sierra leone's baseline report - window of opportunity

CARE Window of Opportunity Baseline, Koinadugu, Tonkolili, March, 2009

Window of Opportunity Project Baseline Survey of the Population in Seven

Chiefdoms of Koinadugu District and Three Chiefdoms of

Tonkolili District

March 2009

Draft Report

CARE International in Sierra Leone Ministry of Health and Sanitation (MOHS)

Koinadugu, Tonkolili Districts, Sierra Leone

CARE Window of Opportunity Baseline, Koinadugu, Tonkolili, March, 2009 2

Acknowledgements The District Health Management Team (DHMT), the District Council and other stakeholders of Koinadugu and Tonkolili districts are acknowledged for their warm reception of the researchers and timely provision of information for the survey teams. The researchers and supervisors are acknowledged for their assiduous work amidst the various challenges experienced in the course of the survey. The Window of Opportunity Baseline survey would not have been successful without the support of the Peripheral Health Staff in both Koinadugu and Tonkolili districts. CARE remains appreciative of the efforts given by the various actors/actresses that contributed in one way or the other towards the success of the survey.


Table of Contents Acknowledgements: …..................................................................................... 2 1. List of figures: ……………………………………………………...4

2. Executive Summary: ……………………………………………….5 3. Background:………………………………………………………...6 4. Process and Partnership building: ………………………………….9 5. Methods: ………………………………………………………….10

Survey area…………………………………………………… Study population……………………………………………... Questionnaire……………………………………………….. Sample Size………………………………………………… Sample Selection Data collection Data management and analysis

6. Results…………………………………………………………...13 6.1 Socio-demographic characteristics 6.2 Breastfeeding and feeding practices 6.3 Diarrhea 6.4 Acute Respiratory Infection 6.5 Fever, care-seeking behavior 6.6 Maternal and new born care

6. Discussions………………………………………………………26 External comparison Programmatic implications Breastfeeding and feeding practice Diarrhea ARI Care-seeking Fever Maternal and newborn care Information dissemination 7. Bibliography…………………………………………………34 8. Appendices………………………………………………… 34

1. Sierra Leone Planning Map 2. Baseline questionnaire 3. Training schedule 4. Participants in survey


Figures Figue 1: Key baseline results Figure 2: Percentage of who assist during delivery Figure 3: Percentage of who take decision for treatment of a child with diarrhoea Figure 4: Percentage of who take decision for ARI treatment Figure 5: Percentage of care seeking time for ARI Figure 6: Percentage of care seeking places for ARI treatment Figure 7: Percentage sources of information on breastfeeding or child feeding Figure 8: Percentage of information mothers heard on feeding young children Figure 9: Percentage of who assist mothers in making breastfeeding easier Figure 10: Percentage of help offered to mothers with children 0-23 months Figure 11: Liquid given to child three days after delivery Figure 12: Percentage of treatment given to children during episode of diarrhoea Figure 13: Percentage of places visited for treatment of diarrhoea in children Figure 14: Percentage of medications given during child’s illness with ARI Figure 15: Percentage of treatment given for Malaria Figure 16: Percentage source of decision to go for Malaria treatment Figure17: Percentage of anti-malaria treatment given to children Figure 18: Percentage of care seeking time for treatment of children with Fever Figure 19: Percentage of other medications given to children with Fever Figure 20: Percentage of who slept under ITN the previous night before survey?


2. EXECUTIVE SUMMARY Decades of poor governance compounded by eleven years of civil war, have retrogressed the economy, health and social infrastructure of Sierra Leone. These appalling situations have accounted for an estimated 68% of the population living below the poverty line (Earning less than $ 1 per day). Sierra Leone has the lowest gross domestic product (GDP) per capita ($470) and the average life expectancy rates (34.5 years) in the world. Having ranked at the lowest level of the UNDP Human Development Index for the past decade, the level of poverty in Sierra Leone is staggering. A high fertility rate of 6.5 has resulted in 44% of the population aged less than 15 years. Only 36% of the population is literate with women accounting for 90% illiteracy levels1. Amidst this backdrop, CARE Sierra Leone in collaboration with the Ministry of Health and Sanitation in Sierra Leone (MOHS) has embarked upon a three-year USAID funded Infant and Young Child Feeding and Maternal related Nutrition through the Window of Opportunity project (IYCF+rMN ). CARE is presently working with the Window of Opportunity Program in two of the northern districts of Koinadugu and Tonkolili with a total of 12 chiefdoms (Koinadugu 9, Tonkolili 3). Many of the more isolated villages can only be reached by footpaths and it can take up to one or two days’ walk from such isolated villages to the main road. The goal of the Infant and Young Child Feeding Program is to improve the nutritional status of 25,000 children less than two years in 12 chiefdoms in the Koinadugu and Tonkolili Districts of Sierra Leone by 2011. The sampling frame was constructed using village level population data from the 12 chiefdoms where CARE is currently operating. CARE field officers collected population data from every village in the 12 chiefdoms. A total of 394 villages with a population of 87,341 provided the sampling frame on which the sample was drawn. The sample size was 14 households per cluster or a total sample of 420 mother child pairs. Households with a child 0-23 months of age were considered a survey household. Main findings

• 46.3% of deliveries are conducted by TBAs; nurses and doctors accounting for 39.9%.

• 48.7% of decisions for mothers to seek treatment of children 0-23 months with diarrhoea are taken by husbands/partners

• 50.5% of the mothers with children aged 0-23 months interviewed reported that their husbands take decision on care seeking for ARI

• 63.2%) of mothers with children aged 0-23 months received information on breastfeeding from health workers

• 47.7 % of mothers interviewed reported that they had information about exclusive breast feeding. 24.1 % heard information about colostrum

• 55.3 %, 44.7 % of mothers interviewed with under two children reported that they had reduced work load and reduced farm work respectively

1 Human Development Report 2003. UNDP. 2004.


• 22.8% of mothers with children aged 0-23 months interviewed gave plain water to their children three days after delivery whilst only 2.1% of the mothers gave glucose, fresh milk and infant formula

• 76.9% of the children were given treatment with oral rehydration solution (ORS) and salt sugar solution (SSS), combined.

• 44.9% of children aged (0–23) with a diarrheal episode in the past two weeks were taken for treatment at a health facility, hospital, as their first place

• 46.2% of mothers with children aged 0-23 months gave their children only panadol as medication for fever whilst 29.5% gave Aspirin

• 93.1% of children surveyed slept under insecticides treated nets (ITNs) the previous night before the survey

3. BACKGROUND Malnutrition is a chronic problem in Sierra Leone, and it accounts for 46% of the under-five mortality in 2005. 75% of children under five are anaemic, 40% suffer from Vitamin A deficiency, and 40,000 children born every year suffer from iodine deficiency disorder, which is a major cause of birth defects and slows mental and physical development. Furthermore, one third of all children suffer the effects of stunted growth (34.7% - rapid nutritional status assessment, MOHS 2007). According to the same survey, the percentage of children who suffer from low weight for age was 17.6% and wasting (acute short term malnutrition) was 12%. In Sierra Leone, malnutrition that leads to underweight and stunting in children is caused by a host of interrelated factors including lack of access to adequate quantities of good quality food and to health services, as well as, poor environmental quality and the way young children are fed. Practices are embedded in cultural, economic, social and political factors. Barriers to good practices that are consistently found nearly everywhere in Sierra Leone include: limited autonomy on the part of the woman/mother (subject to the directives of her husband, her mother-in-law, and even some ill-informed health advisors); mistrust of the information source; fear of violence or embarrassment; cost of adoption of the new practice; distance to acquire the information, skills, or materials to undertake it; and especially work overload which blocks many women from taking on new, recommended practices. Koinadugu district, and Tonkolili districts the target districts for the IYCF program are among the most remote districts in Sierra Leone with limited coverage by essential infrastructure – telecommunications, road, and networks, etc. These districts are also known for their diversity in the number of tribes that live throughout the districts with five distinct languages spoken. The literacy rates are extremely low. 80% of the population is dependent on agriculture as their main livelihood. With all these factors, the districts still faces some of the steepest barriers to development. In this context, CARE-SL has been implementing a number of projects in health, nutrition, water and sanitation, HIV&AIDS, agriculture, economic development / livelihood and youth sectors in the districts from its Kabala and Makeni sub-offices. Above all, the former child survival project (CSP) (2003-2008) implemented by CARE-SL in 5 chiefdoms of Koinadugu district (with 56 communities with intensive


intervention) had nutrition interventions and met the majority of its objectives. The results from the final evaluation indicated significant changes in breastfeeding and complementary feeding behaviours took place at the household level and that malnutrition (underweight) among children under 2 declined from 26.5% to 18.8%. Data indicated that children and pregnant women visited/attended clinics more regularly rather than going to traditional healers / herbalists and communities on the whole and take their children to be immunized in much larger numbers. Building on the strengths and lessons learned of the former CSP and significantly scale up the geographical coverage of the interventions as well as the programmatic scope (the former CSP focused on prevention in terms of nutrition intervention.). upon the CARE-SL’s existing community-based health and nutrition interventions, the IYCF project aims to improve the nutrition status of children under five, pregnant women and lactating mothers in Koinadugu and Tonkolili districts through strengthening the prevention of malnutrition as well as increasing access to timely and adequate care for children with moderate and severe malnutrition. The window of opportunity for improving nutrition is small – from before pregnancy (maternal nutrition status is known to impact immensely upon the infant nutrition status) through the first two years of life. There is consensus that the damage to physical growth, brain development and formation that occurs during this period is extensive and largely irreversible. Therefore, IYCF package of this project focuses on this short period of time including ensuring good nutrition and health care practices for women during pregnancy and the post partum period. On the other hand, the management of malnutrition cases target children under five. In recognition of multi-faceted nature of malnutrition problems, multi-sectoral and integrated approach will be applied. For prevention, the IYCF intends to promote, protect, and support optimal IYCF and rMN practices by i) empowering communities and individuals with knowledge and skills to make optimal IYCF and rMN choices; ii) strengthening health system support; and iii) improving the enabling environment which includes both food security environment and policy environment around nutrition. Especially for the point iii), CARE-SL increasingly seeks for maximum synergy and integration with its existing agricultural/food security projects to address the issue of ‘access to food’ (one of the biggest challenges in both Tonkolili and Koinadugu) as the final evaluation of the child survival project (2003-2008) reiterated a need to support the communities with livelihood and food security avenues in order to enable people to convert their IYCF+ rMN knowledge into practice. All other interventions build upon the lessons learned from the child survival project, which included the following activities among others: Community-based growth monitoring and promotion (CBGP) including the strengthening of the IYCF counselling through training of the CBGP volunteers; Community Health Club (CHC) as entry points for community mobilisation and behaviour change communication; Behaviour Change and Communication (BCC) to bring about positive changes in IYCF and related maternal nutrition practices through radio, etc.; Pregnant women support group activities; Use of birth waiting homes as one of the contact points to provide IYCF counselling for future mothers; Community-based


Vitamin A distribution for post-partum women; Participatory and joint supervision of Periphery Health Units (PHUs); and Support to PHU outreach initiatives. 3. PROCESS AND STRENGHTENING OF COLLABORATION CARE-SL emphasizes working through local community-based structures as well as DHMT, PHU staff, and local councils to implement programmes and build local capacity. This is in recognition of CARE International programming principles of partnership. CARE-SL and its partners share a commitment to transparency, accountability, teamwork and gender equity, together implementing participatory processes that enable people to analyze and voice their own problems and promote and protect their rights and livelihoods. CARE-SL and its local partners work to empower individual and families at the community level, strengthen the skills of service providers within the health system, and collaborate with government and non-governmental actors at the local and national levels to create or improve health policies. The rationale behind collaboration is to ensure sustainability of program activities focusing on community-based organization (CBOs) such as community health clubs (CHCs) and the PHU staff of the Ministry of Health and Sanitation and the District Councils. For the purposes of the baseline survey, CARE Sierra Leone worked closely with the MOHS. The District Health Management Teams, headed by the District Medical Officer (DMO), actively participated in the planning, training on the IYCF baseline process, training of enumerators (see list of enumerators in Annex 4) on how to take anthropometric measurements as well as the data gathering exercise itself. The District Health Management Team, including PHU staff will also collaborate closely with CARE during the dissemination of baseline findings to communities. Actively engaging MOHS at district level in the baseline survey has provided an opportunity for the two partners to gain a better understanding of their operating relationship, including limitations/capacities on both sides. Planning well in advance, constant communication in an effort to coordinate activities all proved to be critical aspects to the baseline survey process. 4. SURVEY METHODOLOGY As part of this process, CARE developed a Guide entitled: Infant and Young Child Feeding Practices in Emergencies: A Step-by-step Guide to Measuring and Using Data. This Guide helps staff implementing project activities modify the questionnaires, understand the sample, know how to create data entry screen in excel, enter IYCF data in, manage and clean data using Excel, calculate 10 IYCF indicators and report results. The baseline was conducted with a technical assistance from a consultant who facilitated the process. This consultant provided the opportunity to field test the Guide through training and hands on work with staff from CARE’s SL office. 4.1 Survey Area


The survey was conducted in both Koinadugu and Tonkolili Districts each having 11 chiefdoms. Seven out of the eleven operational chiefdoms in Koinadugu and the 3 operational chiefdoms in Tonkolili served as the survey area. 4.2 Study population Households with a child 0-23 months of age were considered a survey household. Once the age of the child was determined, the mother or caretaker of the survey child (<24 months) was interviewed. In the event that a survey team came upon a household with two or more children under 24 months of age, the youngest child (survey child) was selected for the study. In the household where there was no child in the required age group the next closest (by distance) household was taken until 15 Mothers with children under 24 months were interviewed from each cluster. In some cases the survey teams did not find the required 15 children under 24 months in the survey village. The teams were instructed to visit the next closest village, sometimes requiring them to walk 2-3 miles. If the mother of a potential survey child was unavailable at the time of the interview, the interviewer rescheduled a visit for later that same day. Mothers that were away from their homes for longer than the time allocated during survey day were not interviewed. 4.3 Questionnaire development The questions contained in the questionnaire have been carefully written and tested over many years. Some of these questionnaires are based on the WHO Indicators for assessing infant and young child feeding practices, the KPC 2000+ and Rapid CATCH 2007 survey guidance. The questions provide the information needed to calculate the 10 key variables on IYC. The original questionnaire focused mainly on the ten (10) standard indicators on IYCF. To incorporate all data needed to be measured as per log frame additional questions were made to the original IYCF. Some of the modifications made were on Maternal and newborn care, Canadian International Development Agency project (Malaria, ARI, and Diarrhoea), months of inadequate household food provision, household dietary diversity score, Knowledge and awareness and the anthropometric. Also some of the food stuffs were adopted into Sierra Leone local context. The questionnaire was developed in collaboration with the district level Ministry of Health and Sanitation staff and was reviewed by the survey consultant. The survey instrument was further refined during the pre-survey training of CARE and MOHS staff. The 25 field researchers (enumerators, see annex 4) spent four days being trained on how to administer the questionnaire as well as translating the English version of the questionnaire into three local languages (Kuranko, Fullah and Limba). Extra time was spent on translation to ensure that all enumerators were using the same local words to describe the questions. The instrument was subjected to field tests prior to data collection. Field researcher training also included sessions on how to take anthropometic measurements. The District Health Sister conducted this exercise at the under-five clinic at the Koinadugu District Hospital. The baseline survey instrument is included in Annex 2. A questionnaire field guide, field manual, and anthropometric guide were also developed to ensure that all five survey teams approached the collection of quantitative data in the same consistent manner.


4.4 Determination of sample size CARE/Sierra Leone staff decided to calculate sample size based on previous results (baseline child survival data) that is estimating the percent of mothers currently practicing each of the IYCF behaviors which were entered into a sample size calculator of which an initial sample size was chosen. Then a decision was made how other factors such as precision and power will affect sample size before the final sample size was determine/calculated. Given that a 30 cluster sample for anthropometry was also conducted, it was necessary to divide the calculated sample size (IYCF) among the 30 clusters. That is having an equal number of children for the IYCF only (0-5Months of age) and those with both anthropometric and IYCF (children 6-23 months). Further, while the Guide mentioned the need to balance statistical power and financial costs, it was agreed that a total of 900 children 0-23 months be the final sample size of which there should be an equal number for both anthropometric and IYCF.

4.5 Sample selection First stage The sampling frame was constructed using village level population data from the twelve chiefdoms where the Window of Opportunity Project (WoOP) is currently operating. CARE field staff collected population data from the communities in the twelve chiefdoms. A total of 1008 villages with a population of 294,262 provided the sampling frame on which the sample was drawn. Using the population proportionate to size (PPS) method 60 clusters or villages were identified. 30 from areas were CARE is currently implementing activities and 30 as control communities. However, due to severe inaccessibility (as well time and logistical constraints) two of the selected villages/clusters initially selected were replaced with others randomly chosen during the enumerators training. Second stage To facilitate entry points and household selection, village participants and/or field staff working in the area led the process of identifying the direction where to start the survey. This was done by going to the centre of the village and spin a pen, the direction where the pen points was the direction the team moved to identified the first household. Each of the five field teams consisted of four enumerators and a supervisor. Each team was further divided into two sub-teams, with two people on each sub-team. These sub-teams were then trained to begin the survey at the first house where the pen points. If the child was with 0-5 months only the IYCF questionnaire was administered to the caregiver. Upon completion of this initial household survey the teams were then instructed to proceed to the next closest house until the required number of questionnaires was administered. Only households with a child less than 24 months were included in this survey.


4.6 Data Collection Five teams comprised of five people on each team, including one supervisor, were identified from among three CARE projects as well as district level MOHS, youth and council staff. A systematic field management schedule was developed which allowed data from ¾ of each cluster to be collected in one day (average length of interview was about 30-40 minutes). Consequently, a total of six (6) days was required to collect data from the 60 designated clusters including travel to cluster sites. Data collection took place from 15-20 March 2009. Field supervisors checked the questionnaires for completion before departing the survey cluster. If errors were found they were corrected on the spot. All teams were able to communicate via using cell phones with the DME Officer based in Kabala. The DME Officer visited each team in the field to ensure quality of data control of survey procedures. The data collection process was challenging. Some of the villages visited were located so far into remote areas with no access to vehicle. Traveling to several of the more remote sites required the survey teams to walk as far as 8 miles each way across mountainous and forested terrain. 4.7 Data Management and Analysis Data were reviewed in the field at the end of each day by team supervisors. The DME Officer checked samples of questionnaires from the survey teams. If errors were found the team was sent back to the field to make appropriate corrections. Data were entered using Excel spread sheet by hired enumerators though CARE staff also performed re-entry of the data due to so many errors during the initial entry. All data entry and cleaning was undertaken in Kabala where the DME officer for the project is based. 4.8 Limitations Although some clusters were removed from the original sample due to inaccessibility (and replaced with randomly selected clusters), a number of clusters that were thought to be accessible proved to be quite challenging, with survey teams walking up to eight miles one way. Some villages visited indicated that they had not received visitors for over five years. Considering these conditions and the overall remoteness of some of the clusters, it was determined that the sample would not be biased.

5. Survey RESULTS

Table One: 10 IYCF Indicators result table (Comparison by districts)

Sections Variables/Indicators to be analyzed Numerator Denominator Percent


% of children 0-23 months who were put to the breastfed within one hour after birth.

562 895 62.8%

% of children 0-5 months who are fed exclusively with breast milk

131 256 51.2%

Percent of infants 6-9 months of age who receive breast-milk and a solid-, semi-solid or soft food

101 191 52.9%

% of infants 6-8 months of age who received solid, semi-solid or soft foods

73 141 51.8%

% of infants 12-15 months who received breast milk during the previous day

148 156 94.9%

% of children 6-23 months of age who receive foods from 4 or more food groups

123 639 19.2%

% children 6-23 months of age who receive solid, semi-solid or soft foods the minimum number of times or more

144 639 22.5%

% of children 6-23 months of age who receive a minimum acceptable diet

42 639 6.6%

% of children 6-23 months old who receive an iron-rich food or fortified food that is specifically designed for infants and young children

412 639 64.5%

10 Standard IYCF indicators

% of children 0-23 months old who were fed with a bottle during the previous day

136 895 15.2%

% of mothers who seeks someone for ANC when pregnant with the youngest child

815 895 91.1%

% of mothers who received counseling on IYCF + rMN during ANC visits

705 815 86.5%

% of mothers whose birth were assisted by trained and qualified health personnel

357 895 39.9%

% of mothers who seeks post natal care 695 895 77.7%

% of mothers who received counseling on IYCF + rMN during post natal care visits

630 695 90.6%

% of children 6-23 months who received a dose of Vit A during the last six months

538 639 84.2%

Maternal and New Care

% of mothers who received or buy >= 90 iron supplement tablets while pregnant with the youngest child

780 895 87.2%

% of mothers who consumed iron/folic (60mg)while pregnant with the youngest child

752 895 84.0%

% of mothers who received post natal Vit A during the first two months after delivery

646 895 72.2%

% of households living within 5 miles radius of PHU or community outreach points that provide IYCF+rMN services

762 895 85.1%

Diarrhoea diseases % of children under 23 months with an episode of diarrhoea during the last two weeks before the survey

243 895 27.2 %


% of children with diarrhoea during the past two weeks and received increased breast milk

113 243 46.4%

% of children with diarrhoea during the past two weeks and received increased liquids

110 243 45.3%

% of children with diarrhoea during the past two weeks who were given increased food/fluids

33 243 13.6%

% of children with diarrhoea during the past two weeks who were given ORS

160 243 65.8%

% of children with diarrhoea during the past two weeks who were taken for treatment

115 243 47.3%

% of children with diarrhoea during the past two weeks who seeks treatment from CBD Volunteer

0 0 0

% of children with diarrhoea during the past two weeks and were taken for treatment to a health facility

79 243 32.5%

% of mothers who have heard of ORS 750 895 83.8% % of mothers who know how to prepare ORS

398 750 53.1%

% of children under 23 months with an illness of cough during the last two weeks before the survey

309 895 34.5%

% of children under 23 months with an illness of cough and difficult breathing

219 309 70.9%

% of children under 23 months with an illness of cough and difficult breathing and were taken for treatment

157 219 71.7%

% of children under 23 months with an illness of cough and difficult breathing who were taken for treatment within 24 hours after the illness began

109 157 49.8%

ARI

% of children under 23 months with an illness of cough and difficult breathing who were treated with an effective antibiotic

129 157 80.2%

% of children under 23 months with an illness with fever during the last two weeks before the survey

413 895 46.1%

% of children under 23 months with an illness with fever and were taken for treatment

275 413 66.6%

% of children under 23 months with an illness with fever and were treated with an effective antimalaria (ACT) within 24 hours after the fever began

72 275 26.2%

% of households with a mosquito net 608 895 67.9%

Malaria disease

% of households with a mosquito net that is treated with long lasting insecticides

572 608 94.1%


% of children under 23 months who slept under LLIN the night before the survey

535 895 59.8%

5.1 Socio-demographic characteristics Koinadugu and Tonkolili districts are characterized by tribal diversity. Languages spoken in Koinadugu include Kuranko, Limba, Fulla, Yalonka, Madingo , Themne and Susu, while in Tonkolili similar languages such as Limba, Kuranko and Themne are widely spoken. A household in Koinadugu and Tonkolili district is defined as one breadwinner within a house who takes care of his/her family (providing food in which the family eats from the same pot). House structures can hold several households. If a particular ‘house’ or ‘hut’ has four breadwinners, then that ‘house’ would equal four households. Early initiation and exclusive breastfeeding According to the IYCF baseline survey in Koinadugu and Tonkolili districts, all most all mothers (99.6%) had breastfed their youngest child (the survey child) and only 63.2% (562) initiated breastfeeding immediately (within the first hour after delivery), with 77.1% initiating breastfeeding after one hour or more. 51.2% of the children under 24 months were exclusively breastfed. This result could be compared with the demographic and health survey conducted in 2008 which indicated exclusive breastfeeding for the country is 11%. As could be seen in the figure below, as the age increases the rate of exclusive breastfeeding decreases. Children 0-1 months are more likely to be exclusively breastfed compared with the other age categories. Figure One: Age distribution on exclusive breastfeeding

Age distribution Exclu. B/feeding

67.1

55.845.6 41.7

01020304050607080

0-1

Mon

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0-3m

onth

2-3m

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4-5m

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Age

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Also mothers or caregivers were asked what was given to child during the first three days after delivery in addition to breast milk, as given other liquids is widely practiced in Sierra Leone. During the baseline survey, plain water accounted for 22.8% whilst glucose drinks 1%. The figure that follows gave a breakdown on what was given to child during the first three days after delivery. Figure Two: what was given to child during the first three day after delivery?

22.8%

1.1% 0.6% 0.4% 0.4%0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Plai

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Glu

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Infa

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Figure 1 showing percentage of who assist during delivery


46.3

39.2

0.7

13.6

0.205

101520253035404550

TBA

Nur

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Doc

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Fam

ily

No

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According to the figure above, the survey findings indicated that 46.3% of deliveries are conducted by TBAs while 39.9% accounts for institutional deliveries (deliveries done by both doctors and nurses). The figure indicates an insignificant difference (6.4%) between deliveries conducted by TBAs and those conducted by doctors and nurses. Also, the survey revealed that a significant proportion of deliveries (13.6%) were performed by other unskilled attendants such as family members or relatives. Figure 3 showing percentage of who take decision for treatment of a child with diarrhoea

37.1

48.7

3.68.4

0.4 1.80

10

20

30

40

50

60

Self

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Regarding decision to seek treatment for child’s diarrhoea, 48.7% of mothers stated that their husbands/partners usually decided they should seek treatment whilst 37.1% decided


on their own. Only 2.2 % of the decision is often made by a friend/relative or a health worker. Figure 4 showing the percentage of who take decision for ARI treatment

24.2

50.5

7.4 5.9

14

0.5 1.5 1.30

10

20

30

40

50

60Self

Hus

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Inlaw

Otherfamily

Friend

Hea

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Blue Flag

Vol

CBD

Other

Figure 4 shows that 50.5% of the mothers with children aged 0-23 months interviewed reported that their husbands take decision on care seeking for ARI whilst 24.2% decide on their own to seek treatment for children 0-23 months during an episode of ARI. 13.3% of the mothers interviewed indicated that in-laws and other family members take decision on care seeking for children aged 0-23 months during an episode of ARI. However, only 8.3% of the decision is made by friends, health workers, blue flag volunteers, community based distributors and others combined. Figure 5 showing percentage of care seeking time for ARI


20.4

30.6

45.9

3.1

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5

10

15

20

25

30

35

40

45

50

Sam

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Regarding care seeking time for children aged 0-23 months, 45.9 % of the mothers interviewed sought treatment for children with ARI two days after the onset of the disease whilst 30.6% sought treatment the next day after the onset of ARI. It was also observed that 20.4% of the mothers with children aged 0-23 months sought treatment for children with ARI the same day. Only 3.1% sought treatment three days after the onset of ARI in children 0-23 months. Figure 6 showing percentage of care seeking places for ARI treatment

50.2%

6.5%0.6% 0.3%

3.9% 2.9% 0.3% 0.6%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Hos

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Figure 6 indicates the first place of ARI care seeking for children aged (0-23) months who had the illness in the past two weeks. 50.2% sought treatment for ARI in the hospital whilst 6.5% went to TBAs. The graph also shows that 3.9% went to drug peddlers and 2.9% to pharmacies. Only 1.2% went to spiritualist, Blue Flag Volunteers and Community Based Distributors (CBD). Figure 7 showing percentage sources of information on breastfeeding or child feeding

33.1

6.9

17

6.8

16

8.9 7.4 58.4

18.722.9

9.8 9.8 9.1

63.2

8.3

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Older w

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ker

CHC

Figure 7 shows that more than half (63.2%) of mothers with children aged 0-23 months received information on breastfeeding from health workers and 33.1% from older women. However, a only 8.3% and 18.7% got breastfeeding information from Community Health Clubs (CHC) and radio respectively. It is also interesting to not that 22.9% of breastfeeding information received by the survey mothers came from TBAs. Figure 8 showing percentage of information mothers heard on feeding young children


37.1 37.2

47.7

11.4

17.1

31.6

24.1

15.813.3

6.1 6 7.9

0

10

20

30

40

50

60

EIBF

Colos

trum

EBF

One brea

st@ tim

e

Position

ing

Continu

ed BF

Comp

lemen

tary F

Food

type

s

Mea

l freq

uenc

y

Easie

r fee

d

Supp

ort g

roup

Othe

rs

Figure 8 shows the various information mothers interviewed heard about young child feeding. According to the graph, 47.7 % of mothers interviewed reported that they had information about exclusive breast feeding while 37.2 %, 37.1 %, 31.6 % and 24.1 % heard information about colostrum, EIBF, continued BF and complementary feeding respectively. Also, 17.1 %, 15.8 %, 13.3 % and 11.4 % of the mothers surveyed responded that they heard information about Positioning, Food Types, Meal Frequency and One Breast at time respectively. 20 % accounted for information heard about Easier Feed, Support Group and Others. Figure 9 showing percentage of who assist mothers in making breastfeeding easier

46.5

33.4

1.9

11.6

1.3 0.74.6

05

101520253035404550

Mother

/Moth

er-in

-law

Husba

nd

Rival/m

ate

Other f

amily

Neighb

our

Frien

ds

Others

The figure above shows that mother/mothers-in-law provide 46.5 % assistance in making breastfeeding easier for suckling mothers while husbands provide 33.4 %. Rival/mate, other family, neighbor and friends account for 15.5 % while other sources of assistance provide 4.6 %.


Figure 10 showing percentage of help offered to mothers with children 0-23 months

55.3

44.7

31.6

14.517.7

11.719.1

9.2 7.7

19.613.8

4.7

0

10

20

30

40

50

60

Redu

ced wo

rkloa

d

Redu

ced farm

work

Feed

ing

Enco

urag

e EIBF

Enco

urag

e EB

F

Enco

urag

e on

Breas

t

Hold

child

Enco

urag

e CF

Fruit

s

Regu

lar m

eals

Enou

ghfood

Others

Figure 10 indicates the various help offered to mothers interviewed with under two children. According to the above graph, 55.3 %, 44.7 % of mothers interviewed with under two children reported that they had reduced work load and reduced farm work respectively. 31.6 % of the mothers reported having feeding support. In addition, 19.6 %, 19.1 % and 17.7 % reported that they had regular meals, someone to assist hold child and encouraged to practice EBF respectively. Moreover, 14.5 %, 13.8 % and 11.7 % of the mothers reported that they were encouraged to practice early initiation of breastfeeding (EIBF), had enough food and encouraged to have child on the breast. 9.2 % of the mothers were encouraged to practice child feeding. 12.4 % accounted for fruits and other help offered to the mothers. Figure 11 showing Liquid given to child three days after delivery:


22.8%

1.1% 0.6% 0.4% 0.4%0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Plai

n W

ater

Glu

cose

Fres

h M

ilk

Infa

ntFo

rmul

a

Oth

ers

Figure 11 shows that 22.8% of mothers with children aged 0-23 months interviewed gave plain water to their children three day after delivery whilst only 2.1% of the mothers gave glucose, fresh milk and infant formula. It was also observed that other liquids given accounted for 0.4% of the mothers interviewed. Figure 12 showing percentage of treatment given to children during episode of diarrhoea

6.6%

33.7%

65.8%

11.1%

18.9%

28.8%

17.7%

0.4% 2.5% 3.7%8.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Nothing

Wate

rORS

SSS

Rice P

apPills

Syrup

Don't k

now

Jelly

Wate

r

Zincfa

nt

Others

Figure 12 shows treatment of diarrhoea for children aged 0-23 months that had diarrhoea in the past two weeks. 76.9% of the children were given treatment with oral rehydration


solution (ORS) and salt sugar solution (SSS), combined. Also, 28.8% of the children were given pills and 17.7% syrup whilst about 33.7% received plain (hot) water for treatment. The graph also indicates that, 18.9% of children aged 0-23 months that had diarrhoea in the past two weeks were treated with rice water and 2.5% treated with jelly water. Only 3.7% were treated with Zincfant (medicine made up of zinc for the treatment of diarrhea in children). Figure 13 showing percentage of places visited for treatment of diarrhoea in children

44.9%

15.6%

1.2% 0.4%4.1%

0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%

Hos

pita

l

TBA

Trad

ition

al

Blue

flag

vol

Oth

ers

Of the children aged (0–23) with a diarrheal episode in the past two weeks, 44.9% of them were taken for treatment at a health facility, hospital, as their first place; with a significant difference observed between those mothers that sought treatment for children 0-23 months with episodes of diarrhoea from TBAs (15.6%) and other sources (5.7%) including traditional healers and blue flag volunteers.

Figure 14 showing percentage of medications given during child’s illness with ARI

0.3%

8.4%

29.4% 30.7%

1.6% 1.3%

9.4%

19.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Not

hing

Asp

irin

Pan

adol

Sep

trin

Pen

VK

Her

bs

Am

oxil

Don

't

know


The above figure shows the various medications given to children with ARI and mothers/care givers who do not know the medications given. 41.7 % of the medications are antibiotics, while 37.8 % are analgesics. A minimal percentage (1.3 %) of the medications includes herbs. 0.3 % accounts for no medications given while 19.7 % of respondents said they don’t know the medications given. Figure 15 showing percentage of treatment given for Malaria

28.6%

24.2%

1.5% 0.5% 0.4%

5.3% 5.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Hospit

alTB

A

Trad

itiona

l

Spiritu

alCBD

Drug pe

ddler

Pharm

acy

Of the children aged (0–23) with a febrile episode in the past two weeks, 28.6% of them had treatment at a hospital (as their first place); 24.2% of the children had treatment from Traditional Birth Attendance and 2.4% sought treatment from other sources (Traditional healers, Spiritual and Community Based Distributors). Figure 16 showing percentage source of decision to go for Malaria treatment


37.1%

48.7%

3.6%8.4%

0.4% 1.8%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Sel

f

Hus

band

Inla

ws

Oth

erfa

mily

Frie

nds

Hea

lthwor

ker

On decision to seek treatment of child’s fever (malaria), close to half (48.7%) of the mothers surveyed indicated that their husbands/partners generally decided they should seek treatment; with 37.1% made decisions themselves. Only 2.2% of the decision was made by a friend/relative or a health worker. Figure17 showing percentage of anti-malaria treatment given to children

21.8%

11.3%

5.8% 4.4%8.4%

38.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Chloroq

uine

Fans

idar

Am

odiaqu

ine

Quinine

Arte

suna

te

ACT

Accor the survey, 38.2% of children who had a febrile episode that ended during the last two weeks were treated with an effective anti-malarial drug (ACT) within 24 hours after the fever began. 21.8% were treated with chloroquine whilst 29.9% had treatment with Fansidar, Amodiaquine and Artesunate. Figure 18 showing percentage of care seeking time for treatment of children with Fever (Malaria)


27.6%29.5%

21.8%

5.8% 5.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Sam

eday

Nex

tday

Two da

ys

after

Three da

ys

after

Don

't kn

ow

The graph above shows that 27.6% of mothers with children aged 0-23 months sought treatment on the same day (within 24 hours) after the fever (malaria) began whilst 29.5% sought treatment the next day. The graph also revealed that 21.8% sought treatment only after two days from the onset of fever and 5.8% after three days. Only 5.1% did not know when exactly they sought treatment after the onset of fever. Figure 19 showing percentage of other medications given to children with Fever

29.5%

46.2%

12.0% 11.3%

2.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Asp

irin

Pan

adol

Sep

trin

Oth

ers

Don

't kn

ow

Figure 19 indicates that 46.2% of mothers with children aged 0-23 months gave their children only panadol as medication for fever (malaria) whilst 29.5% gave Aspirin. The figure also shows that 12.0% of mothers with children 0-23 months gave Septrin whilst 11.3% gave other drugs. However, only 2.9% of the mothers did not know the drug they gave to children 0-23 months that had fever (malaria). Figure 20 showing percentage of who slept under ITN the previous night before survey?


3.8% 3.3% 1.5%

72.2%

2.1%

17.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Child a

lone

Mot

her

alon

e

Hus

band

alon

e

Mot

her &

Child

Mot

her &

husb

and

Mot

her,c

hild

& hu

sban

d

The figure above indicates that 93.1% of children surveyed slept under insecticides treated nets (ITNs) the previous night before the survey. However, only 6.9% of the respondents (Mothers and husbands, husbands alone and mothers alone) slept under ITNs without their survey children. 6.0 DISCUSSION AND RECOMMENDATIONS 6.1 External comparison The main source of comparison data comes from the 2000 Sierra Leone Multi-indicator cluster survey-2 (MICS2). It is a nationally representative survey of households, women and children. The main objectives of the MICS2 was to provide up-to-date information for assessing the situation of children and women in Sierra Leone at the end of the decade (1990 –2000) and to furnish data on which future MOHS activities could be prioritized. Data from the MICS2 estimates that the infant mortality rate for Sierra Leone is 170 per 1000 and the under-five mortality is 286 per 1000 in 1998. Child malnutrition data indicates that 27% of children under age five in Sierra Leone are underweight or too thin for their age. Thirty-four percent of children were stunted or too short for their age and 10% were wasted or too thin for their height. Breastfeeding during the MICS2 survey was common throughout the districts of Koinadugu and Tonkolili with all mothers having breastfed their youngest child. However, mothers insist on introducing water within the first 3 days of birth or some other liquid within the first few months of birth. Information and education of mothers and child minders are crucial to promoting infant and young child feeding and related maternal nutrition. 47.7 % of mothers from survey areas had information about exclusive breast feeding. 24.1 % heard information about colostrum


46.3% of deliveries are conducted by TBAs; nurses and doctors accounted for 39.9%.

. 63.2% of mothers with children aged 0-23 months received information on breastfeeding from health workers The prevalence of diarrhea reported by caretakers in the MICS2 survey was high (25%). The diarrhea season in Sierra Leone begins with the rainy season in May and June, at which time diarrhea prevalence rates can reach in excess of 30% (MICS2 was conducted in April). Approximately 56% of children with diarrhea received increased fluids during their episode of diarrhea. However, considering the hot and humid climate in Sierra Leone, inadequate levels of fluid intake put children at substantial risk of dehydration due to diarrhea. This baseline survey indicates that 22.8% of children aged 0-23 months are given plain water three days after delivery. Only 9% of under-five children had an ARI infection in the two weeks prior to the MICS2 survey. Of these 17% were taken to a hospital for treatment and 22% were taken to a health center. Overall, 50% of children with ARI were taken to an appropriate health provider. Children in the north endure the highest prevalence of ARI in the country (11% in the north versus 4-9% in other regions); they are the least likely to be treated by an appropriate health provider (40% in the north versus 53-68% in other regions). The current survey reports reveal that regarding care seeking time for children aged 0-23 months, 45.9 % of the mothers interviewed sought treatment for children with ARI two days after the onset of the disease whilst 30.6% sought treatment the next day after the onset of ARI. It could also be observed that 20.4% of the mothers with children aged 0-23 months sought treatment for children with ARI the same day. Only 3.1% sought treatment three days after the onset of ARI in children 0-23 months. According to the MICS2 report 15% of under-five children slept under a bed net the night prior to the survey interview. However, 46.2% of mothers with children aged 0-23 months gave their children only panadol as medication for fever whilst 29.5% gave Aspirin. Furthermore, 93.1% of children surveyed slept under insecticides treated nets (ITNs) the previous night before the survey. 48.7% of decisions for mothers to seek treatment of children 0-23 months with diarrhoea are taken by husbands/partners. This implies that husbands/partners have greater influence in decision making for seeking health care by mothers for under two children are highly influenced by husbands/partners. 6.2 Programmatic implications

6.2.1 Breastfeeding and Feeding practice Patterns of infant feeding are important determinants of a child's nutritional status as well as its vulnerability to infections. Breastfeeding enhances a child's nutritional status as it contains all the necessary nutrients and is readily available. The nutritional value of the


breast milk is further enhanced by its ability to protect against infections such as diarrhea diseases, acute respiratory infections, sepsis, measles and meningitis amongst others. Breast milk has anti allergic properties through its high immunoglobulin A (IgA) content, especially in colostrum (the first milk). Breastfeeding in itself has immense benefits for the mother as it: (1) enhances early postpartum involution of the uterus back to its pre-pregnancy state; (2) promotes better lactation and adequate milk flow, and; (3) provides important psychological bonding between mother and child. Breastfeeding should be continued as long as possible since the protein content in the breast milk is sufficient to meet the need of the child up to the end of the first year of life. However, beyond the age of six months, a period of rapid growth and development, it does not meet the energy and micronutrient requirements. This is why the introduction of appropriate complementary foods at this time becomes vital to the proper growth and survival of the child.

Mothers should start to breastfeed their newborns immediately after delivery, and infants should be exclusively breastfed during the first six months of life. Supplementary food in addition to breast milk should be introduced at about the age of six months of age, with breastfeeding continuing well into the second year of a child’s life, and longer if possible. Breastfeeding was found to be universal in the ten chiefdoms of Koinadugu and Tonkolili districts. Continuous breastfeeding coupled with appropriate complementary feeding until 24 months of age, is important to prevent nutritional deficiencies given that breast milk accounts for a substantial proportion of fat, vitamin A, calcium, and high-quality protein. Although there is an apparently high rate and duration of breastfeeding, various widespread sub-optimal breastfeeding practices exist. The delay in initiation of breastfeeding is filled by the provision of pre-lacteal feeds such as hot water to newborns. The immunological and anti-allergic benefits of the first milk (colostrum) are also lost due to the prevailing practice of discarding it. This practice according to the mothers is meant to clean the breast and provide “clean milk/food for the baby.” 47.7 % of mothers with children 0-23 months have information about exclusive breast feeding. The introduction of complementary feeding usually starts too young, with children being between 2 to 3 months old. At that age rice pap and other foods are usually introduced.

Recommendations

1. Initiation of breastfeeding is delayed beyond the appropriate duration of ‘within one hour after birth’. Pre-lacteal feeds (hot water) are commonly given to


newborns before initiation of breastfeeding. Other inappropriate behaviors such as discarding the colostrums (first milk) are also widespread. Extensive health education at all levels with all groups will be necessary. Given that family members deliver many of the babies in their homes, they (family members) should be targeted to improve on better practices.

2. The prevalence of exclusive breastfeeding is extremely low. Extensive health

education at all levels with all groups will be necessary. Health workers, TBAs, chiefs and cultural societies who could potentially influence this behavior will need to be targeted.

3. Complementary feeding begins too early without appropriate foods. Working with

key stakeholders in a few target communities to identify other foods or combination foods, such as rice pap and groundnut butter, can be promoted at PHU and chiefdom level.

6.2.2 Diarrhea Infants and young children need specific nutritional care when sick to recuperate and prevent increased risk of mortality. Continued feeding and increased intake of fluids during illness is important to prevent weight loss. Feeding after illness with more frequent and larger amounts of nutrient-dense foods over a sustained period of time are also required to regain lost nutrients and energy. A number of studies suggest that diarrhea illness in childhood contributes to secondary malnutrition and that this effect is more severe in malnourished children. Both continued feeding during the illness and increased feeding during the convalescent phase are important in reducing this negative outcome. Continued breastfeeding during diarrhea shortens duration and reduces the risk of dehydration and growth faltering. Non-breastfed children are about three times more likely to develop moderate or severe dehydration during a diarrhea episode than children who are breastfed. Frequent breastfeeding reduces the need for oral dehydration salts (ORS), provides a clean fluid with low solute load, and is more acceptable to sick infants.

Recommendations

1. Nutritional care for children with diarrhea is inadequate. Health care-seeking in general, as well as correctly describing how to mix and use oral rehydration therapy (ORS, recommended home fluids) is particularly low. Working with health facility staff as well as influential stakeholders in the communities will be necessary to ensure proper mixing and use of home fluids and when to seek care.


2. Besides improving the home and nutritional care during diarrhea, health care providers in the PHUs need to be targeted for appropriate training, availability and accessibility of ORS. Consideration should also be given to targeting community health workers and traditional healers.

6.2.3 ARI Care-seeking Acute Respiratory Infections (ARI) is one of the most common reasons for pediatric consultations at health facilities everywhere in the world. ARI includes common colds, ear infections, sore throats, bronchitis and several other conditions; however the majority of ARI-associated deaths in children under- five years of age are due to pneumonia. Most acute respiratory infections are viral, mild and self-limiting. Most children with ARI do not need antibiotics. Early detection and proper case management is the principal strategy for control of ARI. To this end the knowledge of mothers about important ARI symptoms and their care-seeking behavior is critical to reduce further morbidity and prevent mortality. 41.7 % of the medications for ARI in under-two children are antibiotics, while 37.8 % are analgesics. A minimal percentage of 1.3 % of the medications is herbs. The use of analgesics and herbs as medications for ARI are clear indications that are room for health education of mothers/care givers for appropriate health care seeking practices.

Recommendations

1. With a high prevalence of ARI among children in the study area, the corresponding level of care seeking behavior is inadequate. Knowledge of mothers about important ARI symptoms needs to be improved. The use of herbs as medication for ARI should be discouraged through health education and outreach services by PHU staff.

2. Greater understanding of why over half the mothers are not using the health

facility as the first place to go for treatment. Who decides when and where the child should go for treatment should be targeted in an effort to improve health-care seeking behavior.

3. Improving skills of health workers to enable them to conduct appropriate

assessments, classifications and treatments will greatly assist in improving services at the health facility and will hopefully influence mothers’ behavior

6.3.4 Fever Survey results have indicated that 46.2% of mothers with children 0-23 months only give panadol to their children for fever whilst 29.5% give Aspirin 93.1% of the children surveyed slept under insecticides treated nets (ITNs) the previous night before the survey.


Most often, mothers and other caretakers purchase anti-malarial and antipyretic drugs from the informal sector. Unfortunately, due to illiteracy, some mothers do not know how to identify by name the various drugs they purchase from the informer sector. Drug sellers are not always trained to give appropriate advice or information on how and how much to take and children consequently receive incorrect or insufficient amounts. Mothers buy drugs of questionable quality or the wrong type of drugs and even if they have the right drugs, give inappropriate dosages. Inappropriate treatment with these over the counter drugs may contribute to the development of drug resistance. Recommendations

1. Community Health Club and Pregnant Women Support Group sessions should give more attention to information and behavior change messages and practices for child health care.

2. Use Community Health Workers/Health clubs (CHWs/HCs) to establish links between the community and the PHUs. CHWs can play an important role in assuring compliance with anti-malarial drugs, and counseling of families on recognition of illness and care-seeking and home care.

3. Development of behavior change messages and materials based on qualitative and ethnographic data on local perceptions and beliefs about malaria, particularly given the low level of knowledge on transmission of malaria.

4. Raise awareness to communities concerning the dangers of purchasing drugs and/or taking advice from drug peddlers.

5. Increase access to ITNs as well as develop a community-based re-dipping system.

6.2.6 Maternal and Newborn Care The aspect of Maternal and Newborn Care covers antenatal examination, tetanus toxoid immunization, nutrition education, birth waiting home services, skilled attendance at delivery help reduce infant and maternal morbidity and mortality. A mother has to receive at least two doses of tetanus toxoid immunization before the birth of her child so that the newborn will be protected from neonatal tetanus. She also needs a good nutritional status, to prevent anemia in pregnancy and low birth weight.

Among the various maternal care components the coverage with tetanus toxoid vaccination is relatively low (47.5%). Approximately 71% of the mothers stated they saw ‘someone’ for antenatal care; however, only 30% were able to produce a card. Given the high number of births not being attended by a skilled birth attendant maternal health care services are limited at best. Poor access, mother’s knowledge and a lack of trained health workers, including TBAs all contribute to the consistent low levels of care in this area.


Recommendations

1. Strengthen linkages between TBAs and PHUs to promote Pregnant Women Support Group activities and referrals to maximize health service utilization for antenatal, delivery and post natal services.

2. Sensitize men and facilitate father –to-father support groups to promote antenatal, delivery, post natal, new born and referral services.

6.3 Information Dissemination Feedback of the survey results will be given to the District Health Management Team (DHMT), the District Councils as well as NGOs working in Koinadugu. Currently there are monthly coordination meetings with the DHMT and local NGOs. This will provide a platform for dissemination of initial results. In addition, CARE Kabala Base has provided progress reports for 2009 to the Koinadugu District Council. Once the DHMT has been fully briefed on the results, dissemination to chiefdom and section level will take place. In collaboration with PHU staff in their respective chiefdoms, as well as the chiefs themselves, feedback on the survey will be disseminated at section level meeting, where all villagers will be invited. This will also allow for further discussions on the planned activities that will be implemented over the next five years. In addition to community level dissemination the survey report will be circulated at national level to Ministry of Health and Sanitation as well as other international agencies, such as UNICEF, WHO, IRC etc.


7.0 Bibliography

1. Black, R. E., Brown, K. H., Becker, S (1984). “Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh.” Pediatrics 73:799-805.

2. Brown, K. H. (1994). “Dietary management of acute diarrheal disease: Contemporary scientific issues.” J. Nutr. 124(8): 1455S-1459S.

3. Ghosh, S. (1976). “The feeding and care of infants and young children, UNICEF, SCAR, National Printing Works, New Delhi, India, Pp 18 – 32.

4. Government of Sierra Leone, (2000) Status of women and children in Sierra Leone at the end of the Decade.

5. Huffman, S. L. and Combest, C. (1990). “Role of breastfeeding in the prevention and treatement of diarrhea.”. J. Diarrheal Dis. Res. 8(3):68-81.

6. King Savage F, (1985) “Helping mothers to breast-feed,” African Medical And Research Foundation, Nairobi, Kenya, Pp 92 – 109.

7. Victoria, C. G., et al. (1992). « Breastfeeding, nutritional status and other prognostic factors for dehydration among young children with diarrhea in Brazil.” Bull. World Health Organ. 79(4):467-475.

8. WHO MCH Unit (1979). “Breast-Feeding,” Division Of Family Health, Geneva, Switzerland.

9. WHO (1981). “Contemporary patterns of breastfeeding,” Report on collaborational study on breast feeding.

10. Williams C.D., Baumsley, N, Jellife (1994). “Mother and child health – delivering the services,” 3rd Edition (Oxford Press).

11. Winkoff, M (1980) “Weaning, nutrition, morbidity and mortality consequences.” 8.0 Appendices

1. Sierra Leone planning map 2. Survey questionnaire 3. Training schedule for supervisors and interviewers

Time Activity Facilitator Wednesday, 11th March

9:00 – 9:30 Welcome Pre-test of interviewers Importance of measuring IYCF behaviors

Alfred Kirk

9:30 – 10:30 Finalizing the questionnaire

• How developed • Overview to become familiar with the questionnaire

Bokarie Moses Kirk

TEA

10:45 – 1:00 Finalizing the questionnaire

• The questionnaire section by section with a focus on 24-hour recall

• Using the same terms in each language for

Bokarie Moses Kirk


breastfeeding, solid, semi-solid and soft foods, etc. • Comments on questionnaire written down and

shared with team LUNCH 2:00 – 3:00 Which children should be interviewed and how you find

them? Moses Sayoh Kirk

TEA 3:15 – 4:00 Determining data of birth and using a local calendar Alfred 4:00 – 5:00 Constructing the calendar part I: in the classroom

(part II: interviews with key informants will be carried out by a few CARE staff)

• Work by group; each group focuses on a different type of event (political, religious, climate, etc.)

Alfred

Thursday, 12th March 9:00 – 10:30 Interviewing techniques Bockarie

Iysattu TEA 10:45 – 1:30 Field test

• Test of draft instrument • Practice interviewing • Practice sampling with some CARE staff ensuring

that correct sampling procedures were followed

Alfred Bokarie

LUNCH 2:30 – 3:00 Discuss how things went with practice Alfred

Bokarie Moses

3:00 – 4:00 Anthropometry • Definitions of undernutrition • Height-for-age, weight-for-height, weight-for-age,

MUAC

MOHS Kirk

TEA

4:15 – 5:00 Anthropometry: key concepts in measurement • Height, weight, oedema • Age

MOHS Princess Kirk

38

4. Survey participants

Team formation

Location Team members Clusters Koinadugu

Edmond Brandon Momodu Sesay Sulaiman Bangura Abu Bakarr Samura Mohamed .A. Koroma Ibrahim Mansaray

Neini

Mustapha Fofanah

13, 14, 15, 16, 17, 18, 19, 20, 21

Andrew Koroma Anthony .L. Sesay Mathieu Yamba Abu Bakarr Jalloh Mohamed .P. Jimmy Marah

Wara Wara Bafodia, Folosaba Dembelia, Dembelia Sinkunia,

Sulima

Alim Jalloh

6, 7, 8, 24, 25, 26, 27, 28, 29, 30, 31, 32

Lansana Kalokoh Foday .S. S. Mansaray Princes Hawa Lahai Melvin Rogers Babagaleh Jalloh Andrew P. Sesay Tejan Bah

Diang, Wara Wara Yagala, Kasunko, Sengbeh

Peter. T. Sesay

1, 2, 3, 4, 5, 9, 10, 11, 12, 22, 23, 33, 34, 35

Friday, 13th March 9:00 – 10:30 Anthropometry: key concepts in measurement

• Equipment used and guidelines for accuracy • Recording consistently

Standardization of measurement between enumerators Out of range values

MOHS Princess Kirk

TEA 10:45 – 12:00 Field practice for anthropometry Princess 12:00 – 1:00 Review of field practice

• Challenges/solutions Princess Kirk

LUNCH 2:00 – 3:30 Logistics

• Supplies needed • Getting to the field • Selecting the right starting point • Work hours • Reporting back

Alfred Bokarie Andrew

3:30 – 4:00 Tea and workshop wrap up Alfred

39

Michael Fayamba Marah Tonkolili

David Yorpoi Mustapha Massaquoi Sumaila M. Tejan Jr Daniel Kamara

Team One Gbonkolenkeh

Marion Fornah

36, 37, 38, 39, 40, 41, 42, 43

Moses Koker Sulaiman Sesay Abu Bakarr Sheku Albert Mansaray

Team Two

Tane

Iysattu Kamara

50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60

Team One & Two Kholifa Rowalla

44, 45, 46, 47, 48, 49

sierra leone's baseline report - window of opportunity

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