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KPC Mali by iop15920

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									KNOWLEDGE, PRACTICE, COVERAGE

               Baseline Survey Report

                      February 2006

     CHILD SURVIVAL PROJECT 21
                  in
           Koulikoro (Mali)
          HELEN KELLER INTERNATIONAL/MALI




 In collaboration with the Ministry of Health of Mali and local partners




            Author: Dr Xavier Crespin, HKI Cameroon
ACKNOWLEDGMENTS:

HKI is grateful to USAID for funding the Child Survival project in Mali and the KPC survey.

The author of this report acknowledges the contribution of the following people for their time
and effort to the KPC survey:

Coordination Team:

    -    Lina Mahy, HKI Mali Country Director
    -    Dr Sidy Traoré, CS Project Coordinator
    -    Berthé Zoumana, CS Deputy Project Coordinator
    -    Dr Koité Fatou, Nutrition Division (MOH)
    -    Mahomed Traoré, Regional Public Health Directorate, Koulikoro
    -    Modibo Coulibaly, Regional Social Development Directorate, Koulikoro
    -    Dr Xavier Crespin, KPC Survey Trainer and Survey Coordinator

Supervisors:

    1.   Dr Koité Fatou
    2.   Zoumana Berthé
    3.   Dr Sidy Traoré
    4.   Mahomed Traoré
    5.   Modibo Coulibaly

Interviewers:

    1. Aïssata Timbely
    2. Fatoumata Magassouba
    3. Hawa Diarra
    4. Diélika Fomba
    5. Assanatou Traoré
    6. Aïssata Bah
    7. Aïssa Cissé
    8. Coumaré Kadiatou Sanago
    9. Mamou Togola
    10. Soumounou Koulé

Data Entry Staff:

         1. Mamou Togola
         2. Tata Touré Diané

Drivers:
      1.    Omar Traoré
      2.    Bakary Traoré
      3.    Youssouf Traoré
      4.    Ibrahima Traoré
      5.    Abdoulaye Togala




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          LIST OF ABBREVIATIONS AND ACRONYMS:

ARI          Acute Respiratory Infections
BCC          Behavior Change Communication
CATCH        Core Assessment Tool on Child Health
CHC           Community Health Center
CS           Child Survival
DIP           Detailed Implementation Plan
DHS          Demographic Health Survey
ECOWAS       Economic Organization of West African States
IEC          Information Education Communication
IFA           Iron folate Acid
IMCI         Integrated Management of Childhood Illness
IPT         Intermittent Presumptive Treatment
ITN         Insecticide Treated Net
IVACG        International Vitamin A Consultative Group
MOH          Ministry Of Health
MSF         Médecins Sans Frontières
NID         National Immunization Days
NMCP        National Malaria Control Program
NGO         Non Governmental Organization
ORTM         Office de la Radio et Télévision du Mali
PRODESS      Programme de Développement Socio Sanitaire
PVO         Private Voluntary Organization
TBA         Traditional Birth Attendants
SASDE        Accelerated Strategy for Child Survival
SIAN         Semaines d’Intensification des Activités de la Nutrition
SLIS        Système Local d’Information Sanitaire
RMD         Regional Micronutrient Days
VHC          Village Health Committee
VAD          Vitamin A Deficiency
VA           Vitamin A
URTEL       Union des Radio et Télévisions Libres du Mali
WHO          World Health Organization
WAHO         West African Health Organization
WFP           World Food Program
WRA          Women of Reproductive Age




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                                Table of contents

                                                                        PAGE

ACKNOWLEDGEMENTS………………………………………………………………1
LIST OF ABBREVIATIONS AND ACRONYMS…………………………………….. 2
TABLE OF CONTENTS…………………………………………………………………3
EXECUTIVE SUMMARY……………………………………………………………….5

                                                                         PAGE

    1. BACKGROUND…………………………………………………………………... 7
    1.1 Project location…………………………………………………………………….. 7
    1.2 Characteristics of the beneficiary population……………………………………. 7
    1.3 Health, Social and Economic conditions…………………………………………. 8
    1.4 National standards/Policies regarding Maternal and Child Health……………. 9
    1.5 Overview of the CS project………………………………………………………...11
    1.6 Objectives of the KPC survey……………………………………………………...13

    2. PARTNERSHIP BUILDING………………………………………………………13
    2.1 Identifying and involving local partners in the KPC survey…………………….13
    2.2 Specific roles of local partners in the KPC survey………………………………..14

    3. METHODS…………………………………………………………………………. 15
    3.1 Development of the KPC survey questionnaire………………………………….. 15
    3.2 KPC indicators…………………………………………………………………….. 16
    3.3 Sampling design……………………………………………………………………. 16
    3.4 KPC Training………………………………………………………………………. 18
    3.5 Data collection and Quality procedures………………………………………….. 18
    3.6 Data Management………………………………………………………………… 19

    4. RESULTS……………………………………………………………………………19

    5. DISCUSSION………………………………………………………………………. 25
    5.1 Key findings………………………………………………………………………… 25
    5.2 Additional information gathering………………………………………………… 30
    5.3 Information dissemination………………………………………………………… 31

    6. BIBLIOGRAPHY………………………………………………………………… 31


ANNEXES




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                          LIST OF TABLES AND FIGURES


PAGE


Table 1: KPC indicators (results)……………………………………………………19/20

Table 2: Frequency of Malnutrition in the population (children under 2 years of age).21

Table 3: Malnutrition in children under 2 years of age by gender…………………….. 21

Table 4: Percentage of children aged 12-23 months who were fully vaccinated
       (Against the five vaccine-preventable diseases) before the first birthday……… 22

Table 5: Tetanus Toxoid Immunization for Mother’s age……………………………… 23

Table 6: Percentage of children aged 0-23 months whose births
       were attended by skilled health Personnel………………………………………..23

Table 7: Age of mothers and Attendance during delivery by skilled personnel……… 23

Table 8: Illness and feeding practices…………………………………………………… 24

Table 9: Percentage of sick children aged 0-23 months who received increased fluids
       and continued feeding during an illness in the past two weeks
       by mother’s age……………………………………………………………............24



Figure 1: Malnutrition by Age-trunk of Children in Koulikoro……………………… 22




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EXECUTIVE SUMMARY:

Mali has the 7th highest under-5 child mortality rate in the world (229 per 1,000 live births).
Nearly 70% of these deaths occur in children less than 2 years of age. As in other West
African countries, malaria, acute respiratory infection (ARI), diarrhea, and vaccine-
preventable diseases (measles and tetanus), are the leading direct causes of child mortality.
Also, 51% of child mortality is attributable to malnutrition.
The HKI Mali Child Survival project called Nutrition + targets malnutrition as the primary
underlying cause of child mortality in one of the most densely populated and resource
deficient regions of Mali, the Koulikoro region, and will implement the following CS
technical interventions: nutrition, breastfeeding, control of diarrhea and control of malaria.
The project will target children (0-23 months) and Women of Reproductive Age (WRA) in 9
health districts of the region over the 4-year period. The overall project goal is to improve the
nutritional status, morbidity, and mortality of children 0-23 months and WRA. The project
will apply the following strategies: 1) Joint design, implementation, and evaluation of
approaches to deliver a minimum package of essential nutrition services consistent with MOH
standards and protocols; 2) Capacity-building and training to improve access, availability, and
quality of facility-based services; 3) Community mobilization to improve demand for, and use
of, key health services; and 4) Tailored BCC and advocacy to improve key household
behaviors and care-seeking practices and commitment of local decision makers. The
Nutrition+ package will integrate breastfeeding, complementary feeding, and nutritional
management during and after childhood illnesses, management and zinc treatment of diarrhea,
micronutrient nutrition, maternal nutrition, and integrated anemia control. The project is
consistent with USAID objectives in Mali as stated in the Country Strategic Plan (2003-
2012).
Koulikoro region has a total population of 1 895 166.The estimated number of beneficiaries of
the project activities will be 1,017,700 who are people living within a 15-kilometer radius of
functional CHC. It is estimated that 276,700 WRA and 100,600 children 0-23 months will
benefit at the onset of the project, but by the end of the project (2009), 386,250 WRA and
140,450 children 0-23 months will benefit from the project because of construction of 40
additional health centers.
The objectives of the KPC survey were to estimate the Knowledge, Practice and Coverage for
the project indicators; to assist in the identification and prioritization of problems that exist
within the project area as well as to guide the project team to write and finalize the Detailed
Implementation Plan; to develop local capacity to collect, analyze, and use information for
decision-making and finally to build consensus between the project team and all the local
partners. The sampling methodology used was to list all the villages within the project area
(116 villages which currently have CHC out of the total 1,924 villages of the Koulikoro
region). The target groups for the KPC survey were mothers of children between 0-23 months
and the sample size was 300 (10 subjects per cluster). Data was collected with clear adherence
to quality procedures by teams of interviewers who had the responsibility for gathering data
from 30 randomly selected villages. The data was double entered, validated, cleaned and
analyzed, using Epi Info 6.
The key implications of the KPC results for the project are the following:
Nutrition: As a result of the KPC findings indicating dangerous levels of malnutrition in
Koulikoro, it is recommended that HKI Mali continue to advocate for the creation of Intensive
Nutritional Rehabilitation Centers for severely malnourished children at the District Hospital
level and Ambulatory Nutritional Rehabilitation and Education Centers for mild and
moderately malnourished children at the CHC level, in addition to the Nutrition+ package




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interventions. As this is not part of the CS 21 project activities, it is recommended that HKI
Mali collaborate with other partners such as UNICEF, WPF, and MSF etc.
To further improve the nutritional status of children, there is the need to increase food access
to children through collaboration with other NGO involved in food aid distribution in the
region. There is also the need for BCC to inform mothers on appropriate complementary
feeding and a need to continue involving grandmothers as their role is critical to promote
optimal practices at the village level. Also, the MOH in collaboration with HKI and other
partners should develop guidelines and compile a list of traditional local complimentary foods
with their nutritional values and support the education of mothers on these foods.
Regarding the low level of children exclusively breast fed, there is a need for intervention to
change negative traditional cultural practices through BCC. A Minimum IEC Nutrition
Activity Package should be determined for the CHC level and be monitored regularly as part
as the monitoring and evaluation plan. Also, HKI should contribute to the food fortification
process already in place especially with HUICOMA and Grands Moulins industries, which
are both located in Koulikoro town, but also the small scale fortification efforts. In addition
there should be the promotion of the production and consumption of nutritionally rich local
foods.
 Anaemia and Diarrhoea Control: Programmatic recommendations include an increase in
access to ITNs at rural community levels and to educate communities on the benefit of using
ITNs, even though the percentage of children who slept under ITNs is rather encouraging.
Since the level of knowledge and practice of mothers on childhood illness management was
insufficient and therefore in need of improvement, the programmatic implication is to inform
mothers on symptoms of childhood illness. There should also be a focus on BCC tools that
inform mothers on how to access IMCI services. Communication materials should
communicate in local languages in order to effectively convey the information needed to
identify disease symptoms. The competence of health workers in IMCI should be ensured
through training and regular supervision. Furthermore, IEC activities should be much more
targeted at grandmothers as their role was recognized as critical during previous CS project
evaluation and at mothers to ensure that children are given continuous feeding and home
made fluid during the onset of diarrhea as well as designing behavior communication material
demonstrating what and how to feed sick and convalescing children. Also, there is a need to
educate mothers and other child care givers, through IEC and BCC activities, on the
importance of washing their hands with soap especially before feeding children and after
attending to them when they defecate. Finally, there is a need for more collaboration with the
MOH to train health workers on IMCI protocols and to supervise them more regularly.
Since there were a low percentage of births attended by skilled health personnel (16%), the
project team is encouraged to collaborate with the MOH to increase the number of health
workers at the CHC in order to be in line with the national norms. HKI should advocate at the
regional and national level to expand coverage of health care delivery through health
infrastructure development. The current health coverage (within 5 kilometer radius of a
functional CHC) is very low (29%). Even though the three indicators related to child and
mother immunization are rather encouraging compared to the current national immunization
coverage, but still low with regard to the MOH objectives as stated in the PRODESS: 94% for
fully vaccinated children (against 38.9% in the KPC survey) and 92% for measles vaccine
(against 53.3% in this survey), there is the need to have continuous outreach programs at the
regional level to sensitize the population on immunization activities and improve social
mobilization by collaborating with community health agents, local religious leaders, and
women group representatives etc, as well as using rural radios. The new UNICEF SASDE
strategy (the Accelerated Strategy for Child Survival) may also be implemented as part as the
overall strategy to reach more children and their mothers for vaccination.


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1.      BACKGROUND:

1.1    Project location:

This USAID funded Child Survival project, Nutrition+ package, is located in the Koulikoro
Region. Koulikoro is one of 8 regions of Mali and one of the most densely populated and
resource deficient regions of the country. The capital city of the region is Koulikoro which is
located 60 kilometers from Bamako, the Malian capital. (See Annex 1: Maps of Mali and of
Koulikoro region)
The Koulikoro Region is divided into 9 health districts (Annex 2) with 116 currently
functional Community Health Centers (Annex 3: list of the 116 CHCs). The project will
intervene in these 9 districts. This represents an increase of 5 additional districts from the
previous HKI intervention in this region through CS 15.
Koulikoro region has a total population of 1 895 166. The total number of villages is 1924 and
the project will directly target 116 villages. The estimated number of beneficiaries of the
project activities will be 1,017,700 persons who are living within a 15-kilometer radius of
functional CHCs. It is estimated that 276,700 WRA and 100,600 children 0-23 months will
benefit from the project interventions at the onset of the project. An additional 40 CHCs will
be established in the region within the next 4 years and it is projected that 85% of the
population will be covered by the end of the project. This will represent 386,200 WRA and
140,400 children 0-23 months.
The main cities of the region are Koulikoro, Banamba, Dioila, Kati, Kolokani, Kangaba,
Nara, Ouelessebougou and Fana. They are all linked to Bamako by tarred and laterite roads.
Mali’s decentralization process including the first-ever local elections in 1999 is laying the
basis for local participation in local governance. Members of the Communal Council are
elected by direct suffrage and in turn elect the Mayor and also representatives to the Cercle
Council. The number of members of the Communal Council is determined by the size of the
population of the Commune. The Cercle Council elects representatives to the regional
assembly. Koulikoro Region has 108 Communes and 7 Cercles. Communes are empowered
to raise funds through certain taxes and there are several investment programs to support
them. The legal texts give authority to the communes over CHCs but the real involvement of
communes in health activities remains limited. At the village level, there are also Village
Health Committees (VHC).These VHC include representatives of all community members.
Child care is jointly undertaken by various members of the household including the mother,
grandmother, sister or co-wife. The father is often the principal decision-maker playing a
major role in the acquisition of services, household expenditures and distribution of food.
Mali has a strong radio network and HKI initiated its collaboration with the radios and their
membership organizations, URTEL (Union of Free Radios and Televisions of Mali) and
ORTM (Malian Office of Radio Television), based on findings from previous studies,
showing that a large share of the population reporting having received health information
through radio. These radios continue to play a key role in promoting positive health and
nutrition practices and HKI will continue its collaboration with URTEL and ORTM for
Information Education Communication (IEC) and Behavior Change Communication (BCC)
activities.

1.2 Characteristics of the beneficiary population:

Koulikoro’s 9 health districts share similar demographic, cultural, and socio-economic
profiles. 75% of the population lives in rural areas with a majority Bambara-speaking
population (90%). Smaller ethnic groups include Malinké, Peulh, Sarakolé, Somono, and


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Arabic. Rural households are composed of large, extended families under the authority of a
head of household who controls allocation of resources. Polygamy is common and mothers-
in-law and senior wives play influential roles in family decision-making including care and
care seeking practices for children. Islam is the predominant religion with more than 95% of
the population. The remaining population follows mostly traditional beliefs and practices. The
majority of the population practices subsistence agriculture under difficult conditions. Other
activities include trading, fishing, and breeding

1.3 Health, Social, and Economic conditions:

1.3.1 Health Conditions:

The current situation is summarized below:

 Child health and nutritional status: Mali has the 7th highest under five child mortality rate
in the world (for every 1,000 live births, 229 children die before their 5 th birthday). Nearly
50% of these deaths happen in the first year of life and 66% in the first 2 years of life (0-23
months). As in other West African countries, malaria, Acute Respiratory Infections (ARI),
diarrhea, and vaccine-preventable diseases (measles and tetanus) are the leading direct causes
of child mortality in Mali.
The principal causes of childhood death in the Koulikoro Region in 1998 were malaria
(32.0%), ARI (20.6%) and diarrhea (8.5%). Vaccination coverage is low, with only 29% of
children 12-23 months fully immunized. Nearly a quarter (22%) of children has received no
vaccinations at all; and only 49% of children have been vaccinated against measles.
According to the DHS of 2001, 40% of households in the Koulikoro Region have a bednet
and in 57% of households with children 0-59 months old, children slept under a bednet the
day prior to the interview. Recent analyses show that 51% of child deaths in Mali are
attributable to malnutrition, making malnutrition the single greatest risk of child mortality in
Mali. Results of DHS demonstrate widespread nutritional deficiencies: 11% of children under
five are acutely malnourished or wasted; 34% of children under five are underweight; and
39% of under-5 are stunted. Also, 88% of children 6-59 months old are anemic (92% in
Koulikoro Region) with iron deficiency as the leading cause; 63% of children are unprotected
against iodine deficiency disorders.

 Maternal Health and Nutritional Status: The DHS estimates the maternal mortality ratio
in Mali at 557/100,000 live births. The major causes of maternal mortality include
hemorrhage, unsafe abortion, sepsis, and obstructed labor. Also, only 47% of women were
seen for at least 2 prenatal care visits, only 32% had received 2 or more doses of tetanus
toxoid vaccine and 29% of births were attended by trained personnel. The situation in
Koulikoro Region was slightly better, where 61% of women are seen for at least 2 prenatal
consultations during pregnancy and 49% of births are attended by trained personnel.
5.8% of women of reproductive age and 6.7% of those living in rural areas are reported to
have been night blind during their most recent pregnancy. This prevalence is higher than the
cut-off (5%) at which Vitamin A Deficiency is considered a problem of public health
significance in women and children. Anemia is another major underlying cause of maternal
mortality .In Mali, 63% of WRA (68% in Koulikoro Region) and 73% of pregnant women are
anemic. The etiologies of maternal anemia include iron deficiency, malaria, Vitamin A
Deficiency, and intestinal parasites.
29% of Malian women in union have unmet needs for family planning services. The rate for
women in union using modern methods of contraception is 6% nationally and 4% in


8
Koulikoro. Also, low rates of exclusive Breast Feeding (25% nationally) in the first 6 months
post-partum further limit the potential of lactation amenorrhea as a viable method of child
spacing.
HIV screening conducted as part of the DHS found seroprevalence rates of 2%, among
women and 1.3% in men. The District of Koulikoro had a rate of 1.9%. Awareness of
HIV/AIDs is high, but knowledge and use of prevention practices is still low.

1.3.2 Socio-economic conditions:

Koulikoro Region is one of 8 regions in Mali. It surrounds but does not include Bamako, the
Malian capital. The socio- economic conditions for women in Koulikoro correspond to those
for the country in general, with 19% ever having attended school (compared to 34% for men).
Islam is the predominant religion; however, in some districts such as Kolokani, a large
proportion of inhabitants follow traditional animistic beliefs and practices or other religions.
The regional economy is predominantly based on subsistence agriculture, with millet, rice,
and maize as staple crops. There is also some cash-crop agriculture for cotton, peanuts,
tobacco, and cultivation of fruit, combined with market gardening. This agricultural
production is strongly linked to livestock trade, especially in the northern part of the region.
Koulikoro town is important for its port and as the site of two industries: HUICOMA, the
country’s only commercial processing plant for cooking oil (refined cotton seed oil) and the
GRANDS MOULINS DU MALI, the country’s only wheat flour mills.
Political instability in Côte d’Ivoire has jeopardized large parts of Malian international trade.
Malian foreign trade exchange through Côte d’Ivoire represents nearly 80% of the total
amount of Malian international trade. With about 15% of the GDP representing international
aid, the country has a high dependence on foreign assistance which funds more than 50% of
the national budget, among which 90% is for public development activities. The per capita
gross national product is one of the least in the world. Estimates show over 65% of Malians
living below the poverty threshold. Despite the fact that the level of assistance from the
government and NGOs has increased during last years, there is still a need for continuous
support to Koulikoro region especially in the area of health and nutrition.

1.4 National standards/Policies regarding Maternal and Child Health:

In 1997, the Government of Mali adopted the 10-year Health and Social Sector Plan
(PRODESS in French). The specific objectives of PRODESS related to maternal and child
health are to eliminate neonatal tetanus; to reduce by 30% child mortality due to vaccine
preventable diseases; to assure 80% antenatal care coverage for pregnant women; and finally
to increase to 80% women who breastfeed exclusively for the first 6 months of life. The
District Health Teams are responsible for providing technical support to CHCs and these
teams are supported by the Regional Health Directorate and the MOH.
In May 2002, the Strategic Framework for Poverty Reduction was also adopted and confirms
the government’s commitment to the health and nutrition sectors.

Current policies regarding child and maternal health mentioned in the PRODESS are the
following:

    -   IMCI (Integrated Management of Childhood Illnesses) is certainly adopted at the national
        level, but its application is not very effective due to insufficient number of trained health
        workers and lack of logistical support. Koulikoro has been selected as one of the pilot
        regions for IMCI roll-out. A recent review of IMCI implantation recognized that the
        nutrition components were the weakest.


9
     -   Availability of essential drugs and cost recovery policy have been identified as a
         high national priority as part of the PRODESS and following the Bamako Initiative
         providing for district and community management and local financing of primary
         health care. CHC must be self-sustaining through cost-recovery, including hiring and
         compensating its core personnel and re-stocking its pharmacy with essential
         medicines. In fact, funds collected at the CHC are managed by the Village Health
         Committee and mainly used to order essential drugs, but the region is still facing
         shortages of some essential drugs.
     -   Maternal post-partum VA supplementation and VA supplementation of young infants:
         National policy is consistent with international recommendations but the window of
         supplementation is limited to the 40 days following delivery. Before IMCI comes on board
         nationally, MOH policy calls for use of high-dose vitamin A supplementation in children
         with measles, clinical signs of VAD, chronic diarrhea, severe malnutrition, and respiratory
         infections. But, even though national policy and protocols exist, only 7% of sick children
         were prescribed vitamin A supplements by health agents. Also, half of all CHC had
         experienced stock-outs for VA supplements, despite these being listed as essential
         medicines.
     -   Anemia control is a national priority regarding Maternal Health. Community based
         distribution of IFA and supplementation during Micronutrient Days are part of the overall
         strategy. Also there is an agreement to expand the integrated package of anemia control to
         add malaria prophylaxis and de-worming for children and pregnant women because the
         etiology of anemia is multiple with iron deficiency, malaria, and intestinal parasites as the
         major causes. But most of CHC experienced frequent stock-outs for IFA supplements,
         despite these being listed also as essential medicines
     -   Malaria control: the MOH has set up community-based sale points for nets and insecticide
         for re-treatment and has funded activities related to the promotion of insecticide treated
         mosquito nets; however the percentage of households using treated bed nets is still low. As
         part of malaria control, the MOH has also adopted a new procedure for the treatment of
         malaria, including Intermittent Presumptive Treatment (IPT), using Fansidar for chloroquin
         resistance cases and for malaria prevention during pregnancy. The prescription of iron
         supplements to pregnant women is also part of this policy, but compliance with
         supplementation is not appropriately adhered to.
     -   Early initiation as well as exclusive breastfeeding and complementary feeding
         from 6 months for children and improved diets for pregnant and lactating
         women are also part of the national policy regarding child and maternal health, but
         rate of exclusive Breast Feeding in the first 6 months post-partum is still low.
     -   Diarrheal Disease Control: It is based on implementation of the IMCI algorithms at
         the health center and household levels. In addition, BCC is included for the prevention
         of diarrhoea through information on drinking of potable water, food hygiene, and hand
         washing with soap.

In spite of this, the PRODESS is somewhat weak in the area of nutrition. An evaluation of
pre-service training in nutrition for health workers identify several areas of weakness in
compliance with national protocols for the curative and preventive micronutrient
supplementation of children and pregnant and post-partum women.
Based on these weaknesses, HKI Mali continues to provide technical assistance and advocacy to
enhance nutrition components. Also, HKI Mali and the MOH will work on other national
standards/policies regarding Maternal and Child Health to include changes depending on the
evolution of international recommendations:

        Complementary parasite control: The current national policy does not indicate
         complementary parasite control during prenatal care. Following international guidelines and
         results from a demonstration project in Koulikoro, anti-helminthic treatment for pregnant
         women is about to be integrated in the anemia control package



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         Zinc treatment of acute diarrhea: MOH policy has not yet incorporated the latest
          WHO/UNICEF recommendations on zinc treatment of acute diarrhea. HKI Mali proposes to
          the MOH that the Koulikoro region be the pilot region for introduction of the new
          guidelines.
         Maternal post-partum VA supplementation and VA supplementation of young infants:
          Although the policy is consistent with international recommendations, there is a need to
          incorporate the latest IVACG recommendations which bring 2 modifications from previous
          recommendations as soon as they have become global guidelines. HKI Mali proposes to the
          MOH that Koulikoro can serve as a test site for phasing in new national policy.
         Multi-micronutrient supplementation: there is a global research agenda focusing on the
          efficacy and effectiveness of multi-micronutrient supplements (vs. standard IFA) during
          pregnancy on maternal and newborn birth outcomes. If this leads to a change in international
          recommendations, HKI Mali would assist the MOH in its transition to multi-micronutrients
          supplements.

1.5       Overview of the CS project:

1.5.1 History of HKI in Mali:

HKI is a private voluntary organization (PVO) founded in 1915 by a group of American
businessmen and Helen Keller to assist allied soldiers blinded during World War I. Since its
inception, the agency has focused on technology transfer and capacity building. During the
1970s, the agency reoriented its programs to give priority to blindness prevention, leading to
development of VAD control programs to prevent childhood blindness.
Our mission is “To save the sight and lives of the most vulnerable and disadvantaged. We
combat the causes and consequences of blindness and malnutrition by establishing programs
based on evidence and research in vision, health and nutrition.”
In Africa, HKI has been a leader in advancing VAD control policies and programs to improve
child and maternal health and survival. HKI provides technical assistance to governments to
carry out nutrition surveys, to assess the strengths and weaknesses of health care services for
nutrition, to assess the potential food vehicles for food fortification, and to monitor and
evaluate the effectiveness of ongoing programs. HKI plays an organizational leadership role
with the Economic Community of West African States (ECOWAS) Nutrition Foru m, the
West Africa Health Organization (WAHO), the Nutrition Focal Points Networks of Central
Africa and Madagascar and other networks to share new scientific evidence, disseminate
lessons learned from programs and advocate the importance of good nutrition for better health
and improved economic and social development. In the past 2 decades, HKI has successfully
implemented, monitored and evaluated 25 USAID funded CS projects.
HKI in Mali had worked with the MOH and other partners since 1996 on VA and iron+folic
acid (IFA) supplementation, nutrition advocacy and information dissemination, BCC, pre-
service nutrition training, food fortification, school health and nutrition, breastfeeding (BF)
and complementary feeding and program research. HKI Mali has been at the forefront in
helping the MOH achieve and maintain high coverage of the vitamin A capsule (VAC)
supplementation for preschool children including transitioning from VAC linked to National
Immunization Days (NIDs) to semaines d’intensification des activités de la nutrition (weeks
of intensification of nutrition activities - SIAN), which were started in June 2003. HKI is the
leading PVO working in nutrition in Mali and is seen as a key nutrition resource for the
MOH, USAID, other donors and partners. HKI is a member of several committees including
the IMCI committee, the NIDS organizing committee, the National Nutrition IEC Task Force
and the Malian Nutrition Network (REMANUT). From October 1999 to September 2003,
HKI-Mali and its CS-15 partners have worked towards the sustainable reduction in infant,
child, and maternal mortality in four health districts of Koulikoro Region.


11
1.5.2 Goal of the CS project:

The overall project goal is to improve the nutritional status, morbidity, and mortality of
children 0-23 months and women of reproductive age in Koulikoro Region (Mali) through the
implementation of a Nutrition+ package, addressing malnutrition, diarrhea and malaria.

1.5.3 Objectives of the CS project:

The CS project objectives include:
   - Increase the access and use of curative and preventive Nutrition+ interventions in
      clinic and outreach;
   - Improve the quality of key Nutrition+ services delivered by sub-national health staff
      (regional, district, sub-district) to households,
   - Improve household knowledge and behaviors related to Nutrition+; and
   - Enhance capacity of partners to plan, implement, monitor and sustain project
      interventions.

1.5.4 Strategies and Intervention activities of the project:

This CS project will apply the following strategies: Joint design, implementation, and
evaluation of approaches to deliver a minimum package of essential nutrition services
consistent with MOH standards and protocols; Capacity-building and training to improve
access, availability, and quality of facility-based services; Community mobilization to
improve demand for, and use of, key health services; and Tailored BCC and advocacy to
improve key household behaviors and care-seeking practices and commitment of local
decision makers.
The Nutrition+ package will integrate breastfeeding, complementary feeding, nutritional
management during and after childhood illnesses, management and zinc treatment of diarrhea,
micronutrient nutrition, maternal nutrition, and integrated anemia control for children 0 -23
months and women of reproductive age. At the facility-level, the Nutrition+ package will be
integrated programmatically from the standpoint of training, coaching, supervision, service
delivery, and BCC.
 Breastfeeding and complementary feeding: Improved feeding practices in early childhood
improve intakes of energy and nutrients, leading to better nutritional status. HKI will catalyze
the government and communities to apply and operationalize the Global Strategy for Infant
and Young Child Feeding in the Koulikoro Region. This strategy calls for implementation of
a comprehensive infant and young child feeding policy, improving access for mothers to
skilled support for breastfeeding and timely introduction of complementary foods, training
and empowering health workers to provide effective counseling and extend their services in
the community through trained lay or peer counselors, and enactment of legislation protecting
the breastfeeding rights of working women, and establishing means for its enforcement in
accordance with international labor standards.
 Nutrition management of childhood illness: The uptake of IMCI is advancing, albeit
slowly in Mali, and Koulikoro has been selected as one of the pilot regions for IMCI
commencement. Even before IMCI comes on board nationally, current MOH policy calls for
use of high-dose vitamin A supplementation in children with measles, clinical signs of VAD,
chronic diarrhea, severe malnutrition, and respiratory infections. But, a recent review of IMCI
implantation recognized that the nutrition components were the weakest. The project will lead
health workers to take a more integrated approach to management of childhood illness,


12
including management of malnutrition and micronutrient deficiencies, consistent with the
components for the IMCI. HKI is on the national IMCI committee.
 Micronutrient nutrition: VA supplementation is a key child survival intervention and HKI
has worked closely with the MOH to ensure high coverage through NIDs, RMDs and now
SIANs. Post-partum VA dosing improves maternal vitamin A status and that of her
breastfeeding infant through the increased VA content of breastmilk. Despite the important
benefits, program coverage in Koulikoro region and throughout Mali is low, largely because
policy formulation has not been accompanied by adequate program planning and
implementation. SIANs and community outreach such as women’s support groups and
woman-to-woman and other NGO programs such as credit and non formal education will be
used to increase coverage. The UNICEF promoted SASDE strategy (the Accelerated Strategy
for Child Survival) has recently (end of 2005) been adopted as a national strategy, and it
remains unclear how the implementation nationwide will be done.
 Integrated anemia control: The etiology of anemia in Koulikoro calls for an integrated
approach to anemia control, including malaria control, iron deficiency control, anti-helminthic
treatment and breastfeeding. Family planning is also a contributor for control, although the
project will not directly address this technical area. HKI Mali will provide training, assist with
the development of protocols, and assist with supervision and monitoring of an integrated
anemia program.
 Diarrheal disease control: The approach for case management will be based on
implementation of the IMCI algorithms at the health center and household levels. In addition,
BCC will include prevention of diarrhea through messages on drinking of potable water, food
hygiene, hand washing and use of latrines. Furthermore, HKI Mali will work at national and
health center levels to operationalize the recent international recommendations on use of zinc
in treatment of acute diarrhea. HKI Mali will also proactively look for funding for operational
research with regard to Zinc and Diarrhea.
 Micronutrient fortification: As part of HKI’s match to the project, HKI will work through
the National Food Fortification Alliance to implement a comprehensive food fortification
program including large-scale fortification, fortification of processed complementary foods,
small-scale fortification through multi-functional platforms and in-home fortification.
Through Match funding, the region of Koulikoro will be the sole region to have serum retinol
data for women and children.

1-6 Objectives of the KPC survey:

         Allowing an estimate of the Knowledge, Practice and Coverage for the project
          indicators

         Assisting the project to identify and prioritize problems that exist within the project
          area and assist the project team to write and finalize the DIP

         Developing local capacity to collect, analyze, and use information for decision-making

         Helping build consensus between the project and all the local partners


2.        PARTNERSHIP BUILDING:

2.1       Identifying and involving local partners in the KPC survey:



13
HKI recognizes the important value of partnership building during the KPC survey process by
involving partners from all levels (the national , regional and community based levels) as well
as helping local partners to understand their roles in information gathering, analysis, and
decision-making.
First of all, the HKI Mali CS 21 Deputy Coordinator ensured to participate in the annual
regional health planning workshop (CROCEP) from 12 to 15 of December, 2005. The
objectives were manifold: for networking purposes and informing stakeholders of the start of
the new project, ensure for the 2006 planning exercise that nutrition concerns are taken into
account in the health districts operational plans, to obtain the latest consolidated information
on 2005 health indicator results.
On December 16th, 2005, the HKI Mali Country Director and the CS 21 Deputy Coordinator
had a the first working session with the newly appointed Regional Health Director, Dr Seydou
Guindo and his staff (Dr Bakary Konaté, chargé de Planification, Mamadou Sory Keita, Chef
Division Hygiène and Dr Bogoba Diarra UNICEF Technical Advisor). The project as well as
the upcoming baseline survey exercise and the regional staff implications were discussed.
On January 19, the HKI office in Mali held a one day information meeting in Koulikoro town
on the KPC survey with the participation of key staff members from NGOs based in the
Koulikoro region; staff members from the Health Districts as well as the Regional Public
Health Directorate; the Regional Social Development Directorate; the representatives of the
Village Health Committees; the UNICEF local office; and the representative of elected
commune before the starting the KPC survey.
Also, an information mission took place in a number of villages to further involve villages’
leaders in the process (from January 27 to February 5 th).
Another information meeting was held in Bamako with the chief Nutrition Division, from the
MOH on January, 26, 2006 where the HKI Mali Director formally introduced the new CS 21
Coordinator. The participants at the meeting finalized and adopted the logistics plan in term of
personnel, transportation plan, various other service and Budget. (Annex 4: Logistics plan).
The Chief Nutrition Division, Dr Samaké Raki Bah, was very interested and ensured the
Division’s support on the project. Dr Samaké confirmed that she had presented the CS 21
project internally at the MOH Cabinet Meeting on January 30, 2006.
During the training session (from February 5 - 8, 2006), the Project Coordinator presented the
project’s goal, objectives, strategies and main intervention activities to the participants. The
Survey Coordinator explained the reasons for carrying out this KPC survey, what a KPC
survey can do and cannot do and the importance of involving the different partners in the
KPC survey process.
The 5 field supervisors and the 10 interviewers (all from the Koulikoro region) were
nominated and approved during this meeting. Among others, criteria for the selection of the
interviewers includes speaking French and the most spoken local language (Bambara) and
having previous experience of being involved in a survey. (Annex 5: list of supervisors and
interviewers)

2.2      Specific roles of local partners in the KPC survey:

Local partners and stakeholders were involved from the beginning of the process and played
key roles in the following activities:

       Organization and participation in the KPC information workshop in Koulikoro

       Selection and recruitment of supervisors and interviewers




14
       Development of the logistics plan

       Planning of the KPC activities

       Development and adoption of the questionnaire and the process of selecting indicators
        and designing sampling strategy

       Data collection, (all the interviewers and 2 of the 5 supervisors who conducted the
        survey were from Koulikoro). The Communities, in some cases, provided guides to
        the teams

       Analysis of the data: They were involved in the data entry process and the assessment
        of the indicators during a meeting

       Planning and using the information generated by the KPC survey: They will actively
        be involved in the development of the project action plan including the DIP (in April)


3.        METHODS:

3.1      Development of the KPC survey Questionnaire:

The process began during the pre implementation phase which involved meetings with local
project partners, assessing data needs, developing the questionnaire, designing the sampling
strategy and training supervisors and interviewers. Thus, during this phase of the KPC survey,
the coordinating team reviewed the French version of the questionnaire, and after close
consultation with the KPC survey coordinator, adapted the KPC questionnaire with all the 26
Rapid CATCH questions.
The issue of adding height to the anthropometric measurement was discussed. It was noted
that for this measure, at least two additional people are needed to measure a child accurately.
Then, because it is both time consuming (and thus expensive) and difficult to measure height
accurately without training, the Mali coordination team decided finally not to include height
related indicators and to maintain weight for age as the only nutritionnal indice to be used
during this KPC survey. Also, weight for age is the most commonly used measurement during
anthropometry studies, and identifies global malnutrition but also a combination of children
who are stunted and wasted. Finally, it has been decided that height for age and weight for
height will be part of another study that the Mali team will perform, immediately after this
KPC survey. (In fact, this indicator is not measured very often as part of the KPC survey).
The questionnaire was then translated, during the training of the interviewers and supervisors,
into the most widely spoken language of the region (Bambara); and again translated back into
French to make sure that all questions had a clear meaning. The team identified local
terminologies and concepts. This took substantial time as the supervisors and interviewers
asked several questions for clarification. Participants mastered the questionnaire during the
training session by interviewing selected mothers during the field testing.
After these tests, the participants made again minor changes on the translation and to the
questionnaire itself. Thus, questions 10, 14 and 26 changed slightly to take into account local
terminologies. The final version of the questionnaire was adopted on the final day of the
training. The questionnaire was then edited, reproduced and distributed to the members of the
5 teams. (Annex 6: Questionnaire in French and English).




15
3.2    KPC Indicators:

After a discussion on how to integrate the majority of the Mali CS project indicators and the
methodology to be used to perform the KPC survey with the members of the coordination
team, and following explanations from the KPC trainer, the coordination team decide to focus
only on the 13 priority Rapid CATCH Indicators (Annex 7: Intervention and definition of the
13 indicators) as they were relevant for the CS project even though not all of them are
mentioned in the original project document. In fact, 11 out of the 13 indicators from the Rapid
Catch are among the project indicators. (Annex 8: list of indicators of the CS 21 project and
Annex 9: List of the 13 Rapid Catch indicators). Other baseline studies will be carried out by
the Mali team to make inquiries on the remaining indicators.
During the training session, the KPC trainer explained to the supervisors and interviewers the
26 questions and the topics covered (Child spacing, Child anthropometry, Maternal and
Newborn care, Breastfeeding/Nutrition, Child Immunization, Malaria prevention, IMCI,
HIV/AIDS and Hand washing). These topics are all relevant to the CS project.
This part of the training related to indicators took a lot of time and effort as the participants
asked several questions on why some indicators can not be integrated to the KPC survey.
Adequate clarification was made regarding the KPC methodology; What a KPC can do and
can not do; the number of indicators that can be included keeping in mind the desire to keep
the questionnaire short.

3.3    Sampling design:

During the planning phase of the KPC survey, the coordination team had decided on the
sampling strategy and all the other important issues related to the KPC survey. All the critical
decisions were made. (Annex 10: Critical decisions points)
The target groups for the KPC survey were mothers of children between 0-23 months who are
the most vulnerable group exposed to health risks and the sample size was 300 (10 per
cluster).
The sampling procedure used was to list all the villages within the project area (116 villages
out of the 1924 villages of the region of Koulikoro). The 116 villages are the only villages
having currently functional Community Health Centers. The cluster sampling methodology
was then used to select the cluster sites. After calculating the cumulative population, the
sampling interval was determined by dividing the total population of the entire program area
by the total number of clusters. Then a random number was chosen (using the Random
Number Table) to identify the starting point on the list to begin selecting clusters. After
selecting the first cluster using the random number, the second cluster was identified by
adding the sampling interval to the random number selected; and by using the same
methodology, all the 30 clusters were selected from the list of 116 villages using the method;
sampling by probability proportional to size. Finally, the 30 villages were randomly selected
from the villages of the project area. (Annex 11: list of the 30 selected villages).
The supervisors and interviewers taking part in the KPC survey were all trained on the
sampling design in addition to selecting the first household based on cluster boundary and
geographical center. To avoid bias in the selection of respondent or subjects, interviewers and
supervisors were trained to strictly comply with selection and interviewing protocols.

3.4    KPC training:

3.4.1 Training of the coordinating team in Bamako:



16
This training was designed for the members of the coordination team who were directly
responsible for designing, organizing, and implementing the KPC survey. Training materials
were all from information received from the KPC workshop in Kampala (August 2005).
The coordinating team was made up of staff from HKI Mali (the Country Director, the Project
Coordinator, and the Deputy Project Coordinator), two staff members of the Regional Health
and of the Regional Social Development Directorates of Koulikoro, one staff from the MOH
(Nutrition Division) and the KPC Survey Coordinator. (Annex 12: Agenda of training of the
coordination team).
The objectives of this training included the following:
- An understanding of the process used and materials needed for implementing a KPC survey
- A KPC survey design, including a sampling protocol, draft questionnaire, data analysis plan,
logistics plan and budget.
This training was held, prior to starting the survey, in Bamako as the capital city of Mali is a
more centralized place and easy to reach for all participants. It was scheduled for only 2 days
due to time constraints (instead of 4 days as suggested during the KPC TOST training);
however the majority of the training package was adequately covered. In addition, all the
members of the coordination team also attended the training for the supervisors and the
interviewers.

3.4.2 Training of the interviewers and supervisors:

The four-day training (Feb 5 – 8, 2006) for interviewers and supervisors was also held in
Bamako. (Annex 13: agenda for the supervisors and interviewers training).
The objectives included the following:
   - Better understanding of how the data collected relate to the project’s objectives,
   - Review of the translated questionnaire, the 26 questions and the topics covered by the
       questionnaire,
   - Review of the 13 Rapid CATCH indicators,
   - Practice on the techniques of interview and the Informed Consent Form (Annex 14),
       using French and Bambara language
   - Practice on the techniques of selecting villages, households and respondents,
   - Better understanding of the role of interviewers and supervisors
   - Review of supervision techniques including using the Quality Improvement Check list
       (Annex 15) and the Daily Interview Form (Annex 16).

The participants developed the local events calendar (Annex 17) and a lexicon (Annex 18).
The last day of the training session was devoted to field testing on the techniques of selecting
randomly the starting household and the subsequent households, techniques of selecting
respondents, using the translated questionnaire and using all the sheets (Events Calendar,
Informed Consent Form, Quality Improvement Check List, and Daily Interview Form).
The village chosen for the field test (on February 9, 2006) was Moribabougou, located 15
kilometers from Bamako. This village was not part of the 30 selected villages for the KPC
survey. The chief of the village was informed on the objectives of the KPC and the field test.
Two days before the test took place, the project coordinator made a visit to the village to
confirm the date of arrival.
The method used to select the first household in the village was the “spin the bottle” method
after the identification of the village boundaries and the center of the village with the help of
the head nurse of this CHC. The survey coordinator reminded the supervisors and the
interviewers that the first household must be chosen randomly in order to make the cluster
sampling valid.


17
3.5    Data collection and quality procedures:

After the training session, the data collection began immediately and was conducted by 5
teams composed of 2 interviewers and 1 supervisor in order to respect the ratio of one
supervisor for two interviewers. Each team had the responsibility for gathering data in a
variable number of selected villages out of a total of 30 randomly selected villages.(Annex
19: distribution of the 30 villages by team).This phase lasted for a period of 4 days due to the
sparse location of the selected villages and in sometime inaccessible road networks in
reaching some of the selected villages. To monitor the quality of interviews and data collected
in the field, each supervisor used two different tools; the Quality Improvement Check list and
the Daily Interview Form.
From the review of the Quality Improvement Checklist, the conclusion was that the
interviewers performed well and followed the protocols correctly. The average length of an
interview was 25 minutes.
From the review of the Daily Interview Forms, the number of households visited was 480.
Out of this number a total of 178 households were without respondent and 2 households had
respondents who refused to participate in the survey. The total number of interviews
completed was 300 as the expected total sample size. Supervisors closely monitored a total 74
interviews whilst questions were being administered. Each supervisor sufficiently reviewed
all the questionnaires before leaving the village for another and observed at least two
interviewers carrying out the interview in each village and for each interviewer. Additional
reviews were made by the rest of the coordinating team members to make sure that the
supervisors and the interviewers were performing according to the data quality control
protocols. Problems reported by the supervisors during the data collection process were: visit
of several households in each village because of non-qualified respondents or absence of
respondent, minor translation difficulties (only in one area, solved with the use of a local
translator), difficulties when measuring weight with the scales (solved by taking the measure
twice), vaccination cards not filled correctly and long distance between households in some
villages.

3.6    Data management and analysis:

The data entry began when the first teams came back from the field. Two data entry
specialists with good experience were hired in Bamako to carry out the data entry process
under the close supervision of the Data Coordinator (who is a HKI staff member with solid
experience in this area). Before the beginning of the data entry process, the Data Coordinator,
the Project Coordinator and the Survey Coordinator agreed on the data entry template and the
data analysis program.
Epi Info was the software used to ensure the accuracy of data entry after the questionnaires
had been cleaned. The Data Manager supervised the data entry, cleaning, and the quality
control of the data throughout the period of the KPC survey. He observed the entire data entry
process and rigorously monitored the entry of the first 10 questionnaires and checked all the
remaining questionnaires immediately after data were entered to make sure that all the data
were being entered properly. Double entry of all data was ensured and minor errors detected
in the two entry data files during validation of the data and were corrected and cleaned to
ensure that two files had corresponding data before analysis. Although, the Data Coordinator
was the person in charge of data management, the data analysis plan was developed with the
Survey Coordinator and the CS Project Coordinator and was submitted to the rest of the
coordinating team for approval. The analysis was immediately performed electronically by
the Coordinating Team using Epi Info.


18
4.     RESULTS

The results of the KPC-survey indicators in Koulikoro are presented in Table 1 below.

Table 1 : KPC indicators

 Indicator                   Numerator       Denominator     Proportion       Confidence
                                                                 (%)          intervals (%)
 Percentage of children          51               300            17                [13.02-
 age 0-23 months who                                                               21.84]
 are underweight (-2 SD
 from     the    median
 Weight-for-age,
 according    to     the
 WHO/NCHS reference
 population)

 Percentage of children          119              300             39.6             [34.13-
 age 0-23 months who                                                               45.46]
 were born at least 24
 months      after    the
 previous surviving child

 Percentage of children          48               300             16               [12.13-
 age 0-23 months whose                                                             20.75]
 births were attended by
 skilled health Personnel

 Percentage of mothers           235              300             78.3             [73.15-
 with children age 0-23                                                            82.77]
 months who received at
 least two tetanus toxoid
 injections before the
 birth of their youngest
 child

 Percentage of children          27               134             20.1             [13.91-
 age 0-5 months who                                                                28.13]
 were          exclusively
 breastfed during the last
 24 Hours
 Percentage of children          64               66              96.9             [88.52-
 age 6-9 months who                                                                99.47]
 received breast milk and
 complementary foods
 during the last 24 hours




19
Table 1 (cont) : KPC indicators

 Indicator                        Numerator   Denominator   Proportion   Confidence
                                                                (%)      intervals (%)
 Percentage of children age           35          90            38.9          [28.96-
 12-23 months who are                                                         49.77]
 fully vaccinated (against
 the      five        vaccine-
 preventable          diseases)
 before the first birthday


 Percentage of children age
 12-23      months      who           48          90            53.3          [42.56-
 received a measles vaccine                                                   63.81]
                                      70          90            77.7          [67.54-
                                                                              85.58]
 Percentage of children age           144         300           48            [42.24-
 0-23 months who slept                                                        53.80]
 under an insecticide-treated
 net the previous night
 Percentage of mothers of
 children age 0-23 months
 who know at least two                228         300           76            [70.68-
 signs of childhood illness                                                   80.63]
 that indicate the need for
 treatment
 Percentage of sick children          7           214           3.3           [1.44-6.90]
 age 0-23 months who
 received increased fluids
 and continued feeding
 during an illness in the past
 two weeks

 Percentage of mothers with
 children age 0-23 months             137         300           45.6          [39.95-
 who cite at least two                                                        51.48]
 known ways of reducing
 the risk of HIV infection

 Percentage of mothers with
 children age 0-23 months
 who report that they wash            208         300           69.3          [63.72-
 their hands with soap/ash                                                    74.43]
 before food preparation,
 before feeding children,
 after defecation, and after
 attending to a child who
 has defecated



20
Frequencies and cross tabulation for some selected indicators:

Indicator: Percentage of children age 0-23 months who are underweight (-2 SD from the
median Weight-for-age, according to the WHO/NCHS reference population): 17%

Table 2: Frequency of Malnutrition in the population (children under 2 years of age)

     Category of malnutrition                    Number             Percent         Cumulative
                                                                                    percent
     Mildly malnourished                             59             19,66%               19,66%
     (Z-score < -1 and > -2)

     Moderately malnourished                         36              12%                31,66%
     (Z-score < -2 and > -3)

     Severely malnourished                           15               5%                36,66%
     (Z-score < -3)

     Not malnourished                               190              63,33               100%
     (Z-score > -1)


The percentage of children with risk of malnutrition was 19.66% while the prevalence of
children underweight (-2 SD from the median) was 17%.

Table 3: Malnutrition in children under 2 years of age by gender:

                               Boys < 2 yrs                            Girls < 2 yrs

                               Number             (%)                  Number            (%)
     Moderately or               33                 23,23%                18               11,39%
     and     severely
     malnourished
     (Z-score < -2)

     Not Moderately               109               76,76%                    140         88,60%
     or      severely
     malnourished
     (Z-score > -2)

     Total                        142                                         158

Odds Ratio: 2.35; 95%Confidence interval for the Odds ratio: {1.21<OR<4.62)

The percentage of malnutrition was at 23.23% for boys and 11.39% for girls. Since the odds
ratio was greater than one (2.35) and 95% of the confidence interval did not include one; it
could be concluded that boys had more chance of being malnourished than girls in the region,
and additional study is recommended for that.




21
Figure 1: Malnutrition by Age-trunk of Children (0-5, 6-11, 12-23 months)


                    Malnutrition by Age-trunk of Children (0-5, 6-11, 12-23
                                           months)


              140

              120

              100
     Number




              80
                                                                      Malnourished
              60
                                                                      Not malnourished
              40

              20

               0
                      0-5 months   6-11 months   12-23 months
                                      Age


The prevalence of malnutrition among children less than 6 months was very low and
increased with age of children: this is not different from National DHS malnutrition
prevalence data. Indeed, when the children begin taking complementary food, the prevalence
of malnutrition increases rapidly.

Indicator: Percentage of children age 12-23 months who are fully vaccinated (against the five
vaccine-preventable diseases) before the first birthday: 38.9%

Table 4: fully vaccinated children before the first birthday

                                    Percent                 Cumulative
                                                            percent
       Received            all      38.9                    38.9
       vaccines


       Did not received             61.1                    100%
       all vaccines


The percentage of children who did not receive all vaccines was 61.1% while the percentage
who was fully vaccinated before the first birthday was 38.9%.

Indicator: Percentage of mothers with children age 0-23 months who received at least two
tetanus toxoid injections before the birth of their youngest child: 78.3%


22
Table 5: Tetanus Toxoid Immunization for Mother’s age

     Age of mother                                   At least 2 Tetanus Toxoid Vaccine
                                                     Received                    Not-received
     < 25 years old                                  99                          44


     > or =25 years old                              136                           21


     Total                                           235                           65

Odds Ratio: 0.35; 95% Confidence interval for the Odds ratio: {0.19<OR<0.64]

More mothers of age equal or more than 25 years old (136) received at least 2 tetanus toxoid
vaccine than mother who were less than 25 years old (99). The odds ratio is less than 1(0.35)
but the confidence interval did not include 1, therefore it could be concluded that the
relationship between the age of mother and the tetanus vaccine status was statistically
significant.

Indicator: Percentage of children age 0-23 months whose births were attended by skilled
health Personnel: 16%

Table 6: Births attended by skilled Health Personnel

                                  Percent                  Cumulative
                                                           percent
     Skilled personnel            16                       16


     Not       skilled            84                       100
     personnel


The percentage of children whose births were not attended by skilled Health personnel was
very high (84%) while the percentage of births attended by skilled personnel is low (16%).


Table 7: Age of mothers and Attendance during delivery by Skilled Personnel

                                                     Attendance during delivery

     Age of mother                                   By Skilled Personnel      By Non-skilled Personnel

     < 25 years old                                  22 (15.4%)                    121 (84.6%)

     > or =25 years old                              26 (16.6%)                    131 (83.4%)

Odds Ratio: 0.92; 95% Confidence interval for the Odds ratio: (0.47<OR<1.72)



23
The percentage of deliveries attended by skilled Health Personnel was greater (16.6%) among
mothers of age equal or more than 25 years old, compared to mothers less than 25 years old
(15.4%).The odds-ratio is less than one however, since the confidence interval for this odds
ration includes one; it could be concluded that there was no relationship between the age of
mother and attendance by skilled personnel during delivery.

Indicator: Percentage of sick children age 0-23 months who received increased fluids and
continued feeding during an illness in the past two weeks: 3.3%

Table 8: Illness and feeding practices

                                                     Child illness

     Feeding practices

     Child encouraged to eat when sick               74

     Child not encouraged to eat when                142
     sick


From a total of 216 mothers of ill children in the survey, 74 mothers (34%) encouraged
feeding whilst 142 mothers did not encourage feeding their children.

Table 9: Percentage of sick children receiving increased fluids and continued feeding
during an illness in the past two weeks by mother’s age

                                 Mother’s age<             Mother’s age > or   Total
                                 25 years                  = 25 years
     Received both
     more fluids and             39                        48                  87
     the same and/or
     more food

     Did not receive
     both more fluids            71                        58                  129
     and the same
     and/or     more
     food

     Total                       110                       106                 216

Odds Ratio: 0.98; 95% Confidence interval for the Odds ratio: (0.59<OR<1.62)

The percentage of sick children receiving increased fluids and continued feeding is higher for
older mothers. The odds ratio is less than one, but since the confidence interval of the odds
ratio included 1, the conclusion was that children receiving increased food and fluid during
illness were not related to the age of the mother.




24
5.     DISCUSSION:

5.1    Key findings of KPC survey and programmatic implications

5.1.1 Nutrition

Indicator:  Percentage of children age 0-23 months who are underweight (-2 SD from the
median Weight-for-age, according to the WHO/NCHS reference population) = 17%

According to WHO/UNICEF recommendations, if the prevalence of malnutrition in a given
population of under five children exceeds 20% for Z-score of -2 SD it is concluded that the
population is malnourished. The results of this study demonstrated that Koulikoro has a -2 SD
prevalence of underweight among children 0-23 months of 17% (Table 2); however the
percentage of children with risk of malnutrition (i.e mild malnutrition) was 19.66%. The
percentage of underweight is lower than what was found from previous studies probably due
to the period when the KPC survey was performed (shortly after the harvest season). Indeed,
according to findings of the DHS, the prevalence of underweight among children 0 to 23
months was 34%. This is very close to the results of the KPC survey in Niger (33.6%),
performed in September 2005. So, even though the current level of malnutrition in Koulikoro
seems to show an improvement, it is, however, very close to the threshold of WHO from
which malnutrition is considered a major public health problem. Also, according to the DHS
2001, it is estimated that 51% of child mortality in Mali is attributable to malnutrition.
Therefore it is obvious that malnutrition among children less than 2-years of age is a real
public health problem and may result from the quasi-permanent famine situation in most of
the sahelian countries including Mali.
From Figure 1, the level of malnutrition among children less than 6 months was low and
increased with the age of children: it was much more pronounced after six months when
children begin taking complementary foods.
From Table 3, the percentage of malnutrition was at 23.23% for boys and 11.39% for girls.
The odds ratio was greater than one (2.35) and 95% of the confidence interval did not include
one; it could be concluded that boys had a greater likelihood of being malnourished than girls
in the Koulikoro region.
These findings are not exceptional in the West African Region where in other countries (like
Guinea e.g.) boys are more malnourished than girls at an early (pre-adolescent) age. One of
the hypothesis is that this could be linked to the fact that those same boys are more a nemic
than girls.
In addition to the Nutrition+ package intervention being planned by HKI Mali in the CS
project area, a Minimum IEC Nutrition Activity Package should be determined for the CHC
level and be monitored regularly as part as of the monitoring and evaluation plan. Also, HKI
should contribute to the food fortification process already in place especially with HUICOMA
and Grands Moulins which are located in Koulikoro. Small scale fortification is also
recommended. To further improve the nutritional status, there is the need to increase food
access to children through collaboration with other partner organizations involved in food aid
distribution in the region. Other recommendations are to continue advocacy for the creation of
Intensive Nutritional Rehabilitation Centers for severely malnourished children at the
Hospital level (even though the prevalence of wasting was not measured during this study)
through collaboration with other partners in the country such as UNICEF, WFP, MSF, etc.
and for more active Ambulatory Nutritional Rehabilitation and Education activities for mild
and moderately malnourished children at the CHC levels (this has already been mentioned in
the National Strategic Food and Nutrition Plan). It is important also to develop the positive


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deviant approach. In addition there should be the promotion of the production and
consumption of nutritionally rich local foods.
Additional information is needed to determine why there was a greater likelihood for boys to
be malnourished than girls and to determine appropriate actions in the region.

Indicator:  Percentage of children age 6-9 months who received breast-milk and
complementary foods during the last 24 hours: 96.9%

The CS 15 end line survey (2003) revealed that, 90% of children 6-9 months receive
complementary feeding in addition to breast milk (a big change from the baseline with a
percentage of 53%). The result from the KPC survey was 96.9%. This is a big improvement
due probably to previous CS interventions in the region which have focused on maternal
education. Grandmothers may have been also key players for the success. This result reflects
a major accomplishment in comparison with the national level (32% from the DHS of 2001)
and with observed statistics in Niger (40%).
Despite this obviously positive trend, there is the need for continuous BCC to inform mothers
on appropriate complementary feeding and a need to continue involving grandmothers as their
role is critical to promote optimal practices at the village level. Also, the MOH in
collaboration with HKI should develop guidelines (if they did not exist already) and compile a
list of traditional local complimentary foods with their nutritional values and support the
education of mothers on these foods.

Indicator:     Percentage of children age 0-5 months who were exclusively breastfed during
the last 24 Hours: 20.1%

From the CS 15 Project endline survey, only 8% of children (0-5 months) were exclusively
breast fed in Koulikoro and this percentage was at 25 % at the national level (DHS 2001). In
the KPC survey in Niger, it was reported being as low as 5.7% of children to be exclusively
breast fed. In this KPC survey, the percentage is 20.1%. The proportion of exclusive breast
feeding observed was higher than previous research findings in Koulikoro. This might have
resulted from implementation of breast feeding IEC activities established and implemented by
the MOH and NGOs including HKI Mali as part of the national policy regarding child and
maternal health. This rate, however, is still low compared to the national level and to the
target level.

Given the current situation, there is a need for interventions to change negative traditional
cultural practices through BCC. Using rural radios and local influential people such as
grandmothers may contribute to a positive behavioural change. Specific breastfeeding
education to inform mothers on the advantages of giving breast milk right after delivery and
exclusively for 6-months should be integrated into IEC intervention packages at the CHC and
community levels. Support to the Baby Friendly Hospital Initiative and to the Breastfeeding
Weeks campaign is also recommended.

5.1.2 Integrated Anaemia and Diarrhoea Control For Mothers and Children:

Malaria Control:

Indicator:     Percentage of children age 0-23 months who slept under an insecticide-treated
net the previous night: 48%




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From the DHS, there were 57 % of children under five in Mali who slept under ITNs. The
National Malaria Control Program (NMCP), however, estimated that percentage at only 17 %
nationwide in 2003, close to the 22% as reported by the Local Health Information System,
2004.
The KPC survey in Koulikoro, however, indicated that 48% of children slept under ITNs the
previous night mostly with their mothers. This percentage is rather encouraging compared to
the rest of the country but still needs to be improved when compared with the NMCP’s
objective of 60%.
Programmatic recommendations are to increase access to ITNs at rural community levels and
to educate communities on the benefit of using ITNs properly. This can be done during an
IEC session at the CHC and by using rural radios network.

Integrated Management of Childhood Illnesses (IMCI):

Indicator:     Percentage of mothers of children age 0-23 months who know at least two
signs of childhood illness that indicate the need for treatment: 76%

From the KPC survey in Niger, 63.3% of child care givers knew at least two signs of
childhood illness that indicate the need for treatment. No specific information was found on
this indicator from previous studies in the country. The KPC survey in Koulikoro registered a
percentage of 76%. This is possibly linked to previous CS intervention projects in the region.
Even though the level of this indicator is high, the target objective is to attain a 100%
knowledge level of mothers to symptoms related to childhood illness that indicate the actual
need for treatment.
The programmatic implication is to continue to educate mothers on symptoms of childhood
illness, in order to increase the level of knowledge and practice of mothers. There should also
be a focus on BCC tools that inform mothers on how to access IMCI services.
Communication materials should be developed in the local languages in order to effectively
convey the information needed to identify disease symptoms. The competence of health
workers in IMCI should be strengthened through training and regular supervision.

Maternal and New Born Care:

Indicator: Percentage of children age 0-23 months whose births were attended by skilled
Health Personnel: 16%

From the DHS 2001, the percentage of births attended by skilled Health Personnel was 29%
at the national level and 49% in Koulikoro. The SLIS/2004 reported a percentage of 40% in
Koulikoro but this included births attended by Traditional Birth Attendants ( WHO norms do
not take into consideration TBA as they are not considered qualified Health Personnel when
tabulating this indicator).This KPC survey finding registered a very low 16%, even when
comparing with the result found in Niger (28%). The conclusion is that the access to health
care delivery services is poor. In fact, the current health coverage is very low with only 29%
of populations within 5 kilometer radius of a functional CHC having access to basic health
services. The insufficient number of qualified personnel at the CHC may also be a major
contributor of the low skilled personnel attended child births.Table 6 shows that the
percentage of children whose births were not attended by skilled Health Personnel was very
high (84%) while the percentage of births attended by skilled personnel is low (16%).Table 7
shows that the percentage of deliveries attended by skilled Health Personnel was higher
(16.6%) among mothers of age equal-to or greater than 25 years old, compared to mothers


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less than 25 years old (15.4%). The odds-ratio is less than one however, since the confidence
interval for this odds ratio includes one; it could be concluded that there was no relationship
between the age of mother and attendance by skilled personnel during delivery
Given this critical situation (84% of births not attended by skilled Health Personnel and 29%
of populations having access to health services), there is a need to increase the number of
qualified health workers at the CHC in order to be in line with the national norms. Even
though HKI Mali’s mandate is not to construct new health facilities, the Mali HKI office
could carry out advocacy at the regional and national level to expand coverage of health care
delivery through health infrastructure development.

Diarrhea Control:

Indicator: Percentage of sick children age 0-23 months who received increased fluids and
              continued feeding during an illness in the past two weeks: 3.3%

The CS 15 endline survey indicated that in 63 % of cases of diarrhea, infants are given as
much or more food than usual. The result of the KPC in Niger for this indicator showed
22.6%.The result of the KPC for this indicator, however, showed 3.3% indicating an
extremely low percentage of sick children, receiving increased fluid and continued feeding
during illness. It has to be noted that there is a slight difference of the indicator: for the CS15
end line survey, the illness was specified as diarrhea, whereas the question for the KPC survey
asks mothers in case of <<illness>> in general. Nevertheless, this shows a very poor level of
knowledge and practice by mothers on what nutrition action to take when their child is sick.
Table 8 shows that out of a total of 188 mothers of ill children in the survey, 79 mothers
(42%) encouraged feeding whilst 109 mothers did not encourage feeding in their children.
Table 9 shows that the percentage of sick children that received increased fluids and
continued feeding is slightly in case of older mothers. The odds ratio is less than one, but
since the confidence interval of the odds ratio included 1, therefore the conclusion was that
children receiving increased food and fluid during illness were not related to the age of the
mother
With regard to these very poor practices by mothers regarding childhood illness, there is an
urgent need for IEC interventions. Activities should be much more targeted at grandmothers,
as their role to change the community norms was recognized as critical during previous CS
project evaluation. Also, mothers should be targeted to ensure that children are given
continuous feeding and home made fluids during the onset of diarrhea, as well as designing
behavioral change communication material demonstrating what and how to feed sick and
convalescing children. There is also a need for more collaboration with the National IMCI
Program to train health workers on diarrhea related IMCI protocols and to supervise them
more regularly.

Indicator:     Percentage of mothers with children age 0-23 months who report that they
wash their hands with soap/ash before food preparation, before feeding children, after
defection, and after attending to a child who has defecated: 69%

The percentage from the KPC was relatively high compared to other studies particularly with
the Niger survey (0.3%). If properly reported during this survey, this situation is rather
encouraging even though the objective is to have all the mothers or care givers washing their
hands with soap before food preparation and feeding children. From observations in the field
however, the majority of mothers wash their hands before feeding children or after child
defecation, but usually without using soap. The interviewers were not instructed to verify the


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actual availability of soap in the household. Therefore, it might be the case that women have
answered according to their knowledge instead of actual practice.
Whatever the case, there is a need to continue to educate mothers and other child care givers,
through IEC and BCC activities on the importance of having their hands cleaned especially
before feeding children and after attending to them when they defecate.

5.1.3 Other Rapid Catch Indicators:

Indicator: Percentage of mothers with children age 0-23 months who received at least two
tetanus Toxoid injections before the birth of their youngest child: 78.3%

Indicator: Percentage of children age 12-23 months who are fully vaccinated (against the five
vaccine-preventable diseases) before their first birthday: 38.9 %

Indicator: Percentage of children age 12-23 months who received a measles vaccine: 53.3%

From the DHS 2001, the percentage of children who received a measles vaccine was 49%. In
2003, however, the percentage had improved to 72% (SLIS).This KPC survey indicated a
percentage of 53.3% for children who received a measles vaccine (when using the vaccination
card) and 77.7% (when tabulation was based on the mother’s statement).This is close to
results reported in 2003 by the SLIS.
From the DHS 2001, the percentage of fully vaccinated children was at 29% (with 22% of
children never vaccinated).The percentage of children fully vaccinated nationwide was 49%
in 2003 (SLIS). This KPC survey indicated a percentage of 38.9%; a decrease from the 2003
situation reported in the SLIS.
The DHS revealed also that the percentage of mothers that received 2 or more doses of
tetanus toxoid vaccine was 32% nationwide and 61% for the region of Koulikoro. This KPC
survey indicated a percentage of 78.3%, an improvement from the 2001 situation.
The conclusion is that the three indicators related to child and mother immunization are rather
encouraging compared to the current national immunization coverage, but still low with
regard to the MOH objectives as stated in the PRODESS: 94% for fully vaccinated children
(against 38.9% in the KPC survey) and 92% for measles vaccine (against 53.3% in this survey
based on information gathered from vaccination cards).Table 4 shows that 61.1% of children
did not receive all vaccines as required at this age. Table 5 shows that more mothers older
than 25 years old (136) received at least 2 tetanus toxoid vaccine compared to mothers who
were less than 25 years old (99). The odds ratio is less than 1(0.35) but the confidence interval
did not include 1, therefore it could be concluded that the relationship between the age of
mother and the tetanus vaccine status was statistically significant.
There is, therefore, the need to have continuous outreach programs at the regional level to
sensitize the population on immunization activities and improve social mobilization during
NIDs by collaborating with community health agents, religious leaders, and women group
representatives etc, as well as using rural radios. The new UNICEF SASDE strategy (the
Accelerated Strategy for Child Survival) may also be implemented as part as the overall
strategy to reach children for vaccination.
Additional information is needed to determine why older mothers have a better tetanus
vaccine status than mothers less than 25 years old and determine appropriate actions.




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Finally, based on lessons learned from the CS 15 and based on problems identified from
this KPC survey, suggestions for the CS 21 project are the following:

      -   Advocate for the increase of health coverage with significant numbers of CHC having
          a complete Minimum Activity Package both on site and for outreach interventions
      -   Advocate for the increase the number of qualified health workers at CHC level in
          order to be in line with national norms
      -   Increase the capacity of health staff at regional, district and CHC levels with adequate
          training sessions for newly appointed nurses and retraining for other staff on both
          preventive and curative nutrition interventions and on monitoring/AQ techniques
      -   Reinforcement of IMCI at the district and CHC level with regular supervision
      -   Strengthen managerial capacity of community based structures to avoid essential
          drugs stock-outs
      -   Increase the commitment of MOH staff at the national and regional levels to
          incorporate maternal and child nutrition into health services with nutrition-related
          activities being part of district annual action plans being systematically evaluated
      -   Continue to support regional micronutrient initiatives such as the RMDs and the
          SIANs in order to maintain high VAC and IFA coverage and the new UNICEF/MOH
          SASDE strategy (the Accelerated Strategy for Child Survival) which has recently been
          adopted as a national strategy
      -   Implementation of a more comprehensive IEC strategy including a Minimum IEC
          Nutrition Activity Package for CHC
      -   Continue to involve grandmothers and other local influential people to change
          community norms and to promote optimal maternal and child nutrition/health
          practices for BCC interventions.
      -   Continue fruitful collaboration with the rural radios and their membership
          organizations URTEL and ORTM in addition to the development and utilization of
          other IEC material in order to have a large share of the population receiving nutrition
          information
      -   Strengthen intersectorial collaboration (ministries of agriculture, education, social
          development, communication, infrastructure development, etc.)
      -   Continue to involve the regional representatives of Koulikoro to the planning,
          implementation and evaluation of the project. Furthermore, the participation of local
          NGOs and other partners to the project interventions may guarantee more success.
      -   Perform additional studies to improve understanding of issues.

5.2       Additional Information Gathering:

The findings of the KPC survey in Koulikoro after analysis raised some unresolved questions
such as:
   - Why older mothers have a greater tetanus vaccine status than mothers less than 25
       years old?
   - Why the percentage of children who are exclusively breast fed is still low?
   - Why the level of malnutrition is higher among boys than girls?
   - Why fluids and foods intake are not increased for sick children?
   - Why women do not deliver in health centres?

It is recommended that the CS project team conduct some additional studies such as
qualitative research, focus group discussions, and observational studies to better understand
the above issues and how to approach intervention strategies.


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It is also noted that the HKI Mali team will conduct other studies to make inquiries on the
remaining CS 21 indicators after this KPC survey in Koulikoro region.

5-3       Information Dissemination:

After the survey, the Coordination Team met in Bamako to discuss the findings of the survey
(February 18, 2006). Following that, a meeting of partners involved in the project will be held
to discuss the results of the survey and to prepare the DIP workshop (which is scheduled for
March).
It is also planned that the Core Team members meet with key personalities of the MOH and of
the USAID mission in Bamako to share the results of the survey.
A copy of the KPC report will be sent to the USAID mission and to other partners. The KPC
survey and other study results will all be presented at the DIP preparation workshop.



6.        Bibliography :

      -   Programme de Développement Socio Sanitaire (PRODESS II), 2005-2009, Décembre
          2004

      -   Cadre Stratégique de Lutte contre la Pauvreté (CSLP) du Mali, Mai 2002

      -   CS 21 Project document, November 2004

      -   USAID Country Strategic Plan (2003-2012), March 2001

      -   Report of the final evaluation of HKI Community Neonatal Health Project, July 2004

      -   Baseline survey of CS project of Koulikoro, February 2000

      -   KPC survey Report (Diffa, Niger), September 2005

      -   CS XV project in Koulikoro, Detailed Implementation Plan

      -   Présentation de la Région de Koulikoro, Document de la DRSP, 2005

      -   Annuaire, Système Local d’Information Sanitaire (SLIS), Juillet 2004

      -   Rapport Bilan 1er semestre 2005 et Programmation 2 ème semestre 2005, Compile DNS,
          Comité technique du PRODESS, Juillet 2005

      -   Enquête Démographique et de Santé (EDSM-III), Mali, 2001




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