AN · 2020. 4. 30. · Lead by: Dr: Shafiullah Samim, Dr. M. Khalid Zakir and Dr. Nazir Sajid Author: Beka Teshome and Dr. Sayed Rahim Rastkar Funded by: AHF-OCHA Action Contre la

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Rapid SMART Assessment Report Qala-e-Naw IDP Camps, Badghis province

Date: 4-11 April 2019

Lead by: Dr: Shafiullah Samim, Dr. M. Khalid Zakir and Dr. Nazir Sajid

Author: Beka Teshome and Dr. Sayed Rahim Rastkar

Funded by: AHF-OCHA

Action Contre la Faim

AAH is a non-governmental, non-political and non-religious organization

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TABLE OF CONTENTS

AKNOWLEDGMENT ....................................................................................................................................... 4

ACRONYMS AND ABBREVIATIONS ................................................................................................................ 5

EXECUTIVE SUMMARY .................................................................................................................................. 7

1. BACKGROUND ....................................................................................................................................... 9

2. Objectives............................................................................................................................................ 10

2.1. General objective ............................................................................................................................. 10

2.2. Specific objectives ....................................................................................................................... 10

3. METHODOLOGY .................................................................................................................................. 10

3.1. Geographic target area and population group ........................................................................... 10

3.2. Survey period .............................................................................................................................. 11

3.3. Survey design .............................................................................................................................. 11

3.4. Sample size .................................................................................................................................. 11

3.5. Sampling procedures .................................................................................................................. 12

3.5.1. First stage sampling: selection of clusters .......................................................................... 12

3.5.2. Second stage sampling: selection of households ............................................................... 12

3.6. Organization of the Survey ......................................................................................................... 13

3.6.1. Survey Coordination............................................................................................................ 13

3.6.2. Survey Teams ...................................................................................................................... 13

3.6.3. Training of the Survey Teams .............................................................................................. 13

3.7. Data collection and field work .................................................................................................... 14

3.7.1. Children anthropometric survey ......................................................................................... 14

3.7.2. Maternal nutritional status ................................................................................................. 15

3.7.3. Child Morbidity ................................................................................................................... 15

3.8. Data quality assurance ................................................................................................................ 15

4. Data management and Analysis ......................................................................................................... 15

5. Results ................................................................................................................................................. 15

5.1. Mean z-scores, Design Effects and excluded subjects ................................................................ 15

5.2. General characteristics of study population and households .................................................... 16

5.2.1. Households and children 6-59 months ............................................................................... 16

5.2.2. Pregnant and Lactating Women ......................................................................................... 17

5.3. Anthropometric results ............................................................................................................... 17

5.3.1. Distribution by sex and age ................................................................................................. 17

5.3.2. Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)

and by sex ........................................................................................................................................... 18

5.3.3. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or

oedema 19

5.3.4. Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) .................. 20

5.3.5. Prevalence of underweight based on weight-for-age z-scores .......................................... 21

5.3.6. Prevalence of stunting based on height-for-age z-scores and by sex ................................. 22

5.4. Child morbidity ............................................................................................................................ 22

5.5. Maternal nutritional status ......................................................................................................... 23

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5.6. Prevalence of Combined Acute Malnutrtion based on WHZ and/or MUAC .............................. 23

5.7. Proportion of acutely malnourished children enrolled in & referred to a nutrition program ... 23

6. DISCUSSION ......................................................................................................................................... 24

6.1. Nutritional status ........................................................................................................................ 24

6.2. Child health indicators ................................................................................................................ 26

7. Recommendations .............................................................................................................................. 26

Annexes ....................................................................................................................................................... 27

Annex 1: Plausibility check for: Badghis_IDP_camps_segment A _April_2019_Afghanistan.as ............ 28

Annex 2: Plausibility check for: Badghis_IDP_camps_Segment B _April_2019_Afghanistan.as ............ 28

Annex 3: Selected clusters, segment A, Qala-e-Naw IDP camp .............................................................. 29

Annex 4: Selected clusters, segment B, Qala-e-Naw IDP camp .............................................................. 30

Annex 5: Rapid SMART Assessment questionnaires for children and pregnant and lactating women . 32

Annex 6: Event calendar ......................................................................................................................... 34

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AKNOWLEDGMENT

This survey would not have been possible without the financial support provided by Afghanistan

Humanitarian Fund (AHF). Action Against Hunger (AAH) would also like to thank all stakeholders and

partners who provided support to the Rapid SMART Assessment teams in Qala-e-Naw city IDP Camps,

Badghis province:

Public Nutrition Department (PND), Nutrition cluster and Afghanistan Information Management

Working Group (AIM-WG) for their support in methodological review and validation.

Badghis Provincial Public Health Directorate (PPHD) and currently Badghis Provincial Nutrition

officer (PNO) for the support provided in the authorization of the survey.

All the community members for welcoming and supporting the survey teams during the data

collection process.

All health stakeholders who are currently providing health and nutrition services in the IDP camps

Afghan Youth Services Organization (AYSO) especially Dr. Anasul Haq Rahimi, Dr. Abdullah

Qarizada and Dr. Amanullah Saqeb for the smooth implementation of the assessments in Qala-e-

Naw city IDP camps in Badghis province.

Survey teams composed of enumerators and supervisors for making the whole process smooth.

AAH teams at Kabul and Paris for technical, logistics and administrative support.

Statement on Copyright

© Action Against Hunger

Action Against Hunger is a non-governmental, non-political and non-religious organization.

Unless otherwise indicated, reproduction is authorized on condition that the source is credited. If reproduction

or use of texts and visual materials (sound, images, software, etc.) is subject to prior authorization, such

authorization was render null and void the above-mentioned general authorization and was clearly indicate

any restrictions on use.

The content of this document is the responsibility of the authors and does not necessarily reflect the views of

AAH and AHF.

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ACRONYMS AND ABBREVIATIONS

AAH Action Against Hunger

AfDHS Afghanistan Demographic Health Survey

AHF Afghanistan Humanitarian Fund

AIM-WG Assessment Information Management Working Group

AYSO Afghan Youth Services Organization

cGAM Combined Global Acute Malnutrition

CI Confidence Interval

cSAM Combined Severe Acute Malnutrition

CSO Central Statistics Organization

DD Date

ENA Emergency Nutrition Assessment

GAM Global Acute Malnutrition

HAZ Height for Age Z score

HH Households

IDP Internally Displaced People

IMAM Integrated Management of Acute Malnutrition

IPD-SAM Inpatient Department for Severe Acute Malnutrition

MAM Moderate Acute Malnutrition

MHT Mobile Health Team

MM Month

MoPH Ministry of Public Health

MUAC Mid-Upper Arm Circumference

NGO Non-Governmental Organisation

NRC Norwegian Refugee Council

OPD-MAM Outpatient Department for Moderate Acute Malnutrition

OPD-SAM Outpatient Department for Severe Acute Malnutrition

PLW Pregnant and Lactating Women

PND Public Nutrition Department

PNO Public Nutrition Officer

PPHD Provincial Public Health Directorate

PPS Probability Proportional to Size

RC Reserve Cluster

RUSF Ready-to Use Supplementary Food

RUTF Ready-to-use Therapeutic Food

SAM Severe Acute Malnutrition

SD Standard Deviation

SMART Standardized Monitoring of Assessment of Relief and Transition

TSFP Targetted Supplementary Feeding Program

UNICEF United Nations Children's Fund

UNOCHA United Nations Office for Coordination and Humanitarian Affairs

http://cso.gov.af/en

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WASH Water Sanitation and Hygiene

WAZ Weight for Age Z score

WHO World Health Organization

WHZ Weight for Height Z score

WVI World Vision International

YYYY Year

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EXECUTIVE SUMMARY

In April 2019, AAH) in collaborations with Ministry of Public Health (MoPH) of Badghis province, conducted

two nutrition assessments in Qala-e-Naw IDP Camps. This was done in response to the need to determine

the malnutrition levels and to inform the intervention response for the camps.

The main objective of the surveys was to assess the current nutrition situation among children 0-59

months of age and Pregnant and Lactating Women (PLW) in Qala-e-Naw IDP Camps of Badghis province

and provide key recommendations.

The surveys applied a two-stage cluster sampling using the SMART methodology based on probability

proportional to population size (PPS). Stage one sampling involved the sampling of the clusters to be

included in the survey while the second stage sampling involved the selection of the households from the

sampled clusters. The smallest geographical unit in Qala-e-Naw IDP Camps i.e. a Chief/Malik defined a

cluster. A total of 866 children aged 6-59 months (418 from segment A and 448 children from segment B)

were assessed.

Data collection took place from 4th to 11th of April, 2019, in two phases. The first phase rapid nutrition

assessment conducted in segment A (Kharistan, Jar Khoshk, Jar Haji Sakhi, Chakaran between 4-7 April)

while the second phase rapid nutrition assessment was conducted in segement B (Zaimati, Sanjidak,

Baghlar, Shamal Darya between 8-11 April 2019). In segment A, out of 250 households planned, 234 were

assessed and in segment B, all planned households were surveyed.

The survey results indicated a Global Acute Malnutrition (GAM) rate for children 6-59 months old based

on WHZ and oedema of 7.5 % (5.6 – 10.0 95% C.I.) and 8.3% (5.8-11.8 95% CI) in segment A and segment

B of Qala-e-Naw city IDP camp, respectively. The results also indicated a very high rates of chronic

malnutrition of 40.0% (35.3 – 44.9 95%C.I.) and 47.5% (40.2-55.0 95% CI) in segment A and segment B,

respectively. Undernutrition among Pregnant Women based on Middle Upper Arm Circumference

(MUAC) <230 mm was 28.4% and 39.3% in segment A and segment B, respectively.

SUMMARY OF KEY SURVEY FINDINGS:

Child Health and Nutrition Status

Indicators Segment A Qala-e-Naw city IDP camps Result

Segment B Qala-e-Naw city IDP camps Result

GAM rate among children aged 6-59 months based on Weight for Height- Z- Score <-2 SD and/or Oedema

7.5 % (5.6 – 10.0 95% C.I.)

8.3% (5.8-11.8 95% CI)

SAM rate among children aged 6-59 months based on Weight for Height Z-Score <-3 SD and/or Oedema

1.9 % (1.0 – 3.9 95% C.I.)

1.6 % (0.6- 4.1 95% CI)

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GAM rate among children aged 6-59 months based on MUAC <125 mm and/or Oedema

8.1 % ( 5.6 – 11.7 95% C.I)

8.7% (6.4-11.8 95% CI)

SAM rate among children aged 6-59 months based on MUAC <115 mm and/or Oedema

2.4 % (1.3 – 4.4 95% C.I.)

1.6% (0.7- 3.5 95% CI)

GAM rate among children aged 6-59 months based on combined criteria (WHZ <-2 SD and/or MUAC <125

mm and/or Oedema)*

10.9 % (8.4-14.0 95% C.I.)

13.1 % (10.7-15.8 95 % CI)

SAM rate among children aged 6-59 months based on combined criteria (WHZ <-3 SD and/or MUAC <115

mm and/or Oedema)*

3.4 % (2.0- 5.8 95% C.I.)

2.9 % (1.6- 5.3 95% CI)

Stunting or chronic malnutrition among children aged 6-59 months based on Height for Age Z-Score <-2 SD

40.0 % (35.3 – 44.9 95%C.I.)

47.5 % (40.2-55.0 95% CI)

Underweight among children aged 6-59 months based on Weight for Age Z-Score <-2SD

21.6 % (17.7 – 26.1 95% C.I)

26.6 % (22.3-31.4 95 % C.I)

Children aged 6-59 months that reported of having Diarrhea during the past 14 days of the survey (based

on two weeks recall method) 31.6 % 33.9 %

Women Nutrition Status

Indicators Segment A Qala-e-Naw city IDP camps Result

Segment B Qala-e-Naw city IDP camps

Result

Undernutrition among Pregnant Women based on MUAC <230 mm

25.0% 41.7 %

Undernutrition among only Lactating Women based on MUAC < 230 mm

30.3% 36.7

Undernutrition among Pregnant and Lactating Women based on MUAC <230mm

28.4 %

39.3 %

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1. BACKGROUND

Badghis is one of the thirty-four provinces of Afghanistan, located in the isolated hills of

northwestern Afghanistan. Badghis is bordered with Turkmenistan to the north, Faryab to the east, Ghor

to the southeast, and Herat to the south. More than two-thirds of the province’s area (69%) is

mountainous or semi mountainous terrain, while more than one-fifth of the area (22%) is made up of

plain land and the remaining is semi-plain land (9%). The province is divided into six districts (Ab Kamari,

Jawand, Muqur, Qadis, Bala Murghab, and Qala-e-Now).

The province was carve out of portions of Herat Province and Meymaneh (current Faryab Province) in

1964 and has a total area of 20,591 km. The province comprises 1,182 villages, with estimated population

of 530,574 people (CSO’s 2018/19). Agriculture is the province’s primary economic activity. It is

considered as one of the most underdeveloped province in the country. It has multiethnic groups such as

Tajik, Pashtun, Uzbek, Turkmen, and Baloch representing 62%, 28%, 5%, 3%, and 2% respectively. The

population is mostly Sunnis. The province has two rivers namely, Murghab River in the North and the Hari-

Ruud River in the South.

Badghis is one of the provinces most affected by drought in 2018. Followingthe drought, internally

displaced persons (IDP) started arriving in Qala-e-Naw IDP Camps from all districts in Badghis province .

According to UNOCHA & PPHD in Badghis, the population of the IDP in Qala-e-Naw IDP Camps in April

2019 was 133,000 individuals, with 19,000 households. According to the Badghis Multi-Sector Rapid

Assessment1, the humanitarian situation in the IDP camps was alarming with women and children being

among the most affected in terms of health, nutrition and general living conditions. The MUAC

measurement results show a GAM rate of 32.8% (24.8 - 42.0 95% C.I.); Moderate Acute Malnutrition

(MAM) rate of 16.9% (10.7 - 22.8 95% C.I.); and Severe Acute Malnutrition (SAM) of 15.9% (10.9 - 25.4

95% C.I.) indicating a crtitical serious nutrition situation in the area. The finding of this assessment also

show that communities have been facing a critical food security crisis and drinking water shortage as a

result of the drought. The drought situation remains dynamic with fluctuating numbers of displaced

people as some return back to their origin place while some new IDP arrive in the temporary settlements.

Back in July 2018, Action Against Hunger conducted a rapid assessment in the selected hotspot locations

and the finding revealed GAM rate of 10.0% and Severe Acute Malnutrition (SAM) rate of 2.7% in Badghis.

To mitigate the deteriorating situation in Qala-e-Naw IDP Camps, World Vision International (WVI) has

been implementing various interventions in the IDP camps namely food security, water, sanitation and

hygiene (WASH), nutrition and health.

In order to rapidly collect reliable nutrition data and to address the current nutritional problems of the

community in the IDP camps, the Nutrition Cluster along with the Assessment and Information

Management Working Group/PND/MoPH recommended two assessments using Rapid SMART

methodology in Qala-e-Naw IDP Camps. AAH conducted the assessments in partnership with Afghan

Youth Services Organization (AYSO).

1Badghis Multi-Sector Rapid Assessment Summary June 2018.

https://en.wikipedia.org/wiki/Provinces_of_Afghanistan

https://en.wikipedia.org/wiki/Afghanistan

https://en.wikipedia.org/wiki/Herat_Province

https://en.wikipedia.org/wiki/Meymaneh_Province

https://en.wikipedia.org/wiki/Tajik_people

https://en.wikipedia.org/wiki/Murghab_River

https://en.wikipedia.org/wiki/Hari-Rud

https://en.wikipedia.org/wiki/Hari-Rud

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2. OBJECTIVES

2.1. General objective

The overall objective of the rapid SMART assessments was to estimate the current prevalence of acute

malnutrition among children 6-59 months of age and PLW in Qala-e-Naw city IDP camps, Badghis province

2.2. Specific objectives

The specific objectives included the following:

To estimate the prevalence of global and severe acute malnutrition in children aged 6-59 months.

To estimate the prevalence of acute malnutrition among PLW using MUAC.

To estimate the prevalence of diarrhea among children 6-59 months in the last two weeks prior

to the survey dates.

To estimate prevalence of chronic malnutrition and underweight among children aged 6-59

months.

3. METHODOLOGY

3.1. Geographic target area and population group

The two Rapid SMART assessments were carried out in in segment A (Kharistan, Jar Khoshk, Jar Haji Sakhi,

Chakaran) and segment B (Zaimati, Sanjidak, Baghlar, Shamal Darya) of Qala-e-Naw IDP Camps. The IDP

arrived to Qala-e-Naw IDP Camps from all districts of Badghis province. The IDP has multi ethnics origin

such us Tjik, Pashtoon, Aimaq, and Uzbek. Dari was more spoken than Pashto in the IDP population. All

the 115 Chief/Malik2 (62 in segment A & 53 in segment B) were included in the sampling frame. The study

population was children from the age of 6 to 59 months and PLW.

2Chief/Malik are the community elders, which are acting as leader of a group of families or a single village at whole.

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Qala-e-Naw IDP Camps location, Badghis province

3.2. Survey period

A four-days training was organized between 31 March to 3rd April 2019 and data collection took place

from 4th to 11th of April, 2019, in two phases. The first phase data collection was conducted in segment

A between 4-7 April) while the second phase data collection was conducted in segment B between 8-11

April 2019.

3.3. Survey design

The two rapid nutrition assessmenst (Segment A & Segment B) in Qala-e-Naw IDP Camps were cross-

sectional with two-stage cluster samplings based on the SMART methodology.

3.4. Sample size

A pre-determined sample size of 25 clusters with 10 households (250 households) was chosen for the each

rapid assessment and was expected to be enough to ensure representativeness with acceptable

precision3. To reach required sample, the rapid SMART methodology4 proposes to use a simplified rule to

convert children into households:

3As per the rapid SMART guideline, a sample size of minimum 200 children would be enough to estimate GAM prevalence for cluster random sampling. 4GUIDELINES. Rapid SMART surveys for Emergencies. Developed by ACF – International, SMART Initiative at ACF – Canada and CDC Atlanta. Version 1, September 2014

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A. When the percentage of children under age of 5 is below 15%, 25 clusters of 12 households would

be enough to estimate GAM prevalence.

B. When the percentage of children under age of 5 is above 15%, 25 clusters of 10 households would

be enough to estimate GAM prevalence.

As the reference percentage of under-5 population for Afghanistan is 17.3% (Afghanistan Updated

Population CSO 2018-19), the option B was applied. 25 Cluster of 10 households were selected randomly

using PPS by ENA software (2015 updated version) out of the total list of population living in the IDP camps

near to Qala-e-Naw city in the different camps.

3.5. Sampling procedures

The surveys applied a two-stage cluster sampling method referring to the SMART methodology based on

probability proportional to population size (PPS). Stage one sampling involved the sampling of the clusters

to be included in the survey while the second stage sampling involved the selection of the households

from the sampled clusters. The smallest geographical unit in Qala-e-Naw IDP Camps i.e. a Chief/Malik

defined a cluster.

3.5.1. First stage sampling: selection of clusters

List of Chief/Malik with their respective population was obtained from the national NGO AYSO and

community leaders. Chief/Malik in the IPD camps were considered as clusters and the sampled clusters

were selected with probability proportional to population size (PPS). All the 115 villages of Qala-e-Naw

IDP Camps (62 in segment A & 53 in segment B) along with their respective populations were entered into

ENA software and clusters were selected automatically to be included in the survey (annex 3 & 4). There

was no inaccessible clusters for both rapid assessments. In Chief/Malik where more than one cluster was

assigned, segmentation was done and the required number of clusters selected randomly. Segmentation

was done in chief/malik 34 of segment B. Upon arrival to the cluster, the teams mapped the area and used

water tankers, static mobile health sites and hills as landmarks.

3.5.2. Second stage sampling: selection of households

Household definition: Group of people living under same roof and sharing food from the same pot. In

households with multiple wives, those living and eating in different houses were considered as separate

Households (HHs). Wives living in different houses and eating from same pot were considered as one HH.

The second stage of sampling was the selection of households within the selected clusters (Chief/Malik)

using a systematic random method as described below.

On arrival at the Chief/Malik:

The survey team introduced themselves and the objective of the survey to the Chief/Malik leader.

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In collaboration with the Chief/Malik leader, the team prepared a list of all households in the

Chief/Malik. Abandoned households were not listed.

The required number of households were selected using systematic random sampling.

The sampling interval was determined by:

Sampling interval = Total number of sampling units in the population

Number of sampling units in the sample (10)

Selection of the first sampling unit: A number between 1 and the sampling interval was randomly

chosen.

Selection of the following sampling units: Number of the 1st sampling unit + sampling interval;

etc.

In cases where there was no eligible child but having PLW, a household was still considered part of the

sample, where only anthropometric data of PLW was collected. If a respondent was absent during the

time of household visit, the teams left a message and re-visited later to collect data, with no substitution

of households.

Each team was assisted by a Chief/Malik guide (Chief/Malik leader) to lead and guide the survey team

within the Chief/Malik and locating the selected households.

3.6. Organization of the Survey

3.6.1. Survey Coordination

With the lead of Action Against Hunger Afghanistan, communication was done of survey objectives to all

the relevant administrative authorities, community leaders as well as stakeholders such as MoPH, PND,

PPHD and other partners.

3.6.2. Survey Teams

Eight teams each comprising two enumerators (1 male & 1 female) were deployed to collect data in all

the selected clusters from 4th to 11th April 2019. Four supervisors were assigned to supervise the survey

teams (1 supervisor per 2 survey teams).

3.6.3. Training of the Survey Teams

Training was carried out by AAH’s survey manager and was conducted in the local language5. Four

supervisors (1 supervisor per 2 teams), were responsible for ensuring the recording of all data collected

as well as ensuring accuracy of measurements taken, methodology and any other technical issues raised

while in the field. Candidates with prior experience in nutrition survey were given preference. Training

5ACF surveillance team members had been trained on anthropometric measurement, survey methodology, interview skill and other practical aspects in addition to their extensive experience in carrying out surveys in Afghanistan.

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was conducted for four days from 31st March to 3rd April 2019, and training covered survey objectives,

basic malnutrition, concept of sampling and SMART survey methodology followed by anthropometric

measurements, recognition of the signs and symptoms of malnutrition including nutritional bi-lateral

oedema and interview techniques.

As a mean to verify anthropometric skills of enumerators and to detect differences among measurers a

standardization test was conducted during the fourth day of the training. Ten children were measured

once by the survey supervisor and then each of the 16 enumerators were allowed to measure the

children’s weight, height and MUAC twice with a time interval between individual measures. Observations

of errors in the performance of each team with regards to undertaking measurements and completing

the questionnaires were identified, discussed and corrected with all team members by the team

supervisors and the survey manager.

3.7. Data collection and field work

3.7.1. Children anthropometric survey

Structured questionnaires (annex 5) were used to collect anthropometric and morbidity data from all

children within the eligible age range (6-59 months) using anthropometric questionnaire. Once measured,

visible small mark on the left upper arm or on the fingernails of the child was made in order to avoid

measuring the same child several times. The collected data were:

Age: The age of children was estimated based on using birth certificate record, vaccination card or parent

records of exact birth dates or ages in completed months. In case the above-mentioned documents were

not available, local event calendar was used (annex 6). The calendar of local events was jointly developed

with the survey assistants and camp leaders. All the birth dates were collected in accordance with Hijri

Calendar – Afghanistan Official Calendar and were converted to Georgian format using date converter.

Sex: Male or female

Weight: Children’s weights were taken without clothes using SECA scales (100g precision).

Height/length: Children were measured using wooden UNICEF measuring boards (precision of 0.1cm).

Children less than 87 cm were measured lying down, while those greater than or equal to 87 cm were

measured standing up.

Mid-upper arm circumference: MUAC measurements were taken at the mid-point of the left upper arm

using child tapes (precision of 0.1cm).

Bilateral pitting oedema: Assessed by the application of normal thumb pressure on both feet for 3

seconds. Occurrence of pitting oedema on both feet upon release of the fingers indicated nutritional

oedema classified as severely malnourished.

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3.7.2. Maternal nutritional status

The nutritional status of pregnant and lactating women was assessed based on MUAC measurements.

MUAC measurements were taken at the mid-point of the left upper arm using adult tapes.

3.7.3. Child Morbidity

Two-weeks retrospective morbidity data was collected from mothers/caregivers of all children (6-59

months) included in the anthropometric measurement. The mother/caregiver was asked whether or not

the child had diarrhea in the two weeks preceding the survey.

3.8. Data quality assurance

Assurance of data quality was insured through conducting high quality training for survey teams coupled

with standardization test, practical field exercise (pre - test survey) and close supervision of survey teams

during data collection. The survey supervisors were in charge of the data quality control as they ensured

that HH selection was done correctly, interviews were done correctly and consistently from one

household to the other and anthropometric measurements were correctly taken. All the filled

questionnaires were reviewed in the field by the survey supervisors for accuracy and completeness before

the teams left the given clusters. The survey supervisors reported daily and submitted all the verified

completed forms to the survey manager for review and feedback given every evening. Field visits were

also done by the survey manager during the survey period to ensure quality during data collection. Daily

data entry and regular plausibility checks were done and feedback given to survey team.

4. DATA MANAGEMENT AND ANALYSIS

The anthropometric data were analyzed using ENA software 2011 version (updated 9 July 2015). The

indices were compared to the World health Organization (WHO) Standards 2006 to determine the levels

of wasting, underweight and stunting. SMART flags: WHZ -3 to 3; HAZ -3 to 3; WAZ -3 to 3 were used in

final analysis to exclude zscores with extreme values from observed mean. Morbidity and PLW data were

analyzed on excel.

5. RESULTS

5.1. Mean z-scores, Design Effects and excluded subjects

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Table 5-1 and 5-2 shows the distribution of the sample statistics for the surveys. The standard deviations

(SD) for WHZ, WAZ & HAZ were within the acceptable range of 0.8-1.2. However, with design effect of

2.32, for HAZ in segment B, the sample population showed some degree of heterogeneity for chronic

malnutrition.

The overall data quality was scored as excellent (score of 5% for segment A, score of 8% for segement B).

For more information, see the plausibility check in Annex 1 & 2.

Table 5-1: Mean z-scores, design effect and excluded subjects, Qala-e-Naw city IDP camp (Segment A)

Indicator N Mean z-scores ± SD

Design Effect (z-score < -2)

z-scores not available*

z-scores out of range

Weight-for-Height 411 -0.33±1.09 1.00 0 7

Weight-for-Age 412 -1.16±1.05 1.03 0 6

Height-for-Age 410 -1.75±1.17 1.00 0 8

* contains for WHZ and WAZ the children with edema.

Table 5-2: Mean z-scores, design effect and excluded subjects, Qala-e-Naw city IDP camp (Segment B) Indicator N Mean z-scores

± SD Design Effect (z-

score < -2) z-scores not available*

z-scores out of range

Weight-for-Height 444 -0.53±1.04 1.20 0 4

Weight-for-Age 447 -1.46±0.93 1.13 0 1

Height-for-Age 444 -1.93±1.05 2.32 0 4

* contains for WHZ and WAZ the children with edema

5.2. General characteristics of study population and households

5.2.1. Households and children 6-59 months

In segment A, out of 250 households planned, data was collected from a total of 234 households (94%)

and in segment B, all the 250 planned households were surveyed (100%). In Segment A, 16 households

were recorded as non-response households. Further, about 216.5% of the sample size of children 6-59

months of age was met without resulting to visit the 4 reserve clusters (RCs). A total of 866 children aged

6-59 months (418 children from segment A and 448 children from segment B) were assessed for their

nutritional status using anthropometric measurements.

Table 5-3: Summary of households and children 6-59 months planned and those surveyed

Number of HH planned

Qala-e-Naw city IDP camp Segment A

250

Qala-e-Naw city IDP camp Segment B

250

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5.2.2. Pregnant and Lactating Women

In these assessments, a total of 556 pregnant & lactating women (275 in segment A, 281 in segment B)

were screened for malnutrition by MUAC.

5.3. Anthropometric results

5.3.1. Distribution by sex and age

The age and sex distribution of the sample population in the two surveys are illustrated in Table 5-4 and

5-5. Among the surveyed children, 453 (52.3%) were boys while 413 (47.7%) were girls. The overall sex

ratio of the surveyed children in both segments was 1.1 indicating that both sexes were equally

represented within the sample. Similarly, the distribution of the sample children age groups did not also

vary from the normal accepted percentage, which also shows that the sample was unbiased.

Table 5-4: Distribution of age & sex of children 6-59 months, Qala-e-Naw city IDP camp (segment A)

Table 5-5: Distribution of age & sex of children 6-59 months, Qala-e-Naw city IDP camp (segment B)

Number of HH surveyed


234


250

Number of children 6-59 months planned


200


200

Number of children 6-59 months surveyed


418


448

Boys Girls Total Ratio

AGE (mo) no. % no. % no. % Boy: girl

6-17 47 50.0 47 50.0 94 22.5 1.0

18-29 43 42.2 59 57.8 102 24.4 0.7

30-41 52 52.0 48 48.0 100 23.9 1.1

42-53 41 53.9 35 46.1 76 18.2 1.2

54-59 32 69.6 14 30.4 46 11.0 2.3

Total 215 51.4 203 48.6 418 100.0 1.1

Boys Girls Total Ratio

AGE (mo) no. % no. % no. % Boy: girl

6-17 52 51.5 49 48.5 101 22.5 1.1

18-29 75 54.7 62 45.3 137 30.6 1.2

18

5.3.2. Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by

sex

GAM WHZ is defined as <-2 z scores weight-for-height and/or oedema while severe acute malnutrition is

defined as <-3z scores weight-forheight and/or oedema.

The prevalence of GAM and SAM in the IDP camps are presented in Table 5-6 & 5-7. Prevalence of GAM

in segment A was 7.5% (5.6 - 10.0 95% C.I.), whereas SAM was 1.9% (1.0 - 3.9 95% C.I.). GAM among

households in segment B was 8.3% (5.8 - 11.8 95% C.I.), and SAM was found to be 1.6 % (0.6 - 4.1 95%

C.I.). No oedema case was observed during the assessment in both segments.

In the final analysis, 11 children (7 in segment A & 4 in segment B) were excluded due to out of range

values using SMART flags (-3 to 3 Z-score).

Table 5-6: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex, segment A

The prevalence of oedema is 0.0 %

Table 5-7: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex, segment B

30-41 48 52.2 44 47.8 92 20.5 1.1

42-53 40 51.9 37 48.1 77 17.2 1.1

54-59 23 56.1 18 43.9 41 9.2 1.3

Total 238 53.1 210 46.9 448 100.0 1.1

All

n = 411 Boys

n = 211 Girls

n = 200

Prevalence of global malnutrition (<-2 z-score and/or oedema)

(31) 7.5 % (5.6 - 10.0 95% C.I.)

(16) 7.6 % (5.1 - 11.1 95% C.I.)

(15) 7.5 % (4.6 - 11.9 95% C.I.)

Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)

(23) 5.6 % (4.0 - 7.8 95% C.I.)

(10) 4.7 % (2.5 - 8.7 95% C.I.)

(13) 6.5 % (4.1 - 10.1 95% C.I.)

Prevalence of severe malnutrition (<-3 z-score and/or oedema)

(8) 1.9 % (1.0 - 3.9 95% C.I.)

(6) 2.8 % (1.3 - 5.9 95% C.I.)

(2) 1.0 % (0.3 - 3.8 95% C.I.)

All

n = 444 Boys

n = 236 Girls

n = 208

Prevalence of global malnutrition (<-2 z-score and/or oedema)

(37) 8.3 % (5.8 - 11.8 95% C.I.)

(21) 8.9 % (5.8 - 13.5 95% C.I.)

(16) 7.7 % (4.8 - 12.1 95% C.I.)

Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)

(30) 6.8 % (4.4 - 10.2 95% C.I.)

(17) 7.2 % (4.2 - 12.0 95% C.I.)

(13) 6.3 % (3.7 - 10.3 95% C.I.)

Prevalence of severe malnutrition (<-3 z-score and/or oedema)

(7) 1.6 % (0.6 - 4.1 95% C.I.)

(4) 1.7 % (0.6 - 4.5 95% C.I.)

(3) 1.4 % (0.3 - 6.2 95% C.I.)

19

The prevalence of oedema is 0.0 %

5.3.3. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema

As shown in table 5-8 & 5-9, younger children 6-29 months were the most malnourished by WHZ than any

other age group .Table 5-10 shows the distribution of acute malnutrition based on WHZ and oedema. No

cases of kwashiorkor were observed in the sample. Malnutrition was presented as marasmas only.

Table 5-8: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, segment A

Severe wasting

(<-3 z-score)

Moderate wasting (>= -3 and <-2 z-

score )

Normal (> = -2 z score)

Oedema

Age (mo) Total no. No. % No. % No. % No. %

6-17 91 4 4.4 12 13.2 75 82.4 0 0.0

18-29 101 4 4.0 4 4.0 93 92.1 0 0.0

30-41 98 0 0.0 0 0.0 98 100.0 0 0.0

42-53 75 0 0.0 4 5.3 71 94.7 0 0.0

54-59 46 0 0.0 3 6.5 43 93.5 0 0.0

Total 411 8 1.9 23 5.6 380 92.5 0 0.0

Table 5-9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, segment B

Severe wasting

(<-3 z-score)

Moderate wasting

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Oedema


6-17 97 4 4.1 12 12.4 81 83.5 0 0.0

18-29 137 3 2.2 8 5.8 126 92.0 0 0.0

30-41 92 0 0.0 7 7.6 85 92.4 0 0.0

42-53 77 0 0.0 1 1.3 76 98.7 0 0.0

54-59 41 0 0.0 2 4.9 39 95.1 0 0.0

Total 444 7 1.6 30 6.8 407 91.7 0 0.0

Table 5-10: Distribution of acute malnutrition and oedema based on weight-for-height z-scores

Qala-e-Naw city IDP camp

(Segment A) Qala-e-Naw city IDP camp (Segment B)

<-3 z-score >=-3 z-score <-3 z-score >=-3 z-score

Oedema present Marasmic kwashiorkor

No. 0 (0.0 %)

Kwashiorkor No. 0

(0.0 %)

Marasmic kwashiorkor No. 0

(0.0 %)

Kwashiorkor No. 0

(0.0 %)

Oedema absent Marasmic No. 12

Not severely malnourished

Marasmic No. 11

Not severely malnourished

20

5.3.4. Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema)

The prevalence of global acute malnutrition based on MUAC (<125mm) and/or oedema in segment A was

8.1% (5.6 - 11.7 95% C.I.) and of severe acute malnutrition (MUAC <115mm and/or oedema) was 2.4%

(1.3 - 4.4 95% C.I.). In segement B, the prevalence of global acute malnutrition based on MUAC was 8.7%

(6.4 - 11.8 95% C.I.), and SAM was found to be 1.6% (0.7 - 3.5 95% C.I.). Detailed results are presented in

tables 5-11 & 5-12.

Table 5-11: Prevalence of acute malnutrition based on MUAC cut offs (and/or oedema) and by sex., segment A

Table 5-12: Prevalence of acute malnutrition based on MUAC cut offs (and/or oedema) and by sex., segment B

According to table 5-13 & 5-14, younger children 6-29 months were more malnourished by MUAC than

older children above 2 years of age. This is consistent with the known fact that MUAC tends to identify

younger children.

Table 5-13: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, segment A

Severe wasting

(< 115 mm)

Moderate wasting

Normal (> = 125 mm )

Oedema

(2.9 %) No. 406 (97.1 %)

(2.5 %) No. 437 (97.5 %)

All

n = 418 Boys

n = 215 Girls

n = 203

Prevalence of global malnutrition (< 125 mm and/or oedema)

(34) 8.1% (5.6 - 11.7 95%

C.I.)

(13) 6.0% (3.4 - 10.6 95% C.I.)

(21) 10.3% (6.2 - 16.7 95%

C.I.)

Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema)

(24) 5.7% (3.8 - 8.6 95% C.I.)

(8) 3.7% (1.9 - 7.3 95% C.I.)

(16) 7.9% (4.5 - 13.4 95%

C.I.)

Prevalence of severe malnutrition (< 115 mm and/or oedema)

(10) 2.4% (1.3 - 4.4 95% C.I.)

(5) 2.3% (0.8 - 6.7 95% C.I.)

(5) 2.5% (1.1 - 5.5 95% C.I.)

All

n = 448 Boys

n = 238 Girls

n = 210

Prevalence of global malnutrition (< 125 mm and/or oedema)

(39) 8.7% (6.4 - 11.8 95% C.I.)

(20) 8.4% (5.5 - 12.7 95%

C.I.)

(19) 9.0% (6.4 - 12.6 95%

C.I.)

Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema)

(32) 7.1% (5.1 - 10.0 95% C.I.)

(16) 6.7% (4.3 - 10.4 95%

C.I.)

(16) 7.6% (4.9 - 11.6 95%

C.I.)

Prevalence of severe malnutrition (< 115 mm and/or oedema)

(7) 1.6% (0.7 - 3.5 95% C.I.)

(4) 1.7% (0.6 - 4.4 95% C.I.)

(3) 1.4% (0.5 - 4.4 95% C.I.)

21

(>= 115 mm and < 125 mm)


6-17 94 7 7.4 13 13.8 74 78.7 0 0.0

18-29 102 3 2.9 10 9.8 89 87.3 0 0.0

30-41 100 0 0.0 1 1.0 99 99.0 0 0.0

42-53 76 0 0.0 0 0.0 76 100.0 0 0.0

54-59 46 0 0.0 0 0.0 46 100.0 0 0.0

Total 418 10 2.4 24 5.7 384 91.9 0 0.0

Table 5-14: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, segement B

Severe wasting

(< 115 mm)

Moderate wasting

(>= 115 mm and < 125 mm)

Normal (> = 125 mm )

Oedema


6-17 101 6 5.9 21 20.8 74 73.3 0 0.0

18-29 137 1 0.7 11 8.0 125 91.2 0 0.0

30-41 92 0 0.0 0 0.0 92 100.0 0 0.0

42-53 77 0 0.0 0 0.0 77 100.0 0 0.0

54-59 41 0 0.0 0 0.0 41 100.0 0 0.0

Total 448 7 1.6 32 7.1 409 91.3 0 0.0

5.3.5. Prevalence of underweight based on weight-for-age z-scores

Weight for Age is a composite index that measures both stunting and wasting. The prevalence of

underweight in segment A and segment B of Qala-e-Naw city IDP camp was 21.6% (17.7 - 26.1 95% C.I.)

and 26.6% (22.3 - 31.4 95% C.I.), respectively as indicated in table 5-15 & 5-16.

Table 5-15: Prevalence of underweight based on weight-for-age z-scores by sex., segment A

Table 5-16: Prevalence of underweight based on weight-for-age z-scores by sex., segment B

All

n = 412 Boys

n = 212 Girls

n = 200

Prevalence of underweight (<-2 z-score)

(89) 21.6% (17.7 - 26.1 95% C.I.)

(44) 20.8% (15.0 - 27.9 95% C.I.)

(45) 22.5% (16.4 - 30.0 95% C.I.)

Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)

(65) 15.8% (12.8 - 19.3 95% C.I.)

(31) 14.6% (9.9 - 21.1 95% C.I.)

(34) 17.0% (12.9 - 22.1 95% C.I.)

Prevalence of severe underweight (<-3 z-score)

(24) 5.8% (3.7 - 9.1 95% C.I.)

(13) 6.1% (3.4 - 10.9 95% C.I.)

(11) 5.5% (2.6 - 11.2 95% C.I.)

All

n = 447 Boys

n = 237 Girls

n = 210

Prevalence of underweight (<-2 z-score)

(119) 26.6% (22.3 - 31.4 95% C.I.)

(68) 28.7% (23.0 - 35.1 95%

C.I.)

(51) 24.3% (17.9 - 32.1 95%

C.I.)

Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)

(92) 20.6% (17.3 - 24.3 95% C.I.)

(50) 21.1% (17.1 - 25.8 95%

C.I.)

(42) 20.0% (14.9 - 26.3 95%

C.I.)

22

5.3.6. Prevalence of stunting based on height-for-age z-scores and by sex

Stunting is indicated by low height/length for age compared to WHO standard 2006. From the survey

findings, the stunting rate for children aged 6-59 months in Qala-e-Naw city IDP camp was 40.0% (35.3 -

44.9 95% C.I.) in segment A and 47.5% (40.2 - 55.0 95% C.I.) in segment B as indicated in table 5-17 & 5-

18.

Table 5-17: Prevalence of stunting based on height-for-age z-scores and by sex., segment A

Table 5-18: Prevalence of stunting based on height-for-age z-scores and by sex., segment B

5.4. Child morbidity

High prevalence of diarrhoea was recorded in both segment A and B of Qala-e-Naw city IDP camp (Table

5-19). Nearly one-third of surveyed children reportedly suffered from diarrhoea in the two weeks prior to

the assessment (31.6% in segment A and 33.9% in B)

Prevalence of severe underweight (<-3 z-score)

(27) 6.0% (3.9 - 9.3 95% C.I.)

(18) 7.6% (4.5 - 12.5 95% C.I.)

(9) 4.3% (2.1 - 8.7 95% C.I.)

All

n = 410 Boys

n = 208 Girls

n = 202

Prevalence of stunting (<-2 z-score)

(164) 40.0% (35.3 - 44.9 95%

C.I.)

(83) 39.9% (33.6 - 46.6 95%

C.I.)

(81) 40.1% (32.3 - 48.4 95%

C.I.)

Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)

(102) 24.9% (21.2 - 29.0 95%

C.I.)

(51) 24.5% (19.3 - 30.6 95%

C.I.)

(51) 25.2% (20.0 - 31.4 95%

C.I.)

Prevalence of severe stunting (<-3 z-score)

(62) 15.1% (11.8 - 19.1 95%

C.I.)

(32) 15.4% (11.7 - 20.0 95%

C.I.)

(30) 14.9% (10.3 - 20.9 95%

C.I.)

All

n = 444 Boys

n = 235 Girls

n = 209

Prevalence of stunting (<-2 z-score)

(211) 47.5% (40.2 - 55.0 95%

C.I.)

(123) 52.3% (44.4 - 60.1 95%

C.I.)

(88) 42.1% (31.4 - 53.6 95%

C.I.)

Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)

(150) 33.8% (28.3 - 39.8 95%

C.I.)

(81) 34.5% (27.9 - 41.7 95%

C.I.)

(69) 33.0% (24.7 - 42.6 95%

C.I.)

Prevalence of severe stunting (<-3 z-score)

(61) 13.7% (10.4 - 18.0 95%

C.I.)

(42) 17.9% (13.5 - 23.2 95%

C.I.)

(19) 9.1% (5.6 - 14.5 95% C.I.)

23

Table 5-19: Morbidity among children 6-59 months, Qala-e-Naw city IDP camps, Badghis Province, April 2019

5.5. Maternal nutritional status

From the survey findings, 28.4% and 39.3% of women were found to be acutely malnourished in segment

A and B, respectively as indicated in table 5-20.

Table 5-20: Maternal nutritional status based on MUAC cut-off points for PLW, Qala-e-Naw city IDP camps, Badghis Province, April 2019

5.6. Prevalence of Combined Acute Malnutrtion based on WHZ and/or MUAC

The Combined GAM (cGAM) and Combined SAM (cSAM) among children 6-59 months based on WHZ and

or MUAC (mm) is shown in table 5-21.

Table 5-21 : Prevalence of Combined Acute Malnutrtion based on WHZ and/or MUAC for children 6-59 months old

Combined Indicator Qala-e-Naw city IDP

camp (Segment A)

Qala-e-Naw city IDP camp (Segment

B)

Global Acute Malnutrition (<-2 z-score and/or oedema and/or < 125 mm)

(45) 10.9% (8.4-14.0 95% CI)

(58) 13.1% (10.7-15.8 95%CI)

Severe Acute Malnutrition (<-3 z-score and/or oedema and/or < 115 mm)

(14) 3.4% (2.0- 5.8 95% CI)

(13) 2.9% (1.6- 5.3 95% CI)

5.7. Proportion of acutely malnourished children enrolled in & referred to a nutrition program

The number of children enrolled in the nearby therapeutic feeding program was only 11.8 % and 7.7% in

segment A and segment B, respectively. Overall, of children identified as acutely malnourished by the

survey teams only 20.6% in segment A and 12.8% in segment B were enrolled in a program at the time of

survey (Table 5-22). The low coverage of nutrition services is seen as a gap in response needs in the camps.


(Segment A) Qala-e-Naw city IDP camp

(Segment B)

n % n %

Diarrhea 6-59 months, two weeks recall

139 31.6 % 160 33.9 %


(Segment A) Qala-e-Naw city IDP camp

(Segment B)

n % n %

Global Acute Malnutrition (GAM) MUAC < 230 mm

58 28.4% 88 39.3%

Moderate Acute Malnutrition (MAM) MUAC < 230 -≥185 mm

56 27.5% 87 38.9%

Severe Acute Malnutrition (SAM) MUAC < 185 mm

2 0.9% 1 0.4%

24

All acutely malnourished children found during assessment were referred using referral forms to the

nearby health centre with OPD-SAM and OPD-MAM programme.

Table 5- 22: Proportion of Acutely Malnourished Children 6-59 Months Enrolled in a Treatment Programme

Sample Enrolled in

an OPD-SAM Enrolled in an

OPD-MAM

Enrolled in an IPD-SAM Not Enrolled

Acutely malnourished children 6-59 months by WHZ, MUAC, or oedema (N=45) in segment A

(4) 8.9 % (3) 6.7 % (0) 0.0 % (38) 84.4 %

Acutely malnourished children 6-59 months by WHZ, MUAC, or oedema (N=58) in segment B

(3) 5.2 % (2) 3.4 % (0) 0.0 % (53) 91.4 %

6. DISCUSSION

6.1. Nutritional status

The survey results in segment A and segment B revealed GAM rates of 7.5 % (5.6 - 10.0 95% C.I.) and 8.3%

(5.8-11.8 95% CI), respectively. The GAM prevalence based on weight-for-height <-2 z-scores was

classified as medium for both camps according to WHO-UNICEF thresholds for the level of severity of

malnutrition6. There was no significant difference in the level of acute malnutrition between the two

segments of Qala-e-Naw city IDP camp.

The prevalence of cGAM in segment A and segment B was 10.9% (8.4-14.0 95% C.I.) and 13.1% (10.7-15.8

95 % CI), respectively. This indicates a higher proportion of children under-five affected by acute

malnutrition in the camps when considering both WHZ and MUAC criteria instead of considering

separately those 2 indicators. Combined prevalence captures a greater proportion of acute malnourished

children 6-59 months, and may inform better the estimation of SAM and MAM caseloads in the camp,

ultimately, strengthening planning and programming7.

6According to WHO-UNICEF (2018) new prevalence thresholds for the level of severity of malnutrition, GAM rates less than 2.5% are very low, GAM rates between 2.5 - <5% are low, GAM rates between 5-<10% indicate the situation is medium, GAM rates between 10-<15% are high, while GAM rates of 15% and above are very high. https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf 7 The Afghanistan national Integrated Management of Acute Malnutrition (IMAM) guideline includes both WHZ and MUAC as independent admission criteria for SAM and MAM treatment centers

https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf

25

Stunting, identify as low height for age z-score, is caused by long-term insufficient nutrient intake and/or

frequent infections. The stunting rates in both segments are categorized as very high according to WHO-

UNICEF new thresholds of a prevalence8: 40.0% (35.3 - 44.9 95% CI) in segment A, and 47.5 % (40.2 - 55.0

95% CI) in segment B. Very high stunting levels are usually seen in contexts with very low access to health

services, low sanitation levels and low maternal nutritional status. The proportion of malnourished

pregnant and lactating women recorded in the two assessments was high with 28.4% of PLW in segment

A and 39.3% of PLW in segment B being found to have a MUAC of <23cm. Maternal undernutrition affects

a woman’s chances of surviving pregnancy as well as her child’s health. Nutritional status of pregnant and

lactating women are crucial for ensuring healthy fetal growth and development. There is need to design

programs to reverse the high prevalence of chronic malnutrition and maternal malnutrition with all

sectors involved.

The underweight prevalence is higher in segment B, 26.6% (22.3-31.4 95 % C.I) than segment A, 21.6%

(17.7 – 26.1 95% C.I) though not statistically significant. The prevalence of underweight is classified as high

in both camps, using the WHO classification9 for assessing severity of malnutrition by prevalence ranges

among children under 5 years of age

Although not significant, there was a slight decline in the rates of acute malnutrition (figure 2), where a

GAM rate of 10.0 (6.6 - 15.0; 95% CI) and SAM rate of 2.7% (1.2 - 6.0; 95% CI) was recorded in June 2018

in the selected hotspot locations of Badghis province. The reduction in acute malnutrition can be

8 According to WHO-UNICEF (2018) new prevalence thresholds for the level of severity of malnutrition, stunting rates less than 2.5% are very low, stunting rates between 2.5 - <10% are low, stunting rates between 10 - <20% are classified as medium, stunting rates between 20 - <30% are high, while stunting rates of 30% and above are very high. https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf 9 According to WHO (2000) Classification for assessing severity of malnutrition by prevalence, underweight rates less than 10% are low, underweight rates between 10 - 19% are medium, underweight rates between 20 - 29% are classified as high, underweight rates of 30% and above are very high.

10.9%

7.5%8.1%

13.1%

8.3% 8.1%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Combined GAM WHZ GAM MUAC GAM Combined GAM WHZ GAM MUAC GAM

Segment A(Kharistan, Jar Khoshk, Jar Haji Sakhi, Chakaran)

Segment B(Zaimati, Sanjidak, Baghlar, Shamal Darya)

Figure 1: GAM children captured by WHZ, MUAC and Combined MUAC and/or WHZ

https://www.who.int/nutrition/team/prevalence-thresholds-wasting-overweight-stunting-children-paper.pdf

26

attributed to several factors including: i) WVI nutrition & health services implemented through MHT in

the IDP camp; ii) AAH nutrition & health programme in 3 districts (Bala Murghab, Jawand and Ab Kamary);

iii) food distribution by WFP and NRC in the IDP camp.

Sustained multi-sectoral efforts will be necessary to continue this trend in the Qala-e-Naw city IDP camp.

However, the critical nutrition situation of the surveyed population may be aggravated by poor maternal

and child care (high proportion of malnourished women) and high child morbidity. Moreover the food

security is still a major concern considering the vulnerable situation of the surveyed population which is

reliant on food aid both as a source of food and as a major source of income. The nutrition situation in

the Qala-e-Naw city IDP camp is precarious and can further slide into an emergency situation in the event

of any shock. The situation is compounded by the fact that the livelihoods of IDP have been destroyed,

making them more vulnerable to acute food insecurity and disease outbreaks.

6.2. Child health indicators

The prevalence of diarrhea in the survey sample was high. The diarrhea morbidity prevalence found in the

two assessments (31.6% in segment A and 33.9% in segment B) are higher than the national average of

29% [AfDHS, 2015]. The high proportion of children reported to have had diarrhoea in the two weeks prior

to the assessment may partly be attributed to the lack of safe drinking water, and poor hygiene and

sanitation conditions and practices. Much can be done to turn this situation around by improving access

to safe water source, promotion of water treatment options, improving sanitation access and hygiene

promotion as well as focusing on the home management of childhood illness.

7. RECOMMENDATIONS

10 (6.6-15)

2.7 (1.2-6.0)

7.5 (5.6-10,)

1.9 (1.0-3.9)

8.3 (5.8-11.8)

1.6 (0.6-4.1)

0.0

2.0

4.0

6.0

8.0

10.0

12.0

GAM SAM

Pre

vale

nce

Figure 2: Comparison of GAM and SAM prevalencein June 2018 and April 2019

June 2018 April 2019 (segment A) April 2019 (segment B)

27

Although there is slight improvement of the nutrition situation, there is a need to strengthen and

continue to provide all the components of the integrated management of acute malnutrition and

scaling up the services where possible, in order to have better access to the treatment in the

entire IDP camp.

Improve the coverage of Targetted Supplementary Feeding Program (TSFP) for MAM children 6-

23 months and Pregnant and Lactating Women.

Conduct full SMART assessment in Badghis province.

ANNEXES

28

Annex 1: Plausibility check for: Badghis_IDP_camps_segment A

_April_2019_Afghanistan.as

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5

(% of out of range subjects) 0 5 10 20 0 (1.7 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 0 (p=0.557)

Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001


Dig pref score - weight Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (7)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20

0 2 4 10 2 (10)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20

0 2 4 10 2 (12)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20

. and and and or

. Excl SD >0.9 >0.85 >0.80 <=0.80

0 5 10 20 0 (1.09)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 1 (-0.33)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 0 (-0.07)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001

0 1 3 5 0 (p=0.794)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 5 %

The overall score of this survey is 5 %, this is excellent.

Annex 2: Plausibility check for: Badghis_IDP_camps_Segment B

_April_2019_Afghanistan.as

Overall data quality

29

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5

(% of out of range subjects) 0 5 10 20 0 (0.9 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001


Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001


Dig pref score - weight Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (4)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (7)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20

0 2 4 10 2 (9)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20

. and and and or

. Excl SD >0.9 >0.85 >0.80 <=0.80

0 5 10 20 0 (1.04)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 1 (-0.35)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 1 (-0.30)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001

0 1 3 5 0 (p=0.238)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 8 %

The overall score of this survey is 8 %, this is excellent.

Annex 3: Selected clusters, segment A, Qala-e-Naw IDP camp

Geographical unit Population size Cluster #

Kharistan Chief /Malik 02 2100 1


30









Kharistan Chief /Malik 19 2226 RC






Jari Khushk Chief /Malik 29 679 16




Jari Haji Sakhi Chief /Malik 46 910 RC

Jari Haji Sakhi Chief /Malik 48 1407 20


Jari Haji Sakhi Chief /Malik 52 1274 RC



Chakaran Chief /Malik 59 539 24

Chakaran Chief /Malik 62 735 25

Annex 4: Selected clusters, segment B, Qala-e-Naw IDP camp

Geographical unit Population size Cluster #

31

Zaimati Chief /Malik0 2 1470 1






Zaimati Chief /Malik0 12 1155 RC



Sanjitak Chief /Malik0 18 910 9






Baghlar Chief /Malik0 34 2905 15,16

Baghlar Chief /Malik0 35 2940 17




Baghlar Chief /Malik0 39 3514 21,RC



Camp Shamal e darya Chief /Malik0 43 539 24

Camp Shamal e darya Chief /Malik0 47 700 25

Camp Shamal e darya Chief /Malik0 52 504 RC

32

Annex 5: Rapid SMART Assessment questionnaires for children and

pregnant and lactating women Date

(dd/mm/year) Cluster Name

Cluster Number Team Number HH Number

Child Questionnaire 0-59 months

Note only if length is measured for a child who is older than 2 years or height is measured for a child who is younger than 2 years, due to unavoidable circumstances in the field. Child Questionnaire

Child (6-59 months) ID Number

For any child that is identified as acutely malnourished (WHZ, MUAC, or edema)

Q1. Is the child currently receiving any malnutrition treatment services?

Probe, ask for enrollment card, and observe the treatment food (RUTF / RUSF) to

identify the type of treatment service

1=OPD SAM

2=OPD MAM

3=IPD SAM

4=No treatment

98=Don’t know

If the child is not enrolled in a treatment program, refer to nearest appropriate

treatment center

Q2. Did you refer the child?

1=yes

1 2 3 4 5 6 7 8 9 10

Child ID

Sex (f/m)

Birthday (dd/mm/yyyy)

Age (months)

Weight (00.0 kg)

Height or length

(00.0 cm)

Measure (l/h)*

Bilateral

edema Y/N

MUAC (000 mm)

Left arm

With clothes

(y/n)

1

2

3

4

5

6

7

8

33

0=no

Woman (15-49 years) age in years

Physiologic Status of woman

1=Pregnant

2=Lactating

3=Pregnant and lactating

4=None

MUAC measurement (mm)

Child (0-59 months) ID Number

Q3. In the past two weeks, has the child had diarrhea?

Diarrhea defined as the passage of three or more loose or liquid

stools in a day

1=yes

0=no

98=don’t know

General comments (optional)

34

Annex 6: Event calendar

د میاشتو نومونه میاشتی 1393 میاشتی 1394 میاشتی 1395 میاشتی 1396 میاشتی 1397 میاشتی 1398

نوروز نوروز نوروز نوروز نوروز

سمنک سمنک سمنک سمنک سمنک

روز دهقان روز دهقان روز دهقان روز دهقان روز دهقان

سیزده بدل سیزده بدل سیزده بدل سیزده بدل سیزده بدل

شعبان شعبان شعبان شعبان شعبان

روز معارف روز معارف روز معارف روز معارف روز معارف

13 149 37 حمل25

پیروزی مجاهدین پیروزی مجاهدین پیروزی مجاهدین پیروزی مجاهدین

وقت توت وقت توت وقت توت وقت توت

باروکوج کوچی باروکوج کوچی باروکوج کوچی باروکوج کوچی

ماه مبارک رمضان

48 36 24 ثور12

جودرو جودرو جودرو جودرو جودرو

روزمادر روزمادر روزمادر روزمادر روزمادر

عیدرمضان عیدرمضان عیدرمضان عیدرمضان عیدرمضان

عرفه عرفه عرفه عرفه عرفه

جوزا1123354759

شول پسته چندن شول پسته چندن شول پسته چندن شول پسته چندن شول پسته چندن

رسیدن میوه رسیدن میوه رسیدن میوه رسیدن میوه رسیدن میوه 1058 46 34 22

سرطان

عیدقربان عیدقربان عیدقربان عیدقربان عیدقربان

روزاستقلال افغانستان روزاستقلال افغانستان روزاستقلال افغانستان روزاستقلال افغانستان روزاستقلال افغانستان

روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب

ګندم درو ګندم درو ګندم درو ګندم درو ګندم درو

45 اسد92133 57

آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق

روزعاشوری روزعاشوری روزعاشوری روزعاشوری نبله820324456روزعاشوریس

روزمعلم روزمعلم روزمعلم روزمعلم روزمعلم

زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری 43زمان جمع کردن جوزوچواری 31 19 میزان755

روزمیلادالنبی روزمیلادالنبی روزمیلادالنبی روزمیلادالنبی روزمیلادالنبی

برګ درخت هامیریزد برګ درخت هامیریزد برګ درخت هامیریزد برګ درخت هامیریزد 42برګ درخت هامیریزد 30 18 عقرب654

شروع امتحانات مکاتب شروع امتحانات مکاتب شروع امتحانات مکاتب شروع امتحانات مکاتب شروع امتحانات مکاتب

شروع برف باری شروع برف باری شروع برف باری شروع برف باری شروع برف باری

شاندن بخاری شاندن بخاری شاندن بخاری شاندن بخاری شاندن بخاری

41 29 17 قوس553

اولین برف اولین برف اولین برف اولین برف اولین برف

چله خورد چله خورد چله خورد چله خورد چله خورد

چله کلان چله کلان چله کلان چله کلان چله کلان

روخصتی مکاتب روخصتی مکاتب روخصتی مکاتب روخصتی مکاتب روخصتی مکاتب

جدی416284052

یخبندی یخبندی یخبندی یخبندی یخبندی

راهابندمیشه راهابندمیشه راهابندمیشه راهابندمیشه راهابندمیشه

خنکی زیادمیشه خنکی زیادمیشه خنکی زیادمیشه خنکی زیادمیشه خنکی زیادمیشه

39 27 15 دلوه351

کشت کردن پالیز کشت کردن پالیز کشت کردن پالیز کشت کردن پالیز کشت کردن پالیز

جمع کردن بخاری جمع کردن بخاری جمع کردن بخاری جمع کردن بخاری جمع کردن بخاری38 26 14 حړت250

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AN · 2020. 4. 30. · Lead by: Dr: Shafiullah Samim, Dr. M. Khalid Zakir and Dr. Nazir Sajid Author: Beka Teshome and Dr. Sayed Rahim Rastkar Funded by: AHF-OCHA Action Contre la