A mix of illiteracy, cultural practices, poverty and institutional challenges is compounding already high drought-related child malnutrition levels in parts of Kenya.
"Malnutrition is often not recognized as an illness," Janet Ntwiga, a nutrition support officer, in Mwingi, lower-eastern Kenya, told IRIN.
"The family realizes it is serious when the baby is already emaciated and by then they are hiding the baby."
The dearth of health outreaches to remote communities means correcting these misconceptions is a challenge, as IRIN found out after accompanying health officials on a nutrition assessment in Ngomeni, Mwingi.
Ngomeni recorded global acute malnutrition (GAM) rates above 30 percent (15 percent signals an emergency), according to a July Arid Lands Resource Management Project (ALRMP) bulletin.
In one household, one of the children under five was diagnosed as suffering from nutritional oedema, an indicator of severe acute malnutrition, which, if left untreated, can cause death.
"The family may think he [the child] is healthier than the rest of the children given his appearance," noted a health official. Oedema is characterized by swelling.
"These are the kind of cases that are not getting captured at the health facilities, thus the need for outreach."
In addition, local beliefs often prohibit taking children to hospital. Such children miss out on routine immunization among other health interventions, according to health officials.
In another household in Ngomeni, a mother of three explained her reluctance to go to the nearest health centre, 20km away, in the area of Nguni. The distance involved meant she could not take her children; without them, she would have no proof of their condition.
"Who will I say sent me when I go to the hospital?" she asked. The health official wrote a note, indicating the reason for the children's referral, for the woman to take to the local health centre.
Long distances to health centres and sparse health outreach services mean some undernourished populations are missing out on screening and treatment.
"While we may be focusing our interventions on health facilities, these people may not be reached," said Cassim Zuberi, an ALRMP data officer.
Those that can make it to the selected health facilities are enrolled in the Supplementary Feeding Programme (SFP).
"At the hospital there is food by prescription," said Dorcas Mwangangi of Actionaid.
Health officials say such nutrition interventions should be expanded to include other population segments such as children over five and the elderly, who are similarly malnourished.
At present the target population is children younger than five and pregnant and lactating mothers.
According to the ALRMP bulletin, the number of food aid beneficiaries - estimated at 32 percent of the Mwingi population in a UN Office for the Coordination of Humanitarian Affairs report issued on 26 July - and the food ration sizes should be increased to meet growing needs.
Funding and logistical constraints, however, mean not all affected people are being reached.
"People are following the SFP clients home to borrow food," noted Mwangangi. "There is sharing of the SFP food even at the household level."
The lack of dietary diversity is also exacerbating malnutrition, with a meal of maize and beans the norm. "There is a need for nutrition education to be strengthened even at the community level," she added.
Higher prices, fewer options
But staple prices have shot up too: in the wider Mwingi region, maize prices have risen from an average KSh33 (US$0.36) per kilogramme in April to KSh51 ($0.56) in July, according to ALRMP.
Declining milk production, at about 750ml per household, also means malnutrition cases in Mwingi may rise, it added.
A recent Kenya nutrition sector update identified Mwingi as one of the areas with high expected caseloads of malnutrition that are not being covered by partners.
In a region with conflicting basic needs, such as water scarcity, "taking a child to the health centre may also not be the priority", added ALRMP's Zuberi.
Water supply, sanitation and hygiene, given their direct impact on infectious disease, especially diarrhoea, are important for preventing malnutrition, according to the UN World Health Organization.
Diversify to survive
In parts of the Coast region, boosting consumption of diverse drought-tolerant crops has also not been widely embraced, affecting nutrition.
"We have a mono-feeding culture and [drought-resistant] millet and sorghum are sometimes viewed as food for chicken," said Bethuel Wafula, a drought management officer in Kilifi.
"Cassava, which does well here, is sold in the markets and not used for household consumption," added Wafula. “Sometimes if they [the residents] have milk, they don’t drink it themselves [but sell it]".
In Kilifi's Bamba Division, 54km away, a resident, Salama wa Kazungu, told IRIN that sometimes she boiled wild vegetables to feed her family if she failed to sell a bag of charcoal to buy maize flour.
Despite owning some chickens, Kazungu told IRIN she did not supplement her children's diet with the eggs.
"For every egg that they eat, that will be like eating one chicken which I could sell," she said.
The charcoal business is not doing well, with few customers. This is one of the reasons Kazungu gives for not routinely taking her children to hospital for immunization.
"Sometimes we go to the hospital and they [the staff] just write on a card but don't explain what is wrong with the child," she said.