states that ‘children have the right to good quality health care – the best health care possible – to safe drinking water, nutritious food, a clean and safe environment, and information to help them stay healthy’.35 The United Nations Millennium Declaration, signed in September 2000, commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The objective of one of the Millennium Development Goals (MDGs) – MDG 4 - is to reduce child mortality by two thirds between 1990 and 2015. The Constitution of Kenya (2010) states that every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care. The Child Development Chapter presents the results on the following subtopics: vaccinations; neonatal tetanus protection; and care of illnesses (diarrhoea, acute respiratory infections, malaria/fever); and use of solid fuels. 5.1 Vaccinations Immunization plays a key part in reducing preventable childhood diseases and mortality. The Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. The WHO Recommended Routine Immunizations for Children36 states that all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenzae type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. 33Kenya Human Rights Commission. 2010. Towards Equality and Anti-Discrimination: An Overview of International and Domestic Law an Anti-discrimination in Kenya. 34The Kenyan Section of the International Commission of Jurists. 2004. International Human Rights Standards: Reporting Obligations – The Convention of the Rights of the Child. 35The United Nations General Assembly. 1989. The Convention on the Rights of the Child. 36http://www.who.int/immunization/diseases/en. Table 2 includes recommendations for all children and additional antigens recommended only for children residing in certain regions of the world or living in certain high-risk population groups. Kakamega County MICS 2013/14 P a g e | 33 The Kenya Expanded Programme on Immunization (KEPI) was established in 1980 and is integrated within the Department of Preventive and Promotive Health Services of the Ministry of Health as part of the Essential Health Package (EHP). KEPI is now known as the Division of Vaccine and Immunisation (DVI). The Kenya National Immunization Programme immunization schedule is shown below. All vaccines should be received during the first year of life except the second dose of measles given at 18 months. Yellow fever is given at 9 months to children in selected sub-counties in the former Rift Valley province.37 Child Immunization Schedule in Kenya38, 39 Vaccine Age Remarks BCG Vaccine: at birth Intra-dermal left forearm; BCG Scar checked Dose: (0.05mls) Below 1 year Dose: (0.1mls) Above 1 year Oral Polio Vaccine (OPV) 2 drops (orally) Birth dose: OPV 0 At birth or within 2 weeks 1st dose: OPV 1 At 6 weeks 2nd dose: OPV 2 At 10 weeks 3rd dose: OPV 3 At 14 weeks Diphtheria/Pertussis/Tetanus/Hepatitis B/haemophilus influenzae Type b 0.5mls (intra-muscular left outer thigh) 1st dose 6 weeks 2nd dose 10 weeks 3rd dose 14 weeks Pneumococcal Vaccine 0.5mls (intra-muscular right outer thigh) 1st dose 6 weeks 2nd dose 10 weeks 3rd dose 14 weeks Rota Virus (Rotarix) 1.5mls (orally) 1st dose 6 weeks 2nd dose 10 weeks Measles Vaccine at 6 months: in the event of measles outbreak or HIV exposed children (HEI) 6 months 0.5mls (Subcutaneously right upper arm) Measles Vaccine 9 months Measles Vaccine 18 months Yellow Fever 9 months 0.5mls (Intra-muscular left upper deltoid) Other Vaccines Other vaccines refer to those not in the usual KEPI schedule and may include MMR, Typhoid, etc. 37 MICS 2013/14 collected data on Yellow Fever but further analysis is required before the findings can be shared. 38 Ministry of Health, 2013. Mother and Child Heath Booklet. Republic of Kenya 39Kenya is planning to carryout out a Measles-Rubella (MR) and IPV Campaign in 2016, and subsequently include MR in the child immunization schedule in 2017. Kakamega County MICS 2013/14 P a g e | 34 In Kakamega County, the MICS collected data on immunization coverage for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the immunization card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no immunization card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccines as per the schedule. The final immunization coverage estimates are based on information obtained from the immunization card and/or the mother’s report. The percentage of children age 12-23 months and 24-35 months who had received each of the specific vaccines by source of information (immunization card and mother’s recall) is shown in Table CH.1 and Figure CH.1. The denominators for the table are comprised of children age 12-23 months and 24-35 months and only children in these age groups are counted. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the immunization card or the mother’s report. In the last column in each panel, only those children who were fully immunized before their first birthday, as recommended, were included. The proportion of children immunized before the first birthday but without immunization card/record was assumed to be the same as for those with vaccination cards/records. Most children age 12-23 months had been vaccinated against BCG and measles by the age of 12 months (98 and 86 percent, respectively), and had received the first dose of DPT, HepB, and Hib vaccines (97 percent, 96 percent and 96 percent, respectively). The percentages decline for the second and third doses of DPT, HepB, and Hib. Similarly, 97 percent of children age 12-23 months had received Polio 1 by age 12 months and this declines to 83 percent by the third dose. As a result, the percentage of children 12-23 months of age who had been fully vaccinated by their first birthday is 67 percent. The proportion of children fully vaccinated by 12 months of age is lower for children age 24-35 months (57 percent). The individual coverage figures for children age 24-35 months are generally lower to those age 12-23 months suggesting that immunization coverage has been on average improving in Kakamega County between 2011 and 2013. Kakamega County MICS 2013/14 P a g e | 35 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Kakamega County MICS, 2013/14 Children age 12-23 months: Children age 24-35 months: Vaccinated at any time before the survey according to: Vaccinated by 12 months of agea Vaccinated at any time before the survey according to: Vaccinated by 12 months of age Vaccination card Mother's report Either Vaccination card Mother's report Either Antigen BCG1 71.7 27.9 99.6 98.2 53.4 42.7 96.0 92.0 Polio At birth 71.9 23.2 95.1 93.1 53.6 29.8 83.4 80.8 1 71.9 26.4 98.3 97.1 53.6 41.2 94.8 92.6 2 71.9 24.6 96.5 95.3 53.6 39.4 93.0 92.4 32 70.7 12.7 83.4 82.5 53.6 22.9 76.5 74.3 DPT 1 71.9 26.5 98.4 97.2 54.7 41.3 95.9 93.7 2 71.9 24.8 96.7 95.6 54.7 39.5 94.2 93.6 33 71.9 22.4 94.3 93.3 54.7 37.4 92.0 89.4 HepB At birth 71.9 16.7 88.6 85.1 55.4 16.2 71.6 66.8 1 71.9 25.4 97.3 96.2 55.4 39.3 94.7 92.5 2 71.9 24.5 96.4 95.3 55.4 38.6 94.0 93.5 34 71.9 11.2 83.2 82.3 55.4 22.0 77.4 75.2 Hib 1 72.6 25.4 98.0 96.3 57.1 38.2 95.3 93.1 2 72.6 23.7 96.3 94.6 57.1 37.0 94.1 93.5 35 72.6 21.9 94.5 91.9 57.1 34.6 91.6 89.0 Measles (MCV1)7 71.4 24.5 95.9 86.3 53.8 40.9 94.7 83.4 Fully vaccinated8, b 71.9 5.3 77.2 66.9 53.8 14.0 67.8 56.6 No vaccinations 0.0 0.4 0.4 0.4 0.0 4.0 4.0 4.0 Number of children 161 161 161 161 150 150 150 150 1 MICS indicator 3.1 - Tuberculosis immunization coverage 2 MICS indicator 3.2 - Polio immunization coverage 3 MICS indicator 3.3 - Diphtheria, pertussis and tetanus (DPT) immunization coverage 4 MICS indicator 3.5 - Hepatitis B immunization coverage 5 MICS indicator 3.6 - Haemophilus influenzae type B (Hib) immunization coverage 6 MICS indicator 3.7 - Yellow fever immunization coverage40 7 MICS indicator 3.4; MDG indicator 4.3 - Measles immunization coverage 8 MICS indicator 3.8 - Full immunization coverage aAll MICS indicators refer to results in this column b Includes: BCG, Polio3, DPT3, HepB3, Hib3, and Measles (MCV1) as per the vaccination schedule in Kenya 40 Yellow fever immunization coverage not included in analysis Kakamega County MICS 2013/14 P a g e | 36 Figure CH.1: Vacc inat ions by age 12 months (measles by 24 months) , Kakamega County MICS, 2013/14 Table CH.2 presents vaccination coverage estimates among children age 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. Vaccination cards seen by the interviewer were for 71 percent of children age 12-23 months. Overall, 77 percent of children age 12-23 months are fully vaccinated against vaccine preventable childhood diseases while 96 percent are vaccinated against measles. 98 93 97 95 83 97 96 93 86 85 96 95 82 96 95 92 67 0 BCG Polio at birth Polio1 Polio2 Polio3 DPT1 DPT2 DPT3 Measles HepB at birth HepB1 HepB2 HepB3 Hib1 Hib2 Hib3 Fully vaccinated No vaccinations Percent Children Age 12-23 months 92 81 93 92 74 94 94 89 83 67 93 93 75 93 94 89 57 4 BCG Polio at birth Polio1 Polio2 Polio3 DPT1 DPT2 DPT3 Measles HepB at birth HepB1 HepB2 HepB3 Hib1 Hib2 Hib3 Fully vaccinated No vaccinations Children Age 24-35 months Kakamega County MICS 2013/14 P a g e | 37 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against vaccine preventable childhood diseases, Kakamega County MICS, 2013/14 Percentage of children who received: Percentage with vaccination card seen Number of children age 12- 23 months BCG Polio DPT HepB Hib Measles (MCV1) Fulla None At birth 1 2 3 1 2 3 At birth 1 2 3 1 2 3 Total 99.6 95.1 98.3 96.5 83.4 98.4 96.7 94.3 88.6 97.3 96.4 83.2 98.0 96.3 94.5 95.9 77.2 0.4 71.4 161 Sex Male 100.0 93.8 100.0 97.8 81.8 97.5 96.4 92.6 85.6 96.4 95.8 80.7 97.5 96.4 92.5 93.9 74.8 0.0 71.5 76 Female 99.2 96.2 96.8 95.3 84.8 99.2 97.0 95.8 91.3 98.2 97.0 85.3 98.5 96.3 96.3 97.7 79.4 0.8 71.3 85 Area Urban 100.0 96.4 100.0 98.6 85.4 97.8 97.8 95.7 90.1 97.8 97.8 82.0 97.8 97.8 95.7 94.2 78.0 0.0 71.6 86 Rural 99.1 93.6 96.3 94.0 81.1 99.0 95.4 92.6 86.9 96.8 94.8 84.4 98.2 94.5 93.1 97.9 76.3 0.9 71.2 75 Mother’s education None (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 9 Primary 99.3 95.6 98.1 95.9 81.5 97.3 96.2 95.1 82.5 97.3 97.3 85.6 96.6 96.6 95.4 95.0 76.5 0.7 71.0 94 Secondary+ 100.0 98.3 98.3 98.3 91.3 100.0 100.0 98.3 100.0 100.0 97.4 83.8 100.0 98.3 98.3 100.0 82.1 0.0 74.8 57 a Includes: BCG, Polio3, DPT3, HepB3, Hib3, and Measles (MCV1) as per the vaccination schedule in Kenya (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 38 5.2 Neonatal Tetanus Protection The goal of MDG 5 is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. Following on the 42nd and 44th World Health Assembly calls for elimination of neonatal tetanus, the global community continues to work to reduce the incidence of neonatal tetanus to less than one case per 1,000 live births in every sub-county by 2015. The strategy for preventing maternal and neonatal tetanus is to ensure that all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received at least two doses during a particular pregnancy, the mother and child are also considered to be protected against tetanus if the woman:  Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years;  Received at least 3 doses, the last within the previous 5 years;  Received at least 4 doses, the last within the previous 10 years;  Received 5 or more doses anytime during her life. To assess the status of tetanus vaccination coverage in Kakamega County, women who had a live birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth, and if so, how many. Women who did not receive two or more tetanus toxoid vaccinations during this recent pregnancy were then asked about tetanus toxoid vaccinations they may have previously received. Interviewers also asked women to present their vaccination card on which dates of tetanus toxoid are recorded and referred to information from the cards when available. Table CH.3 shows the protection status from tetanus of women age 15-49 years who have had a live birth within the last two years preceding the survey. In Kakamega County, 72 percent of these women were protected against neonatal tetanus Kakamega County MICS 2013/14 P a g e | 39 Table CH.3: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Kakamega County MICS, 2013/14 Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus1 Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Total 30.8 36.9 1.2 2.6 0.6 72.2 306 Area Urban 29.3 41.7 0.0 2.0 1.1 74.1 168 Rural 32.7 31.0 2.8 3.4 0.0 69.8 138 Education None (*) (*) (*) (*) (*) (*) 12 Primary 33.6 34.3 1.9 1.6 0.0 71.4 195 Secondary+ 27.9 41.9 0.0 3.2 0.0 73.0 99 Wealth index quintile Poorest 27.1 40.8 3.7 5.7 0.0 77.3 79 Second 26.9 36.4 1.3 .6 2.8 67.9 69 Middle 30.7 33.6 0.0 1.0 0.0 65.3 58 Fourth 25.6 42.0 0.0 4.4 0.0 72.0 57 Richest (51.0) (28.2) (0.0) (0.0) (0.0) (79.1) 43 Ethnicity of household head Luhya 29.8 38.2 1.3 2.7 .7 72.8 289 Other ethnic group (*) (*) (*) (*) (*) (*) 17 1 MICS indicator 3.9 - Neonatal tetanus protection ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases 5.3 Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading causes of morbidity and mortality of children under-5 years. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1,000 live births and mortality from diarrhoea to 1 death per 1,000 live births by 2025. Malaria is also a major cause of mortality of children under-5 years, leading to about 1,200 deaths children every day, especially in sub-Saharan Africa.41 41UNICEF Fact sheet http://www.unicef.org/media/media_81674.html Kakamega County MICS 2013/14 P a g e | 40 Table CH.4 presents the percentage of children under-5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the 2 weeks preceding the survey. These results measure period-prevalence of those illnesses over a two-week time window. The definition of a case of diarrhoea or fever, in this survey, was the mother’s or caretaker’s report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. In Kakamega County, 18 percent of children under-5 years are reported to have had diarrhoea in the two weeks preceding the survey, five percent symptoms of ARI, and 27 percent an episode of fever (Table CH.4). Children age 0-11 months (31 percent) and those age 12-23 months (26 percent) had experienced an episode of diarrhoea in larger proportions than those in the 24-59 months age group. There are no differentials in episodes of diarrhoea by sex of child and by urban/rural areas. Kakamega County MICS 2013/14 P a g e | 41 Table CH.4: Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea, symptoms of acute respiratory infection (ARI), and/or fever in the last two weeks, Kakamega County MICS, 2013/14 Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhoea Symptoms of ARI An episode of fever Total 17.8 5.0 27.4 806 Sex Male 17.6 2.2 26.8 388 Female 18.0 7.6 28.1 418 Area Urban 18.5 2.9 26.2 405 Rural 17.0 7.1 28.7 401 Age 0-11 months 30.5 5.5 32.4 151 12-23 months 25.8 2.9 26.6 161 24-35 months 14.7 6.6 24.5 150 36-47 months 9.8 3.4 26.1 205 48-59 months 10.0 7.7 28.2 140 Mother’s education None 16.1 8.9 30.2 62 Primary 17.3 4.3 27.4 522 Secondary+ 19.4 5.6 26.8 222 Wealth index quintile Poorest 22.3 7.1 34.0 207 Second 15.6 3.9 24.9 176 Middle 19.3 6.2 26.1 154 Fourth 13.2 3.7 25.8 158 Richest 17.4 3.0 23.3 111 Ethnicity of household head Luhya 17.4 5.1 27.2 764 Other ethnic group (25.0) (2.3) (32.1) 42 ( ) Figures that are based on 25-49 unweighted cases 5.3.1 Diarrhoea Diarrhoea is one of the leading causes of death among children under five worldwide42. Most diarrhoea- related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. In addition, provision of zinc supplements has been shown to reduce the duration and severity of the illness as well as the risk of future 42WHO, 2013. Fact Sheet number 330. Kakamega County MICS 2013/14 P a g e | 42 episodes within the next two or three months. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. During the survey, mothers or caretakers were asked whether their child under-5 years had an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness, including what the child had been given to drink and eat during the episode and whether this was more or less than what was usually given to the child. The overall period-prevalence of diarrhoea in children under-5 years of age was 18 percent (Table CH.4). The period-prevalence was noticeably high among children age 0-11 months (31 percent) which corresponds to the period where children are introduced to complementary feeds, and among children 12-23 months. Table CH.5 shows the percentage of children with diarrhoea in the two weeks preceding the survey for whom advice or treatment was sought and where. Overall, a health facility or provider was seen in 40 percent of cases, predominantly in the public health facilities (36 percent). The pattern was similar by urban/rural areas. Kakamega County MICS 2013/14 P a g e | 43 Table CH.5: Care-seeking during diarrhoea Percentage of children age 0-59 months with diarrhoea in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, Kakamega County MICS, 2013/14 Percentage of children with diarrhoea for whom: Number of children age 0-59 months with diarrhoea in the last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider1, b Public Private Community health providera Total 36.3 14.1 2.6 14.4 39.9 36.5 143 Sex Male 32.9 13.2 4.2 12.0 34.5 43.3 68 Female 39.3 15.0 1.2 16.6 44.8 30.4 75 Area Urban 29.5 11.8 2.5 15.3 32.0 43.4 75 Rural 43.6 16.8 2.8 13.3 48.6 29.0 68 Mother’s education None (*) (*) (*) (*) (*) (*) 10 Primary 31.9 15.8 2.1 14.7 36.4 39.6 90 Secondary+ (39.2) (12.4) (4.3) (9.9) (42.1) (38.5) 43 Ethnicity of household head Luhya 35.3 15.3 2.8 15.5 39.2 35.3 133 Other ethnic group (*) (*) (*) (*) (*) (*) 11 1 MICS indicator 3.10 - Care-seeking for diarrhoea a Community health providers includes both public (Community health worker and Mobile/Outreach clinic) and private (Mobile clinic) health facilities b Includes all public and private health facilities and providers, but excludes private pharmacy ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Table CH.6 provides information on drinking and feeding practices during diarrhoea. Overall, about one in five (20 percent) of under five children who experienced an episode of diarrhoea in the last two weeks preceding the survey were given more than usual to drink while 29 percent were given about the same. Twenty-nine percent were given somewhat less, but 19 percent were given much less than usual. Only one percent of children under-5 years of age who had an episode of diarrhoea in the last two weeks preceding the survey were given more to eat than usual while 25 percent were given about the same quantity of food. Thirty-four percent were given somewhat less to eat and 24 percent were given much less during this period. Kakamega County MICS 2013/14 P a g e | 44 Table CH.6: Feeding practices during diarrhoea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Kakamega County MICS, 2013/14 Drinking practices during diarrhoea Eating practices during diarrhoea Number of children age 0-59 months with diarrhoea in the last two weeks Child was given to drink: Total Child was given to eat: Total Much less Somewhat less About the same More Nothing Missing/DK Much less Somewhat less About the same More Nothing Total 18.5 29.4 28.8 19.7 2.2 1.4 100.0 23.7 34.0 24.8 1.3 16.3 100.0 143 Sex Male 19.7 32.1 29.7 13.8 1.8 2.9 100.0 30.5 28.0 29.7 0.0 11.9 100.0 68 Female 17.5 27.0 28.0 24.9 2.6 0.0 100.0 17.6 39.4 20.3 2.5 20.2 100.0 75 Area Urban 12.3 21.6 38.7 23.2 1.6 2.6 100.0 21.3 27.6 29.4 2.5 19.1 100.0 75 Rural 25.4 38.0 18.0 15.8 2.8 0.0 100.0 26.3 40.9 19.7 0.0 13.1 100.0 68 Mother’s education None (*) (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 10 Primary 16.9 33.8 28.8 17.6 0.8 2.2 100.0 21.5 36.5 26.2 0.0 15.7 100.0 90 Secondary+ (24.4) (22.9) (31.3) (20.1) (1.3) (0.0) 100.0 (27.9) (28.7) (17.9) (4.3) (21.2) 100.0 44 Ethnicity of household head Luhya 20.0 27.8 27.7 20.6 2.4 1.5 100.0 24.0 34.3 24.3 1.4 16.0 100.0 133 Other ethnic group (*) (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) (*) 11 ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 45 Table CH.7 shows the percentage of children age 0-59 months with diarrhoea in the last two weeks preceding the survey, who received oral rehydration salts (ORS), recommended homemade fluids, and zinc during an episode of diarrhoea. Since children may have been given more than one type of liquid, the percentages do not necessarily add to 100. Forty-six percent of children received fluids from ORS packets or pre-packaged ORS fluids and 80 percent received recommended homemade fluids (cereal gruel – uji; fresh fruit juice; soups; fresh or fermented milk). Eighty-nine percent of the children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or any recommended homemade fluid), while 22 percent received zinc. In addition, 16 percent received ORS and zinc. Kakamega County MICS 2013/14 P a g e | 46 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration salts (ORS), recommended homemade fluids, and zinc, Kakamega County MICS, 2013/14 Percentage of children with diarrhoea who received: Number of children age 0-59 months with diarrhoea in the last two weeks Oral rehydration salts (ORS) Recommended homemade fluids ORS or any recommended homemade fluid Zinc ORS and zinc1 Fluid from packet Pre- packaged fluid Any ORS Cereal Gruel(Uji) Fresh or Fermented Milk Fresh fruit juices Soups Any recommended homemade fluid Tablet Syrup Any zinc Total 35.8 12.0 46.0 68.6 18.1 8.0 39.4 80.1 89.0 10.5 13.2 22.3 16.4 143 Sex Male 30.4 9.3 39.7 67.5 18.9 10.8 42.5 78.0 85.2 9.7 15.8 22.6 16.4 68 Female 40.8 14.5 51.7 69.6 17.4 5.6 36.5 82.0 92.5 11.2 10.9 22.1 16.4 75 Area Urban 35.2 5.3 40.4 67.2 17.3 2.5 33.4 73.3 85.1 11.2 10.7 19.9 16.3 75 Rural 36.6 19.4 52.1 70.1 19.0 14.2 45.9 87.6 93.3 9.7 16.0 25.0 16.5 68 Ethnicity of household head Luhya 36.9 10.7 46.9 70.5 18.6 8.7 40.6 80.7 90.3 10.3 11.9 20.7 16.3 133 Other ethnic group (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 11 1 MICS indicator 3.11 - Diarrhoea treatment with oral rehydration salts (ORS) and zinc (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 47 Table CH.8 provide the proportion of children age 0-59 months with diarrhoea in the last two weeks preceding the survey who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, 55 percent of children with diarrhoea received ORS or increased fluids, 92 percent received ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.6 with that of Table CH.7 on oral rehydration therapy, it is evident that 57 percent of children received ORT and, at the same time, feeding was continued, as is recommended. Table CH.8 also shows that all children having had diarrhoea in the two weeks preceding the survey were given various forms of treatment or drug. Kakamega County MICS 2013/14 P a g e | 48 Table CH.8: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given oral rehydration therapy with continued feeding and percentage who were given other treatments, Kakamega County MICS, 2013/14 Children with diarrhoea who were given: Not given any treatment or drug Number of children age 0-59 months with diarrhoea in the last two weeks Zinc ORS or increased fluids ORT (ORS or recommended homemade fluids or increased fluids) ORT with continued feeding1 Other treatments Pill or syrup Injection Intra- venous Home remedy, herbal medicine Other Anti- biotic Anti- motility Other Unknown Anti- biotic Non- antibiotic Unknown Total 22.3 54.9 91.6 56.5 12.0 1.0 2.1 2.2 1.1 0.0 1.4 0.5 2.2 7.0 4.4 143 Sex Male 22.6 46.6 87.0 54.0 6.2 0.0 3.5 4.6 0.0 0.0 1.7 0.0 3.2 8.7 7.3 68 Female 22.1 62.4 95.8 58.8 17.2 2.0 0.9 0.0 2.2 0.0 1.2 0.9 1.2 5.4 1.8 75 Area Urban 19.9 51.3 89.3 54.6 17.6 0.0 1.9 1.9 2.2 0.0 0.0 0.0 0.0 8.3 4.4 75 Rural 25.0 58.8 94.2 58.7 5.9 2.2 2.3 2.5 0.0 0.0 3.0 1.0 4.5 5.5 4.4 68 Ethnicity of household head Luhya 20.7 55.9 93.1 56.3 11.9 1.1 1.8 2.4 1.2 0.0 1.5 0.0 2.3 7.5 3.7 133 Other ethnic group (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 11 1 MICS indicator 3.12 - Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 49 Table CH.9 provides information on the source of ORS and zinc for children who benefitted from these treatments. The main source of ORS was a health facility or provider (81 percent), mainly from a public health facility (65 percent).43 43More variables could not be analysed due to small number of cases reported. Kakamega County MICS 2013/14 P a g e | 50 Table CH.9: Source of ORS and zinc Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given ORS, and percentage given zinc, by the source of ORS and zinc, Kakamega County MICS, 2013/14 Percentage of children who were given as treatment for diarrhoea: Number of children age 0-59 months with diarrhoea in the last two weeks Percentage of children for whom the source of ORS was: Number of children age 0-59 months who were given ORS as treatment for diarrhoea in the last two weeks Percentage of children for whom the source of zinc was: Number of children age 0-59 months who were given zinc as treatment for diarrhoea in the last two weeks Health facilities or providers Other source DK/Missing A health facility or providerb Health facilities or providers Other source A health facility or providerb ORS zinc Public Private Community health providera Public Private Community health providera Total 46.0 22.3 143 64.6 16.2 4.2 12.8 6.4 80.8 66 (70.0) (22.6) (5.8) (7.4) (92.6) 32 a Community health provider includes both public (Community health worker and Mobile/Outreach clinic) and private (Mobile clinic) health facilities b Includes all public and private health facilities and providers Kakamega County MICS 2013/14 P a g e | 51 5.3.2 Acute Respiratory Infections Symptoms of ARI were collected during the Kakamega County MICS to capture pneumonia disease, which is a leading cause of death in children under-5 years. Once diagnosed, pneumonia is treated effectively with antibiotics. Studies have shown a limitation in the survey approach of measuring pneumonia because many of the suspected cases identified through surveys are in fact, not true pneumonia.44 While this limitation does not affect the level and patterns of care-seeking for suspected pneumonia, it limits the validity of the level of treatment of pneumonia with antibiotics, as reported through household surveys. The treatment indicator described in this report must therefore be taken with caution, keeping in mind that the accurate level is likely higher. Mothers’ knowledge of danger signs is an important determinant of care-seeking behaviour. In the MICS, mothers or caretakers were asked to report symptoms that would cause them to take a child under-5 years for care immediately at a health facility. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.10. Overall, 29 percent of women knew at least one of the two danger signs of pneumonia – fast and/or difficult breathing. The most commonly identified symptom for taking a child to a health facility is when the child develops a fever (88 percent): fast breathing (17 percent), and difficult breathing (23 percent). 44Campbell, H. et al. 2013.Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatment. PLoS Med 10(5): e1001421. doi:10.1371/journal.pmed.1001421 Kakamega County MICS 2013/14 P a g e | 52 Table CH.10: Knowledge of the two danger signs of pneumonia Percentage of women age 15-49 years who are mothers or caretakers of children under age 5 by symptoms that would cause them to take a child under age 5 immediately to a health facility, and percentage of mothers who recognize fast or difficult breathing as signs for seeking care immediately, Kakamega County MICS, 2013/14 Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/caretakers who recognize at least one of the two danger signs of pneumonia (fast and/or difficult breathing) Number of women age 15-49 years who are mothers/caretakers of children under age 5 Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has difficult breathing Has blood in stool Is drinking poorly Has other symptoms Total 34.2 35.7 87.7 16.6 22.6 10.8 21.6 73.1 29.1 501 Area Urban 31.0 34.8 87.8 16.0 21.1 8.1 19.4 76.5 28.8 264 Rural 37.7 36.8 87.6 17.3 24.2 13.8 24.1 69.3 29.4 237 Education None (11.5) (28.0) (73.7) (6.2) (11.8) (3.9) (16.1) (70.0) (18.0) 25 Primary 31.3 38.6 86.3 17.3 22.7 10.8 21.0 72.0 28.8 318 Secondary+ 43.6 31.2 92.7 16.8 24.1 12.1 23.8 75.9 31.5 158 Wealth index quintile Poorest 29.3 27.6 81.5 9.5 20.6 5.6 23.5 73.1 27.0 117 Second 27.5 30.0 84.4 11.7 23.9 8.2 15.8 71.0 28.5 107 Middle 38.2 37.7 93.7 22.1 17.5 12.0 25.0 70.8 27.4 101 Fourth 39.3 47.8 91.6 26.1 28.1 19.3 23.1 77.2 36.0 93 Richest 39.1 38.8 89.1 15.7 23.9 10.7 20.6 74.2 27.1 84 Ethnicity of household head Luhya 33.4 34.3 87.3 16.6 22.2 9.9 21.8 73.6 29.1 470 Other ethnic group (45.6) (57.2) (93.9) (16.2) (28.5) (24.4) (18.2) (65.9) (28.5) 31 ( ) Figures that are based on 25-49 unweighted cases 5.3.3 Solid Fuel Use More than 3 billion people around the world rely on solid fuels for their basic energy needs, including cooking and heating. Solid fuels include biomass fuels, such as wood, charcoal, crops or other agricultural waste, dung, shrubs and straw, and coal. Cooking and heating with solid fuels leads to high levels of indoor smoke which contains a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is their incomplete combustion, which produces toxic elements such as carbon monoxide, polyaromatic hydrocarbons, and sulphur dioxide (SO2), among others. Use of solid fuels increases the risks of incurring acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, asthma, or cataracts, and may contribute to low birth weight of babies born to pregnant women exposed to smoke. The primary indicator for monitoring use of solid fuels is the proportion of the population using solid fuels as the primary source of domestic energy for cooking, shown in Table CH.11. Overall, 95 percent of the household population in Kakamega County use solid fuels for cooking, consisting mainly of wood (79 percent). Use of solid fuels in urban areas (91 percent) is equally high as in rural areas (99 percent). Differentials with respect to household wealth and the educational level of the household Kakamega County MICS 2013/14 P a g e | 53 head are also important. Use of solid fuels varies by the educational level of the household head (none, 100 percent; primary education, 98 percent; secondary or higher, 88 percent). The use of solid fuel is 99 percent for poorest households and 79 percent for those in the richest households. Kakamega County MICS 2013/14 P a g e | 54 Table CH.11: Solid fuel use Percent distribution of household members according to type of cooking fuel mainly used by the household, and percentage of household members living in households using solid fuels for cooking, Kakamega County MICS, 2013/14 Percentage of household members in households mainly using: Number of household members Electricity Liquefied Petroleum Gas (LPG) Natural Gas Biogas Kerosene Solid fuels Other fuel No food cooked in the household Total Solid fuels for cooking1 Coal/ Lignite Char- coal Wood Straw/ Shrubs/ Grass Agricultural crop residue Total 1.8 1.1 0.2 0.6 0.9 0.6 13.8 79.2 1.2 0.3 0.2 0.2 100.0 95.0 5,666 Area Urban 3.9 2.0 0.5 0.9 1.6 0.0 22.3 68.3 0.3 0.0 0.2 0.0 100.0 90.9 2,653 Rural 0.0 0.2 0.0 0.3 0.3 1.1 6.3 88.8 2.0 0.5 0.2 0.4 100.0 98.6 3,013 Education of household head None 0.0 0.0 0.0 0.0 0.0 1.1 6.2 89.3 1.9 0.9 0.5 0.0 100.0 99.5 630 Primary 0.1 0.4 0.0 0.6 0.4 0.6 10.1 85.8 1.4 0.2 0.0 0.3 100.0 98.2 3,216 Secondary+ 5.5 2.6 0.7 0.8 2.2 0.3 23.2 63.5 0.7 0.1 0.3 0.0 100.0 87.8 1,781 Wealth index quintile Poorest 0.0 0.0 0.0 0.0 0.0 0.3 2.2 95.9 0.7 0.0 0.4 0.6 100.0 99.0 1,131 Second 0.0 0.0 0.0 0.0 0.0 0.6 2.4 96.4 0.2 0.0 0.0 0.4 100.0 99.6 1,132 Middle 0.0 0.0 0.0 0.0 0.7 1.1 10.2 85.2 2.1 0.7 0.0 0.0 100.0 99.3 1,133 Fourth 0.0 0.1 0.0 0.0 1.4 0.5 16.6 79.4 1.4 0.6 0.1 0.0 100.0 98.5 1,135 Richest 9.1 5.3 1.2 2.9 2.6 0.4 37.3 39.2 1.7 0.0 0.4 0.0 100.0 78.7 1,135 Ethnicity of household head Luhya 1.3 0.9 0.2 0.6 0.8 0.6 11.8 81.8 1.3 0.3 0.1 0.2 100.0 95.8 5,243 Other ethnic group 7.8 3.4 0.2 0.5 2.3 0.0 38.2 46.6 0.6 0.0 0.4 0.0 100.0 85.4 422 1 MICS indicator 3.15 - Use of solid fuels for cooking ( ) Figures that are based on 25-49 unweighted cases Kakamega County MICS 2013/14 P a g e | 55 Solid fuel use by place of cooking is depicted in Table CH.12. The presence and extent of indoor pollution are dependent on cooking practices, places used for cooking, as well as types of fuel used. According to the Kakamega County MICS, 23 percent of the population living in households using solid fuels for cooking, cook food in a separate room that is used as a kitchen. The percentage that had food cooked in separate room used as a kitchen is 25 percent in urban areas and 22 percent in rural areas. The proportion is higher for households with a head of household with secondary/higher education and for those in the richest 20 percent of the households than their counterparts. Table CH.12: Solid fuel use by place of cooking Percent distribution of household members in households using solid fuels by place of cooking, Kakamega County MICS, 2013/14 Place of cooking: Number of household members in households using solid fuels for cooking In the house In a separate building Outdoors Other place Missing Total In a separate room used as kitchen Elsewhere in the house Total 23.1 17.5 52.4 6.8 0.1 0.0 100.0 5,383 Area Urban 24.5 18.5 47.2 9.7 0.0 0.0 100.0 2,411 Rural 21.9 16.7 56.6 4.5 0.2 0.0 100.0 2,972 Education of household head None 21.4 18.1 55.3 5.3 0.0 0.0 100.0 626 Primary 20.1 18.0 55.0 6.7 0.2 0.0 100.0 3,157 Secondary+ 30.0 16.2 46.3 7.5 0.0 0.0 100.0 1,564 Wealth index quintile Poorest 19.8 37.1 38.8 4.3 0.0 0.0 100.0 1,120 Second 19.9 13.8 60.4 5.4 0.5 0.0 100.0 1,128 Middle 23.3 10.4 57.6 8.6 0.0 0.1 100.0 1,125 Fourth 16.9 10.5 65.2 7.4 0.0 0.0 100.0 1,117 Richest 38.7 15.5 36.7 9.0 0.0 0.0 100.0 893 Ethnicity of household head Luhya 22.8 17.0 53.5 6.6 0.1 0.0 100.0 5,022 Other ethnic group 26.8 25.0 37.8 10.4 0.0 0.0 100.0 361 5.3.4 Malaria/Fever Malaria is a major cause of death of children under five years worldwide. In Kenya, malaria accounts for about 31 percent of outpatient consultations and five percent of hospital admissions.45 The results of the Kenya Malaria Indicator Survey 2010 showed that children age 5–14 years had the highest prevalence of malaria (13 percent). The prevalence in children below five years increased from four percent in 2007 to eight percent in 2010. Malaria prevalence was also nearly three times as high in rural areas (12 percent) 45 President’s Malaria Initiative – Kenya Malaria Operational Plan FY 2014 Kakamega County MICS 2013/14 P a g e | 56 as in urban areas (5 percent).46 Malaria transmission and infection risk in Kenya is determined largely by altitude, rainfall patterns and temperature. Preventive measures and treatment with an effective antimalarial can dramatically reduce malaria mortality rates among children. In areas where malaria is common, WHO recommends indoor residual spraying (IRS), use of insecticide treated bednets (ITNs) and prompt treatment of cases with recommended anti-malarial drugs. In 2010 the WHO issued a recommendation for universal use of diagnostic testing to confirm malaria infection and apply appropriate treatment based on the results. According to the guidelines, treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible. This recommendation was based on studies that showed substantial reduction in the proportion of fever that are associated with malaria to a low level.47 This recommendation implies that the indicator on proportion of children with fever that received antimalarial treatment is no longer an acceptable indicator of the level of treatment of malaria in the population of children under age five. However, as it remains the MDG indicator and for purposes of comparisons, as well as assessment of patterns across socio-demographic characteristics, the indicator remains a standard MICS indicator. Children with severe malaria symptoms, such as fever and/or convulsions, should be taken to a health facility. Further, children recovering from malaria should be given extra liquids and food, and younger children should continue breastfeeding. In Kenya, the Division of Malaria Control (DOMC) and Presidents Malaria Initiative (PMI), have put in place the following interventions for malaria control and case management: indoor residual spraying (IRS); distribution of insecticide-treated nets; intermittent preventive treatment of pregnant women (IPTp): provision of prompt diagnosis and effective treatment at all levels of the health care system; advocacy, communication and social mobilisation through Behaviour Change Communication (BCC); monitoring and evaluation; and health systems strengthening and integration. The Malaria Control Programme is guided by the National Malaria Communication Strategy 2010 – 2013; Kenya National Malaria Strategy 2009 – 2017 - Towards a Malaria-free Kenya; and the National Guidelines for the Diagnosis, Treatment and Prevention of Malaria in Kenya 2010. Insecticide-treated mosquito nets, or ITNs, if used properly, are very effective in offering protection against mosquitos and other insects. The use of ITNs is one of the main health interventions implemented to reduce malaria transmission in Kenya. The questionnaire incorporated questions on the availability and use of bed nets, both at household level and among children under-5 years of age and pregnant women. In addition, all households in Kakamega County MICS were asked whether the interior dwelling walls were sprayed with an insecticide to kill or repel mosquitoes that spread malaria during the 12 months preceding the survey. 46Division of Malaria Control [Ministry of Public Health and Sanitation], Kenya National Bureau of Statistics, and ICF Macro. 2011. 2010 Kenya Malaria Indicator Survey. Nairobi, Kenya: DOMC, KNBS and ICF Macro. 47D'Acremont, V et al. 2010. Reduction in the proportion of fevers associated with Plasmodium falciparum parasitaemia in Africa: a systematic review. Malaria Journal 9(240). Kakamega County MICS 2013/14 P a g e | 57 In Kakamega County, the survey results indicate that 77 percent of households had at least one insecticide treated net (Table CH.13), and 45 percent at least one ITN for every two household members. Further, five percent of households received indoor residual spraying during the last 12 months, and 47 percent had at least one ITN for every two household members and/or received IRS during the last 12 months. Kakamega County MICS 2013/14 P a g e | 58 Table CH.13: Household availability of insecticide treated nets and protection by a vector control method Percentage of households with at least one mosquito net, one insecticide treated net (ITN), and one long-lasting treated net, percentage of households with at least one mosquito net, one insecticide treated net (ITN) per two people, and one long-lasting treated net, percentage of households with at least one ITN and/or indoor residual spraying (IRS) in the last 12 months, and percentage of households with at least one ITN per two people and/or with indoor residual spraying (IRS) in the last 12 months, Kakamega County MICS, 2013/14 Percentage of households with at least one mosquito net: Percentage of households with at least one net for every two personsa: Percentage of households with IRS in the past 12 months Percentage of households with at least one ITN and/or IRS during the last 12 months3 Percentage of households with at least one ITN for every 2 persons and/or received IRS during the last 12 months4 Number of households Any mosquito net Insecticide treated mosquito net (ITN)1 Long-lasting insecticidal treated net (LLIN) Any mosquito net Insecticide treated mosquito net (ITN)2 Long-lasting insecticidal treated net (LLIN) Total 85.6 77.3 73.7 51.0 44.6 41.6 4.9 78.3 46.6 1,221 Area Urban 85.5 76.7 74.7 53.3 47.1 44.2 6.6 77.8 49.9 614 Rural 85.8 78.0 72.8 48.8 42.0 38.9 3.1 78.8 43.3 607 Education of household head None 77.2 68.8 63.0 38.4 34.7 30.9 1.4 69.8 35.7 150 Primary 86.5 78.5 75.1 46.3 39.3 36.5 2.5 78.8 40.3 644 Secondary+ 87.6 79.1 76.0 63.6 56.8 53.8 9.7 80.9 60.5 416 Wealth index quintile Poorest 81.6 73.4 68.2 36.5 30.9 28.9 2.3 73.6 32.3 246 Second 85.1 78.7 75.6 41.5 38.2 35.1 0.3 79.0 38.4 218 Middle 88.3 77.9 74.6 50.5 44.2 40.4 3.8 78.8 45.9 232 Fourth 89.2 77.4 73.9 58.8 47.9 44.3 2.7 78.8 49.5 234 Richest 84.4 79.0 76.1 64.7 58.6 55.9 13.2 81.1 63.1 292 Ethnicity of household head Luhya 85.9 77.8 73.9 50.0 43.4 40.3 4.4 78.6 45.1 1,101 Other ethnic group 82.6 73.3 72.4 60.6 55.4 53.7 9.6 76.4 60.9 120 1 MICS indicator 3.16a - Household availability of insecticide-treated nets (ITNs) - One+ 2 MICS indicator 3.16b - Household availability of insecticide-treated nets (ITNs) - One+ per 2 people 3 MICS indicator 3.17a - Households covered by vector control - One+ ITNs 4 MICS indicator 3.17b - Households covered by vector control - One+ ITNs per 2 people Kakamega County MICS 2013/14 P a g e | 59 a The numerators are based on number of usual (de jure) household members and does not take into account whether household members stayed in the household last night. MICS does not collect information on visitors to the household Kakamega County MICS 2013/14 P a g e | 60 Tables CH.14 and CH.15 provide further insight on access to ITNs. Overall, 26 percent of individuals are estimated to have access to ITNs, i.e. they could sleep under an ITN if each ITN in the household was used by two people. Access is slightly higher in urban (28 percent) than in rural (25 percent) areas. Access to an ITN ranges from 13 percent in the poorest households to 42 percent in the richest households. Table CH.14: Access to an insecticide treated net (ITN) - number of household members Percentage of household population with access to an ITN in the household, Kakamega County MICS, 2013/14 Number of ITNs owned by household: Total Percentage with access to an ITNa Number of household membersb 0 1 2 3 4 5 6 7 8 or more Total 22.7 22.2 24.1 19.7 6.0 2.9 2.1 0.2 0.2 100.0 26.0 5,666 Number of household members 1 43.0 42.8 12.3 1.1 0.7 0.0 0.0 0.0 0.0 100.0 57.0 168 2 33.6 35.4 22.1 6.5 2.4 0.0 0.0 0.0 0.0 100.0 31.0 232 3 22.8 29.9 25.0 18.8 2.2 0.9 0.4 0.0 0.0 100.0 47.3 461 4 18.8 22.8 28.8 22.6 4.7 1.2 1.0 0.0 0.0 100.0 29.6 764 5 13.0 7.9 37.9 30.8 6.9 2.0 1.5 0.0 0.0 100.0 41.2 803 6 19.7 12.1 34.2 22.1 5.2 3.6 3.1 0.0 0.0 100.0 11.9 975 7 15.4 11.0 15.7 28.6 16.4 8.3 4.6 0.0 0.0 100.0 29.3 748 8 or more 15.5 14.9 13.3 26.5 12.5 8.2 6.4 1.2 1.6 100.0 12.8 1,514 a Percentage of household population who could sleep under an ITN if each ITN in the household were used by up to two people bThe denominator is number of usual (de jure) household members and does not take into account whether household members stayed in the household last night. MICS does not collect information on visitors to the household Kakamega County MICS 2013/14 P a g e | 61 Table CH.15: Access to an insecticide treated net (ITN) - background characteristics Percentage of household population with access to an ITN in the household, Kakamega County MICS, 2013/14 Percentage with access to an ITNa Number of household membersb Total 26.0 5,666 Area Urban 27.5 2,653 Rural 24.6 3,013 Wealth index quintile Poorest 12.9 1,131 Second 21.9 1,132 Middle 24.4 1,133 Fourth 28.7 1,135 Richest 42.0 1,135 Ethnicity of household head Luhya 25.2 5,243 Other ethnic group 36.1 422 a Percentage of household population who could sleep under an ITN if each ITN in the household were used by up to two people bThe denominator is number of usual (de jure) household members and does not take into account whether household members stayed in the household last night. MICS does not collect information on visitors to the household Overall, 79 percent of ITNs were used during the night preceding the survey (Table CH.16). Eighty-one percent of household members in urban areas used ITNs during the night preceding the survey while 76 percent in rural areas. Table CH.16: Use of ITNs Percentage of insecticide treated nets (ITNs) that were used by anyone last night, Kakamega County MICS, 2013/14 Percentage of ITNs used last night Number of ITNs Total 78.7 2,238 Area Urban 81.2 1,079 Rural 76.4 1,159 Wealth index quintile Poorest 81.7 352 Second 81.2 403 Middle 81.3 429 Fourth 79.9 468 Richest 72.4 587 Ethnicity of household head Luhya 79.6 2,041 Other ethnic group 69.6 197 Kakamega County MICS 2013/14 P a g e | 62 As for children under the age of five years, who constitute an important vulnerable group, 71 percent slept under an ITN the night preceding the survey (Table CH.17). This figure rises to 83 percent considering only children living in a household with at least one ITN. The proportion of boys under-5 years who slept under an ITN the night preceding the survey is 68 percent while it is 73 percent for girls. Variations are evident by type of place of residence; 75 percent in urban areas and 66 in rural areas. Kakamega County MICS 2013/14 P a g e | 63 Table CH.17: Children sleeping under mosquito nets Percentage of children age 0-59 months who slept under a mosquito net last night, by type of net, Kakamega County MICS, 2013/14 Percentage of children age 0- 59 who spent last night in the interviewed households Number of children age 0-59 months Percentage of children under age five who the previous night slept under: Number of children age 0-59 months who spent last night in the interviewed households Percentage of children 0-59 months who slept under an ITN last night in households with at least one ITN Number of children age 0-59 living in households with at least one ITN Any mosquito net An insecticide treated net (ITN)1 A Long- lasting insecticidal treated net (LLIN) An ITN or in a dwelling sprayed with IRS in the past 12 months Total 97.2 806 77.9 70.5 67.5 70.7 784 82.7 668 Sex Male 97.3 388 75.5 67.6 64.8 67.7 377 80.5 317 Female 97.1 418 80.2 73.2 69.9 73.5 406 84.7 351 Area Urban 96.5 405 84.6 75.4 73.0 75.4 390 90.4 326 Rural 97.9 401 71.3 65.7 62.0 66.1 393 75.4 342 Age 0-11 months 98.0 151 84.3 78.3 75.4 78.6 148 89.0 130 12-23 months 98.7 161 78.8 72.6 69.2 72.6 159 85.7 134 24-35 months 97.1 150 72.6 63.7 60.9 64.1 146 76.3 122 36-47 months 95.9 205 76.2 66.9 63.3 66.9 196 81.7 161 48-59 months 96.6 140 78.3 71.9 70.0 72.3 135 80.4 121 Mother's education None 99.4 62 75.2 60.6 54.0 60.6 62 (73.7) 51 Primary 97.7 522 75.9 68.8 66.3 69.1 510 79.6 441 Secondary+ 95.3 222 83.6 77.5 74.3 77.5 211 93.1 176 Wealth index quintile Poorest 97.6 207 76.5 66.4 62.0 66.9 202 78.9 170 Second 98.1 176 79.3 71.2 68.6 71.2 173 81.6 151 Middle 98.3 154 76.4 69.2 68.9 69.2 151 84.9 123 Fourth 97.7 158 77.0 70.0 65.8 70.3 155 82.6 131 Richest 92.9 111 82.1 80.1 76.8 80.1 103 88.9 93 Kakamega County MICS 2013/14 P a g e | 64 Ethnicity of household head Luhya 97.1 764 77.4 69.7 66.7 69.9 741 82.0 630 Other ethnic group (100.0) 42 (86.8) (84.4) (81.9) (84.4) 42 (95.0) 37 1 MICS indicator 3.18; MDG indicator 6.7 - Children under age 5 sleeping under insecticide-treated nets (ITNs) ( ) Figures that are based on 25-49 unweighted cases Kakamega County MICS 2013/14 P a g e | 65 Table CH.18 gives further insight into the use of mosquito nets by household members of any age, 62 percent who slept under an ITN the night prior to the survey. This figure increases to 75 percent considering only household members living in a household with at least one ITN. Overall, 63 percent of household members slept under an ITN the previous night or in a dwelling which had IRS in the past 12 months. In urban areas, 66 percent of household members slept under an ITN the night preceding the survey while the figure is 58 percent in rural areas. Women were more likely to sleep under an ITN than men as 65 percent slept under an ITN compared with 59 percent for men. Variations were also noted by education of head of household and by household wealth. Table CH.18: Use of mosquito nets by the household population Percentage of household members who slept under a mosquito net last night, by type of net, Kakamega County MICS, 2013/14 Percentage of household members who the previous night slept under: Number of household members who spent the previous night in the interviewed households Percentage of household members who slept under an ITN last night in households with at least one ITN Number of household members in households with at least one ITN Any mosquito net An insecticide treated net (ITN)1 A Long- lasting insecticidal treated net (LLIN) An ITN or in a dwelling sprayed with IRS in the past 12 months Total 69.4 61.6 58.2 62.5 5,265 75.2 4,316 Sex Male 66.1 58.6 55.1 59.6 2,563 71.9 2,088 Female 72.6 64.5 61.2 65.3 2,702 78.3 2,228 Area Urban 75.0 65.7 63.4 66.8 2,436 81.5 1,964 Rural 64.6 58.1 53.8 58.9 2,829 69.9 2,352 Age 0-4a 78.2 70.3 67.4 70.5 806 82.8 684 5-14 62.6 54.7 51.7 55.4 1,655 66.6 1359 15-34 64.6 57.7 54.8 59.0 1,551 70.4 1,272 35-49 79.3 72.8 67.2 73.9 616 88.5 507 50+ 78.3 67.3 63.3 68.7 634 87.0 490 Education of household head None 61.1 53.7 46.8 54.0 598 69.1 464 Primary 68.1 60.7 58.1 61.2 3,046 74.0 2,500 Secondary+ 75.1 66.6 63.0 68.2 1,585 79.5 1,328 Missing/DK (68.7) (54.5) (48.8) (62.2) 36 (*) 23 Wealth index quintile Poorest 64.8 57.1 53.7 57.6 1,073 72.3 848 Second 63.4 56.6 53.3 56.8 1,071 70.3 862 Middle 70.9 62.1 58.5 62.8 1,069 75.1 885 Fourth 73.7 63.3 60.3 64.5 1,070 77.6 872 Richest 74.7 69.6 65.9 71.7 982 80.7 848 Ethnicity of household head Luhya 69.5 61.8 58.3 62.5 4,896 75.0 4,033 Other ethnic group 68.6 59.7 57.7 62.3 370 78.1 283 1 MICS indicator 3.19 - Population that slept under an ITN Kakamega County MICS 2013/14 P a g e | 66 a The results of the age group 0-4 years do not match those in Table CH.18, which is based on completed under-5 interviews only. The two tables are computed with different sample weights. ( ) Figures that are based on 25-49 unweighted cases Table CH.19 provides information on care-seeking behaviour during an episode of fever in the past two weeks. As shown in Table CH.19, advice was sought from a health facility or a qualified health care provider for half of the children with fever; these services were provided mainly by the public sector (40 percent). Advice was sought from a health facility or provider for 54 percent of male cases while the percentage is 46 percent for females. However, no advice or treatment was sought in 25 percent of the cases. Table CH.19: Care-seeking during fever Percentage of children age 0-59 months with fever in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, Kakamega County MICS, 2013/14 Percentage of children for whom: Number of children with fever in last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider1, b Public Private Community health providera Total 39.8 25.8 1.6 9.8 49.7 25.0 221 Sex Male 43.1 24.7 0.8 7.6 54.2 25.4 104 Female 36.9 26.8 2.2 11.7 45.8 24.6 117 Area Urban 39.3 33.5 0.0 11.8 51.3 15.3 106 Rural 40.2 18.8 3.0 7.9 48.3 33.9 115 Ethnicity of household head Luhya 39.3 25.2 1.7 10.4 48.6 25.5 208 Other ethnic group (*) (*) (*) (*) (*) (*) 14 1 MICS indicator 3.20 - Care-seeking for fever a Community health providers include both public (Community health worker and Mobile/Outreach clinic) and private (Mobile clinic) health facilities b Includes all public and private health facilities and providers as well as shops (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 67 Mothers were asked to report all of the medicines given to a child to treat the fever, including both medicines given at home and medicines given or prescribed at a health facility. Artemisinin-based Combination therapy (ACT) is the first line antimalarial recommended by the WHO and used in the country. In addition, confirmation of malaria is done on all fever cases through a malaria test. Twelve percent of children with fever in the last two weeks preceding the survey were treated with an artemisinin-based combination therapy (ACT) while 26 percent received another antimalarial (Table CH.20). Kakamega County MICS 2013/14 P a g e | 68 Table CH.20: Treatment of children with fever Percentage of children age 0-59 months who had a fever in the last two weeks, by type of medicine given for the illness, Kakamega County MICS, 2013/14 Children with a fever in the last two weeks who were given: Number of children with fever in last two weeks Anti-malarials Other medications Other Missing/DK SP/ Fansidar Chloroquine Amodia- quine Quinine Artemisinin- based Combination Therapy (ACT) Other anti- malarial Antibiotic pill or syrup Antibiotic injection Paracetamol/ Panadol/ Acetaminophen Aspirin Ibuprofen Total 2.1 0.0 2.5 2.6 12.4 26.0 48.6 2.5 54.4 1.0 1.5 12.4 0.5 221 Sex Male 3.9 0.0 1.5 1.6 11.3 24.3 51.5 3.6 51.4 0.5 1.5 10.0 0.6 104 Female 0.6 0.0 3.4 3.5 13.4 27.6 46.1 1.6 57.1 1.5 1.5 14.6 0.4 117 Area Urban 1.2 0.0 2.1 2.8 15.6 35.1 47.8 1.6 60.5 1.6 2.4 14.2 0.0 106 Rural 3.0 0.0 2.9 2.4 9.4 17.7 49.4 3.4 48.8 0.4 0.6 10.8 0.9 115 Ethnicity of household head Luhya 2.3 0.0 2.4 2.3 11.4 26.1 47.5 2.7 54.8 1.1 1.1 11.0 0.5 208 Other ethnic group (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 14 (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 69 Overall, 24 percent of children with a fever in the previous two weeks had blood taken from a finger or heel for testing (table CH.21). Thirty-two percent of males and 17 percent of females had their blood taken for testing. In urban areas, the proportion is 29 percent of the children while it is 19 percent in rural areas. In total, 28 percent of children with fever who received antimalarial treatment, were treated with an ACT. Kakamega County MICS 2013/14 P a g e | 70 Table CH.21: Diagnostics and anti-malarial treatment of children Percentage of children age 0-59 months who had a fever in the last two weeks who had a finger or heel stick for malaria testing, who were given Artemisinin-combination Treatment (ACT) and any anti-malarial drugs, and percentage who were given ACT among those who were given anti-malarial drugs, Kakamega County MICS, 2013/14 Percentage of children who: Number of children age 0-59 months with fever in the last two weeks Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti- malarial treatment3 Number of children age 0- 59 months with fever in the last two weeks who were given any antimalarial drugs Had blood taken from a finger or heel for testing1 Were given: Artemisinin- combination Treatment (ACT) ACT the same or next day Any antimalarial drugs2 Any antimalarial drugs same or next day Total 23.9 12.4 7.2 45.0 23.5 221 27.5 100 Sex Male 32.2 11.3 5.3 41.7 19.7 104 (27.1) 43 Female 16.6 13.4 8.8 47.9 26.9 117 27.9 56 Area Urban 28.9 15.6 9.9 56.7 31.0 106 (27.5) 60 Rural 19.3 9.4 4.6 34.2 16.6 115 27.5 39 Mother’s education None (*) (*) (*) (*) (*) 19 (*) 6 Primary 25.0 8.7 5.3 48.8 25.6 143 17.9 70 Secondary+ 26.9 22.0 13.8 39.6 19.7 59 (*) 24 Ethnicity of household head Luhya 21.2 11.4 7.0 43.7 22.3 208 26.1 91 Other ethnic group (*) (*) (*) (*) (*) 14 (*) 9 1 MICS indicator 3.21 - Malaria diagnostics usage 2 MICS indicator 3.22; MDG indicator 6.8 - Anti-malarial treatment of children under age 5 3MICS indicator 3.23 - Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti-malarial treatment ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Kakamega County MICS 2013/14 P a g e | 71 Table CH.22 presents the source of antimalarial for children under five years who were treated with an antimalarial. Forty-five percent of children with a fever in the last two weeks preceding the survey were treated with an antimalarial. Treatment was obtained from a health facility or provider in 92 percent of the cases treated with antimalarials, mostly from public health facilities (52 percent). Kakamega County MICS 2013/14 P a g e | 72 Table CH.22: Source of anti-malarial Percentage of children age 0-59 months with fever in the last two weeks who were given anti-malarial by the source of anti-malarial, Kakamega County MICS, 2013/14 Percentage of children who were given anti- malarial Number of children age 0-59 months with fever in the last two weeks Percentage of children for whom the source of anti-malarial was: Number of children age 0-59 months who were given anti-malarial as treatment for fever in the last two weeks Health facilities or providers Other source A health facility or providerb Public Private Community health providera Total 45.0 221 52.4 31.0 2.6 16.1 91.5 100 Sex Male 41.7 104 (61.4) (29.3) (1.9) (9.3) (98.6) 43 Female 47.9 117 45.6 32.2 3.1 21.3 85.9 56 Area Urban 56.7 106 47.3 31.2 0.0 21.5 87.6 60 Rural 34.2 115 60.3 30.6 6.5 7.9 97.3 39 a Community health providers include both public (Community health worker and Mobile/Outreach clinic) and private (Mobile clinic) health facilities b Includes all public and private health facilities and providers as well as shops ( ) Figures that are based on 25-49 unweighted cases Kakamega County MICS 2013/14 P a g e | 73 Pregnant women living in places where malaria is highly prevalent are highly vulnerable to malaria. Once infected, pregnant women risk anaemia, premature delivery and stillbirth. Their babies are at increased risk of low birth weight, which carries an increased risk of dying in infancy.48 For this reason, steps are taken to protect pregnant women by distributing insecticide-treated mosquito nets and mobilizing for their consistent use; and treatment during antenatal check-ups with drugs that prevent malaria infection (Intermittent preventive treatment/IPT). WHO recommends that in areas of moderate-to-high malaria transmission, all pregnant women be provided an intermittent preventive treatment with Sulfadoxine- Pyrimethamine (SP) at every scheduled antenatal care visit. In the Kakamega County MICS, women were asked of the medicines they had received to prevent malaria in their last pregnancy during the 2 years preceding the survey. Women are considered to have received intermittent preventive therapy if they have received at least 3 doses of SP/Fansidar during the pregnancy, at least one of which was taken during antenatal care. Table CH.23 presents the proportion of pregnant women who slept under a mosquito net during the previous night before the survey. Eighty-two percent of pregnant women slept under any mosquito net the night prior to the survey and 80 percent slept under an insecticide-treated net. This figure rises to 94 percent if we only consider those living in a household with at least one ITN. 48Shulman, CE and Dorman, EK. 2003. Importance and prevention of malaria in pregnancy. Trans R Soc Trop Med Hyg 97(1): 30– 55. Kakamega County MICS 2013/14 P a g e | 74 Table CH.23: Pregnant women sleeping under mosquito nets Percentage of pregnant women age 15-49 years who slept under a mosquito net last night, by type of net, Kakamega County MICS, 2013/14 Percentage of pregnant women who spent last night in the interviewed households Number of pregnant women age 15-49 years Percentage of pregnant women age 15-49 years who the previous night slept under: Number of pregnant women who spent last night in the interviewed households Percentage of pregnant women who slept under an ITN last night in households with at least one ITN Number of pregnant women age 15-49 years living in households with at least one ITN Any mosquito net An insecticide tr

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