Rapid SMART Assessment Report Herat IDPs Camps, Herat … · 2020. 4. 30. · Executive summary In April 2019, Action Against Hunger (AAH) in collaborations with the Ministry of Public

Rapid SMART Assessment Report

Herat IDPs Camps, Herat province

Date: 6-11 April 2019

Lead by: Dr. Baidar Bakht Habib

Author: Dr. Ahmad Abib Habibi, Dr. Sayed Rahim RASTKAR and Beka Teshome

Funded by: AHF-OCHA

Action Contre la Faim

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

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Contents Acknowledgment ......................................................................................................... 6

ABBREVIATIONS ........................................................................................................... 7

Executive summary ......................................................................................................................................... 8

1. background ........................................................................................................... 10

2. Objectives ............................................................................................................ 11

2.1 Specific objective ..................................................................................................................................... 11

3. METHODOLOGY ...................................................................................................... 11

3.1. Geographic target area and population group .................................................................................. 11

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

3.2. Survey design ..................................................................................................................................... 12

3.3. Sample size ........................................................................................................................................ 12

3.4. Sampling procedures ......................................................................................................................... 12

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

3.4.2. Second stage sampling: selection of households ....................................................................... 13

3.5. Organization of the Survey ................................................................................................................ 14

3.5.1. Survey Coordination................................................................................................................... 14

3.5.2. Survey Teams ............................................................................................................................. 14

3.5.3. Training of the Survey Teams .................................................................................................... 14

3.6. Data collection and field work ........................................................................................................... 14

3.6.1. Anthropometric survey ............................................................................................................ 14

3.6.2. Mid-upper arm circumference of women 15 – 49 years........................................................ 15

3.6.3. Child Morbidity ......................................................................................................................... 15

3.7. Data quality assurance ...................................................................................................................... 15

4. Data management and Analysis ............................................................................... 16

5. Results ................................................................................................................. 16

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

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

4.1.1. Pregnant and Lactating Women................................................................................................ 17

4.2. Anthropometric results ..................................................................................................................... 17

4.2.1. Distribution by sex and age ....................................................................................................... 17

4.2.2. Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex 18

4.2.3. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema 19

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

4.3. Prevalence of Combined Acute Malnutrtion based on WHZ and/or MUAC ..................................... 22

4.3.1. Prevalence of underweight based on weight-for-age z-scores .............................................. 23

4.3.2. Prevalence of stunting based on height-for-age z-scores and by sex ................................... 24

4.3.3. Mean z-scores, Design Effects and excluded subjects ........................................................... 24

4.4. Child morbidity .................................................................................................................................. 25

4.5. Maternal nutritional status ............................................................................................................... 26

4.6. Proportion of acutely malnourished children enrolled in & referred to a nutrition program .......... 26

5. discusion .............................................................................................................. 27

6. Recommendations .................................................................................................. 29

7. Annexes ............................................................................................................... 30

Annex 1: Plausibility check for: Herat_IDP camps ( Shaidayee) _April_2019_Afghanistan.as ..................... 30

Annex 3: Selected clusters Herat IDPs Shaidayee camp ............................................................................... 33

Annex 4: Selected clusters Herat IDPs Shahrak Sabz & Shahrak Satar Pahlawan ......................................... 33

Annex 5. Herat IDPs camps field Map. ........................................................................................................... 1

Annex 6: Rapid SMART Assessment questionnaires for children and pregnant and lactating women .......... 1

Annex 7: Event calendar .................................................................................................................................. 1

Tables of Contents Table 5- 1: Summary of households and children 6-59 months planned and those surveyed ............. 16 Table 5-2: Distribution of age & sex of children 6-59 months, Herat city IDPs camp (Shaidayee) .............. 17 Table 5-3: Distribution of age & sex of children 6-59 months, Herat city IDPs camp (Shahrak Setar Pahlawan) .......................................................................................................................................................... 17 Table 5 4: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex ........................................................................................................................................................ 18 Table 5 5: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex ........................................................................................................................................................ 18 Table 5 6: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, Shaidayee camp ............................................................................................................................... 19 Table 5 7: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, Shahrak Sabz & Shahrak Satar Pahlawan camps ............................................................................................ 19 Table 5 8: Distribution of acute malnutrition and oedema based on weight-for-height z-scores. ............... 20

Table 5 9: Distribution of acute malnutrition and oedema based on weight-for-height z-scores. ...... 20 Table 5 10: Prevalence of acute malnutrition based on MUAC cut offs (and/or oedema) and by sex. ........ 20 Table 5 11: Prevalence of acute malnutrition based on MUAC cut offs (and/or oedema) and by sex.21 Table 5 12: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, Shaidayee camp .................................................................................................................................................................. 21 Table 5 13: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, Shahrak Sabz & Shahrak Satar Pahlawan camp ............................................................................................................ 22 Table 5 14: Prevalence of malnutrition based on both criteria (WHZ+MUAC) and by sex........................... 22 Table 5 15: Prevalence of malnutrition based on both criteria (WHZ+MUAC) and by sex........................... 22

Table 5 16: Prevalence of underweight based on weight-for-age z-scores by sex., Herat IDP camps ......... 23

Table 5 17: Prevalence of underweight based on weight-for-age z-scores by sex, Herat IDP camps .......... 23

Table 5 18: Prevalence of stunting based on height-for-age z-scores and by sex., Herat IDP camps .......... 24 Table 5 19: Prevalence of stunting based on height-for-age z-scores and by sex., Herat IDP camps .......... 24 Table 5 20: Mean z-scores, design effect and excluded subjects, Shaidayee camp ...................................... 25 Table 5 21: Mean z-scores, design effect and excluded subjects, Shahrak Sabz & Shahrak Satar Pahlawan camp .................................................................................................................................................................. 25 Table 5 22: Morbidity among children 6-59 months, Herat IDP camps ........................................................ 25 Table 5 23: Morbidity among children 6-59 months, Herat IDP camps ........................................................ 25

Table 5 24: Maternal nutritional status based on MUAC cut-off points for PLW, Herat IDP camps. .......... 26 Table 5 25: Maternal nutritional status based on MUAC cut-off points for PLW, Herat IDP camps. .......... 26 Table 5 26: Proportion of Acutely Malnourished Children 6-59 Months Enrolled in a Treatment Programme ........................................................................................................................................................................... 27

ACKNOWLEDGMENT

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 Assessments team in Herat city IDPs Camps,

Herat province:

Herat Provincial Public Health Directorate (PPHD) and Herat Provincial Nutrition officer (PNO)

for the support provided in the authorization of the survey.

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

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

guidance.

Afghanistan Humanitarian Fund (AHF) for their financial support in the survey.

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

collection process.

All health and nutrition sector stakeholders who are currently providing health and nutrition

services in the IDP’s camps of Herat province.

Agencies for Assistance and Development of Afghanistan (AADA) especially Dr. Abdul Qadir

Baqakhil, Dr. Qudratullah Barak and Dr. Fazal Karim Noori for smoothly implementation of the

assessment in the IDP camps in Herat province.

The survey teams are highly appreciated for doing their very best during the training and

implementation of the assessments.

AAH colleagues 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

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

views of AAH and AHF.

ABBREVIATIONS

AAH Action Against Hunger

AIM-WG Afghanistan Information Management Working Group

CDC Communicable Disease Control

CSO Central Statistics Organization

DoPH Directorate of Public Health

ENA Emergency Nutrition Assessment

GAM Global Acute Malnutrition

HH Household

IDPs Internal Displaced Peoples

IOM International Organization for Migrant

KM Kilo Meter

MAM Moderate Acute Malnutrition

MoPH Ministry of Public Health

MUAC Mid Upper Arm Circumference

NRC Norwegian Refuges council

OPD Outpatient Department

OCHA Office for coordination and humanitarian affairs Common Humanitarian fund

PPS Probability Proportional to Size

PLW Pregnant and lactating Women

PPHD Provincial Public Health Directorate

PND Public Nutrition Department

PNO Provincial Nutrition Officer

RC Reserve Cluster

SAM Severe Acute Malnutrition

SD Standard Deviation

SMART Standardized Monitoring and Assessment of Relief and Transition

TAPI Tajikistan Afghanistan Pakistan India

UNHCR United Nation High Commission for Refuges

UNIECF united Nation International Children’s Emergency Fund

W/H Weight for Height

WFP World Food Program

WHO World Health Organization

WHZ Weight for Height Z score

Executive summary

In April 2019, Action Against Hunger (AAH) in collaborations with the Ministry of Public Health

(MoPH) and Directorate of Public (DoPH) Health of Herat province, conducted two nutrition

assessments in Herat IDPs 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 6-59

months of age, Pregnant, and Lactating Women (PLW) in Herat IDPs Camps of Herat province and

provide key recommendations.

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

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

clusters included in the survey while the second stage sampling involved the selection of the

households from the sampled clusters. The smallest geographical unit in Herat IDPs Camps i.e. a

Chief/Malik defined a cluster. A total of 1,130 children aged 6-59 months (615 from Shaidayee camp

and 515 children from Shahrak Sabz and Shaharak SatarPahlawan) were assessed.

Data collection took place from 6th to 11th of April 2019, in two phases. The first phase rapid nutrition

assessment conducted in (Shaidayee camp of Herat IDPs Camps between 6-8 Aprils) while the second

phase of the rapid nutrition assessment was conducted in Shahrak Sabz and Shaharak Satar Pahlawan

between 8-11 April 2019). Summary of key findings are presented in tables below.

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

based on WHZ and oedema of 8.7 % (6.5 – 11.6 95% C.I.) and 7.1% (4.9-10.3 95% CI) in Shaidayee

and Shahrak Sabz & Shahrak Satar Pahlawan of Herat IDP camp, respectively. The results also

indicated very high rates of chronic malnutrition of 35.9 % (28.1-44.5 95% C.I.) and 40.5 % (30.5-51.5

95% C.I.) in both camps respectively.

It is notable that surveys results shown 25.1% of pregnant and lactating women suffering from

malnutrition in Shaidayee camp and 24.2% of pregnant & lactating women suffering from malnutrition

in Shahraks Sabz & Shharak Satar Pahlawan based on MUAC (<230 mm).

Summary of Key Survey Findings:

Child Health and Nutrition Status

Indicators

Shaidayee Camp

Result

Shahrak Sabz and

Satar Pahlawan

camp Result

GAM rate among children aged 6-59 months

based on Weight for Height- Z- Score <-2 SD

and/or Oedema

8.7 %

(6.5-11.6 95% C.I.)

7.1 %

(4.9-10.3 95% C.I.)

SAM rate among children aged 6-59 months based

on Weight for Height Z-Score <-3 SD and/or

Oedema

1.6 %

(0.9-3.1 95% C.I.)

1.0 %

(0.4-2.2 95% C.I.)


based on MUAC <125 mm and/or Oedema

5.2 %

(3.3-8.1 95% C.I.)

5.6 %

(3.2-9.8 95% C.I.)


on MUAC <115 mm and/or Oedema

1.0 %

(0.5-2.0 95% C.I.)

0.8 %

(0.3-2.0 95% C.I.)


based on combined criteria (WHZ <-2 SD and/or

MUAC <125 mm and/or Oedema)*

10.9%

(8.2-14.2 95% C.I.)

10.5%

(7.5-14.6 95% CI)


on combined criteria (WHZ <-3 SD and/or MUAC

<115 mm and/or Oedema)*

2.1%

(1.3-3.4 95% C.I.)

1.2%

(0.6-2.4 95% CI)

Stunting or chronic malnutrition among children

aged 6-59 months based on Height for Age Z-

Score <-2 SD

35.9 %

(28.1-44.5 95% C.I.)

40.5 %

(30.5-51.5 95% C.I.)

Underweight among children aged 6-59 months

based on Weight for Age Z-Score <-2SD

20.4 %

(15.9-25.8 95% C.I.)

20.0 %

(13.9-28.0 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)

44.9% 48.3%

Nutrition status of Pregnant and lactating

Indicators Shaidayee Camp

Result

Shahrak Sabz and

Satar Pahlawan

camp Result

Undernutrition among Pregnant Women based on

MUAC <230 mm 25.0% 26.7%

Undernutrition among only Lactating Women

based on MUAC < 230 mm 23.3% 24.5%

Undernutrition among Pregnant and Lactating

Women (PLWs) based on MUAC <230mm 25.1% 24.2%

1. BACKGROUND

Herat is one of the thirty-four provinces of Afghanistan, located in the western part of the country.

Together with Badghis, Farah, and Ghor provinces, it makes up the northwestern region of

Afghanistan. It’s primary city and administrative capital is Herat City. The province of Herat is divided

into 20 districts; Enjil, Guzara, Karrukh, Zenda Jan, Pashtoon Zarghoon, Kushk E Rubat Sangi, Gulran,

Adraskan, Kushk e kohna, Ghoryan, Obe, Kohsan, Shindand, Farsi, Chesht e Sahrif, Zerko, Poshko,

Kozeor and Zawol and the Center of Herat. The total population of the province is 205,5141. It is the

second most populated province in Afghanistan behind Kabul Province. The population is multi-ethnic

but largely Persian speaking.

Herat province shares a border with Iran in the West and Turkmenistan in the North, making it an

important trading province. The Trans-Afghanistan Pipeline (TAPI) is expected to pass through Herat

from Turkmenistan to Pakistan and India in the South. The Salma Dam, which is feeding by the Hari

River, is also located in this province.

According to OCHA assessment reports from Dec 2018, recently 16,000 families (around 80,000)

people arrived in Herat province since the last 4 months from Badghis, Ghor, Daikundi, Faryab and 3

districts (Gulran, ZerKoh and Koshk konha) of Herat province. Currently, based on Herat province CDC

database around 30,000 families are living in IDP’s camps near to the Herat city. They are settled in

Central and East part of the province (10-20 KM far from the city) under the tents (some tents are

distributed by IOM and UNHCR) but most of them are using unusable fabrics as tents and living in

warm and sandy deserts of Herat.. Most of the vulnerable population are women and children, they

are suffering from different diseases and at the same time, they have nothing to eat2 By the month of

April 2019, the IDPs who are using unusable fabrics as tent were also affected by heavy raining in

camps area

According to joint Winterization Response Strategy Report September 2018 to February 2019, cluster

partners have noted a decrease in child health conditions associated with poor shelter condition and

lack of adequate health care. For instance, in Herat IDPs camps, 48.6% of households had experienced

frequent cases of acute watery diarrhea and 20 % experience respiratory tract, chest and skin

infections. The situation is deteriorating and multi-faceted, exacerbated by negative coping

mechanisms such as child marriage and labor. A policy brief published by Norwegian Refugee Council

(NRC) 27 Nov 2018 indicates that inability of IDPs to access adequate housing and land, or to find

employment matching their skill set generates a cycle of other needs and negative coping strategy. In

Afghanistan, today 63 % of respondents to the NRC survey rated their housing condition as either

poor or very poor.

Instead of full SMART due to short time, low funded and clear geographical delimited small

administrative units, the two Rapid SMART assessments were conducted in both camps. List of

Chief/Malik with their respective population was obtained from the 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

1 Afghanistan CSO Report 2018-19. 2 Herat Assessment Compiled Report-OCHA Dec 2018.

There was no recent data for the nutrition situation in Herat IDPs camps . The need to get a better

understanding and assess the severity of the current nutrition status of the community in the IPD

camps was raised by the Nutrition Cluster along with Assessment and Information Management

Working Group/PND/MoPH, which recommended two assessments using Rapid SMART

methodology in Herat IDPs Camps. It was also an opportunity to build capacity of the AYSO staffs.

2. OBJECTIVES

2.1 Broad 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 Pregnant, and Lactating Women (PLW) in Herat

IDPs camps, Herat province, Afghanistan.

2.1 Specific objective

The specific objectives included the following:

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

months.

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

months.

To estimate the prevalence of acute malnutrition among the pregnant and lactating women

(PLWs) using Mid-Upper Arm Circumference (MUAC).

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

to the survey dates.

3. METHODOLOGY

3.1. Geographic target area and population group

The two rapid SMART assessments were carried out in Shaidayee camp and Shahrak sabz and

Shaharak Setar pahlawan camp of Herat IDPs Camps. All the 53 Chief/Malik3 (32 in Shaidayee & 21 in

Shahrak Sabz and Shahrak Pahlawan) were included in the sampling frame. The study population was

children from the age of 6 to 59 months and Pregnant and Lactating Women (PLW).

3.2. Survey period

Four-days training was organized from 31st March to 3rd April 2019 and six days data collection took

place from 6th to 11th of April, 2019, in two phases. The first phase data collection was conducted in

3 Chief/Malik is the community leader, which is leading a group of families or households.

Shaidayee between 6-8 April while the second phase data collection was conducted in Shahrak Sabz

and Shahrak Setar Pahlawan between 8-11 April 2019.

3.2. Survey design

The two rapid nutrition assessments (Shahrak Shaidayee camp & Shhahrak Sabz and Shahrak Setar

Pahlawan Camp) in Herat IDPs Camps were cross-sectional with two-stage cluster samplings based

on the SMART methodology.

3.3. 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

precision4. To reach required sample, the Rapid SMART methodology proposes to use a simplified rule

to convert children into households:

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 IDPs camps near to Herat city in the different camps.

3.4. 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 included in the survey while the second stage sampling involved the selection of the

households from the sampled clusters. The smallest geographical unit in IDPs Camps i.e. a Chief/Malik

defined a cluster.

3.4.1. First stage sampling: selection of clusters

List of Chief/Malik with their respective population was obtained from World Vision International

Mobile health teams 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

4As per the rapid SMART guideline, a sample size of minimum 200 children would be enough to estimate GAM prevalence for cluster random sampling.

53 enumeration areas of the IDPs Camps (32 in first & 21 in the second) along with their respective

populations were entered into ENA software and clusters were selected automatically to be included

in the survey ( Annexes 3 & 4) . There was no inaccessible clusters for both rapid assessments.

All the clusters (from the updated sampling frame) with their respective population sizes were entered

into ENA for SMART and 25 clusters were selected. In Chief/Malik where more than one cluster was

assigned, segmentation was done one segment was selected as cluster . The segmentation of clusters

was done based on water tankers, shops and roads.

3.4.2. Second stage sampling: selection of households

Household definition: Group of people living under same roof and sharing food from the same pot5.

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

separate 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 members introduced themselves and explained the objective of the survey to

the Chief/Malik leader.

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

Chief/Malik.

The required number of households was 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 children and having PLWs, 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 the house 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.

5 WFP Household definition

3.5. Organization of the Survey

3.5.1. Survey Coordination

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

to AADA and all the relevant administrative authorities as well as stakeholders such as MoPH, PND,

PPHD, Community leaders and other stakeholders. It was also an opportunity to build capacity of the

AADA staffs.

3.5.2. Survey Teams

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

the selected clusters from 6th to 11th April 2019. Four supervisors were assigned to supervise the

survey teams (1 supervisor per 2 survey teams).

3.5.3. Training of the Survey Teams

Training was carried out by AAH’s survey manager and was conducted in the local language6. Four

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

objectives, basic malnutrition, concept of sampling and Rapid 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 means 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 about undertaking measurements

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

the team supervisors and the Survey Manager.

3.6. Data collection and field work

3.6.1. Anthropometric survey

6ACF 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.

Structured questionnaires (Annex 6) 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 7). 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 2 years were measured lying down, while those greater than or equal to 2 years

were measured standing up.

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

arm used WFP 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.

3.6.2. Mid-upper arm circumference of women 15 – 49 years

All women aged (15-49) were assessed for their nutritional status based on MUAC measurements. The

nutritional status of pregnant and lactating women was derived using the MUAC cut-off of 230 mm.

3.6.3. 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 the

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

3.7. Data quality assurance

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

coupled with standardization test, practical field exercise 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 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. The survey manager also

did Field visits 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 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 z-scores with extreme values from observed mean. Morbidity and PLW data

were analyzed on excel 2010.

5. RESULTS

5.1. General characteristics of study population and households

5.1.1. Households and children 6-59 months

In Shaidayee camp, out of 250 households planned, data was collected from a total of 241 households

(96.4%) and in Shahrak Sabz and Shahrak Setar Pahlawan, out of 250 planned data was collected from

a total 249 households were surveyed (99.6%) and none response rate was 0.4% (10 households were

refused ). Further, the camp population was recorded based on families and the actually survey was

done based on WFP Household definition7 and the surveyed children were higher than expected,

about 282.5% of the sample size of children 6-59 months of age was met without resulting to visit the

six planned reserve clusters (RCs). A total of 866 children aged 6-59 months (615 children from

Shaidayee camp and 504 children from Shahrak Sabz & Shaharak Satar Pahlawan camp) were assessed

for their nutritional status using anthropometric measurement.

Table 5- 1: Summary of households and children 6-59 months planned and those surveyed

7 Group of people living under same roof and sharing food from the same pot

Number of HH planned

Shaidayee camp 250

Shahrak Sabz & Shaharak Satar

Pahlawan camp 250

Number of HH surveyed Shaidayee camp 241

4.1.1. Pregnant and Lactating Women

In these assessments, 450 pregnant & lactating women (223 in Shaidayee camp, 227 in Shahrak Sabz

& Shaharak Satar Pahlawan camp) were screened for malnutrition by MUAC.

4.2. Anthropometric results

4.2.1. Distribution by sex and age

The age and sex distribution of the sample population in the two surveys are illustrated in Table 5-2

and Table 5-3. Among the surveyed children, 583 (51.6%) were boys while 547 (48.4%) were girls. The

overall sex ratio of the surveyed children in Shaidayee was 1.1 and for the Shahrak Sabz and Shahrak

Setar Pahlawan was 1.0 indicating that both sexes were equally represented within the sample. The

overall data quality was scored as Good (score of 12% for Shaidayee, score of 13% for Shahrak sabz and

Shahrak Setar Pahlawan).

Table 5-2: Distribution of age & sex of children 6-59 months, Herat city IDPs camp (Shaidayee)

Table 5-3: Distribution of age & sex of children 6-59 months, Herat city IDPs camp (Shahrak Setar Pahlawan)


Pahlawan camp 249

Number of children 6-59 months

planned

Shaidayee camp 200


Pahlawan camp 200

Number of children 6-59 months

surveyed

Shaidayee camp 615


Pahlawan camp 515

Boys Girls Total Ratio

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

6-17 55 53.9 47 46.1 102 16.6 1.2

18-29 92 50.5 90 49.5 182 29.6 1.0

30-41 77 53.8 66 46.2 143 23.3 1.2

42-53 55 48.2 59 51.8 114 18.5 0.9

54-59 48 64.9 26 35.1 74 12.0 1.8

Total 327 53.2 288 46.8 615 100.0 1.1

Boys Girls Total Ratio

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

6-17 72 52.9 64 47.1 136 26.4 1.1

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

Global acute malnutrition (GAM) WHZ is defined as <-2 z scores weight-for-height and/or oedema

while severe acute malnutrition is defined as <-3z scores weight-for height and/or oedema.

The prevalence of GAM and SAM in the IDP camps are presented in Tables 5-4 and 5-5. Prevalence

of GAM in Shaidayee was 8.7% (6.5–11.6 95% C.I.), whereas SAM was 1.6% (0.9-3.1 95% C.I.). GAM

prevalence in Shahrak sabz & Shahrak Setar Pahlawan) was 7.1% (4.9-10.3 95% C.I.), and SAM was

found to be 1.0% (0.4-2.2 95% C.I.). No oedema case was observed during the assessment in both

camps.

In the final analysis, 18 children (7 in Shaidayee & 11 in Shahrak sabz & Shahrak Setar Pahlawan) were

excluded due to out of range values using observed means SMART flags (-3 to 3 Z-score).

Table 5 4: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)

and by sex

Status

Shaidayee camp

All n = 608

Boys n = 323

Girls n = 285

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

(53) 8.7 % (6.5 - 11.6 95% C.I.)

(33) 10.2 % (7.1 - 14.4 95% C.I.)

(20) 7.0 % (4.2 - 11.6 95% C.I.)

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

(43) 7.1 % (5.0 - 10.0 95% C.I.)

(24) 7.4 % (4.7 - 11.6 95% C.I.)

(19) 6.7 % (3.9 - 11.1 95% C.I.)

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

(10) 1.6 % (0.9 - 3.1 95% C.I.)

(9) 2.8 % (1.4 - 5.4 95% C.I.)

(1) 0.4 % (0.0 - 2.8 95% C.I.)

The survey did not find any cases of Oedema in both Camps. Table 5 5: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex

Status

Shahrak Sabz & Shahra kSatar Pawlawan camp

All n = 504

Boys n = 250

Girls n = 254

18-29 62 44.3 78 55.7 140 27.2 0.8

30-41 51 45.5 61 54.5 112 21.7 0.8

42-53 45 54.2 38 45.8 83 16.1 1.2

54-59 26 59.1 18 40.9 44 8.5 1.4

Total 256 49.7 259 50.3 515 100.0 1.0

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

(36) 7.1 % (4.9 - 10.3 95% C.I.)

(22) 8.8 % (5.5 - 13.8 95% C.I.)

(14) 5.5 % (3.1 - 9.7 95% C.I.)

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

(31) 6.2 % (4.1 - 9.1 95% C.I.)

(18) 7.2 % (4.3 - 11.9 95% C.I.)

(13) 5.1 % (2.7 - 9.4 95% C.I.)

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

(5) 1.0 % (0.4 - 2.2 95% C.I.)

(4) 1.6 % (0.6 - 3.9 95% C.I.)

(1) 0.4 % (0.0 - 3.1 95% C.I.)

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

Age disaggregated results are shown the younger children ( 6-29 months) were more affected than

older children, for more details refer to table 5-6 & 5-7.

Table 5 6: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, Shaidayee camp

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 99 6 6.1 20 20.2 73 73.7 0 0.0 18-29 181 2 1.1 11 6.1 168 92.8 0 0.0 30-41 140 2 1.4 6 4.3 132 94.3 0 0.0

42-53 114 0 0.0 3 2.6 111 97.4 0 0.0 54-59 74 0 0.0 3 4.1 71 95.9 0 0.0

Total 608 10 1.6 43 7.1 555 91.3 0 0.0 Table 5 7: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, Shahrak Sabz & Shahrak Satar Pahlawan camps

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. % 6-17 130 4 3.1 14 10.8 112 86.2 0 0.0

18-29 137 0 0.0 5 3.6 132 96.4 0 0.0 30-41 111 1 0.9 6 5.4 104 93.7 0 0.0 42-53 82 0 0.0 6 7.3 76 92.7 0 0.0 54-59 44 0 0.0 0 0.0 44 100.0 0 0.0 Total 504 5 1.0 31 6.2 468 92.9 0 0.0

Table 5 8: Distribution of acute malnutrition and oedema based on weight-for-height z-scores.

Shaidayee camp

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

Oedema present Marasmic kwashiorkor

No. 0 (0.0 %)

Kwashiorkor No. 0

(0.0 %)

Oedema absent Marasmic

No. 15 (2.4 %)

Not severely malnourished No. 600 (97.6 %)

Table 5 9: Distribution of acute malnutrition and oedema based on weight-for-height z-scores. Shahrak Sabz & Shahra kSatar Pawlawan camp

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

Oedema present Marasmic kwashiorkor

No. 0 (0.0 %)

Kwashiorkor No. 0

(0.0 %)

Oedema absent Marasmic

No. 13 (2.5 %)

Not severely malnourished No. 502 (97.5 %)

4.2.4. 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 Shaidayee

camp was 5.2% (3.3-8.1 95% C.I.) and of severe acute malnutrition (MUAC <115mm and/or oedema)

was 1.0% (0.5-2.0 95% C.I.). In Shahrak sabz & Shahrak Satar Pahlawan camp the GAM prevalence

based on MUAC was 5.6% (3.2-9.8 95% C.I.), and the SAM prevalence was found to be 0.8% (0.3-2.0

95% C.I.). Detailed results are presented in tables 5-10 and 5-11.

Table 5 10: Prevalence of acute malnutrition based on MUAC cut offs (and/or oedema) and by sex. Shaidayee camp

All n = 615

Boys n = 327

Girls n = 288

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

(32) 5.2 % (3.3 - 8.1 95%

C.I.)

(16) 4.9 % (2.7 - 8.7 95% C.I.)

(16) 5.6 % (2.7 - 11.0 95% C.I.)

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

(26) 4.2 % (2.6 - 6.9 95%

C.I.)

(14) 4.3 % (2.2 - 8.2 95% C.I.)

(12) 4.2 % (1.9 - 9.0 95% C.I.)

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

(6) 1.0 % (0.5 - 2.0 95%

C.I.)

(2) 0.6 % (0.1 - 2.6 95% C.I.)

(4) 1.4 % (0.6 - 3.4 95% C.I.)

Table 5 11: Prevalence of acute malnutrition based on MUAC cut offs (and/or oedema) and by sex. Shahrak Sabz & Shahra kSatar Pawlawan camp

All n = 515

Boys n = 256

Girls n = 259

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

(29) 5.6 % (3.2 - 9.8 95% C.I.)

(11) 4.3 % (2.3 - 7.9 95% C.I.)

(18) 6.9 % (3.8 - 12.4 95% C.I.)

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

(25) 4.9 % (2.7 - 8.5 95% C.I.)

(10) 3.9 % (2.2 - 6.7 95% C.I.)

(15) 5.8 % (2.9 - 11.2 95% C.I.)

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

(4) 0.8 % (0.3 - 2.0 95% C.I.)

(1) 0.4 % (0.1 - 2.9 95% C.I.)

(3) 1.2 % (0.4 - 3.7 95% C.I.)

According to table, 5-12 & 5-13, younger children 6-29 months were more malnourished by MUAC

than older children above 2 years of age. This is perhaps indicative of suboptimal feeding practices of

children below 2 years.

Table 5 12: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, Shaidayee camp

Severe wasting

(< 115 mm)

Moderate wasting

(>= 115 mm and < 125 mm)

Normal (> = 125 mm )

Oedema


6-17 102 5 4.9 19 18.6 78 76.5 0 0.0 18-29 182 1 0.5 5 2.7 176 96.7 0 0.0 30-41 143 0 0.0 2 1.4 141 98.6 0 0.0 42-53 114 0 0.0 0 0.0 114 100.0 0 0.0 54-59 74 0 0.0 0 0.0 74 100.0 0 0.0 Total 615 6 1.0 26 4.2 583 94.8 0 0.0

Table 5 13: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, Shahrak Sabz & Shahrak Satar Pahlawan camp

Severe wasting

(< 115 mm)

Moderate wasting

(>= 115 mm and < 125 mm)

Normal (> = 125 mm )

Oedema


6-17 136 4 2.9 14 10.3 118 86.8 0 0.0 18-29 140 0 0.0 7 5.0 133 95.0 0 0.0 30-41 112 0 0.0 2 1.8 110 98.2 0 0.0 42-53 83 0 0.0 2 2.4 81 97.6 0 0.0 54-59 44 0 0.0 0 0.0 44 100.0 0 0.0 Total 515 4 0.8 25 4.9 486 94.4 0 0.0

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

The prevalence of combined GAM among children 6-59 months in Herat IPDs (Shaidayee camp was

10.9% (8.2-14.2 95% CI), Shahrak Sabz & Shahrak Satar Pahlawan camp was 10.5% (7.5-14.6 95% CI)

as presented in table 7 below. The prevalence of combined SAM among children 6-59 months were

in Shaidayee camp : 2.1% (1.3- 3.4 95% CI) ; in Shahrak Sabz & Shahrak Satar Pahlawan camp : 1.2%

(0.6- 2.4 95% CI). Although there is not globally established threshold for combined GAM and SAM,

further analysis done for the caseload calculation suggesting that combined GAM indicator captured

more acutely malnourished children.

Table 5 14: Prevalence of malnutrition based on both criteria (WHZ+MUAC) and by sex.

Shaidayee camp

All n = 608

Boys n = 323

Girls n = 285

Prevalence of global acute malnutrition ( MUAC<125mm+ WHZ<-2 SD)

(66) 10.9% (8.2-14.2 95% CI)

(38) 11.8% (8.4-16.2 95% CI)

(28) 9.8% (6.1-15.5 95% CI)

Prevalence of severe acute malnutrition ( MUAC<115mm+ WHZ<-3 SD)

(13) 2.1% (1.3- 3.4 95% CI)

( 9) 2.8% (1.4- 5.4 95% CI)

(4) 1.4% (0.6- 3.5 95% CI)

Table 5 15: Prevalence of malnutrition based on both criteria (WHZ+MUAC) and by sex.

Shahrk Sabz & Shaharak Satar pahlawan

All n = 504

Boys n = 250

Girls n = 254

Prevalence of global acute malnutrition ( MUAC<125mm+ WHZ<-2 SD)

(53) 10.5% (7.5-14.6 95% CI)

(27) 10.8% (7.6-15.2 95% CI)

(26) 10.2% ( 6.5-15.7 95% CI)

Prevalence of severe acute malnutrition ( MUAC<115mm+ WHZ<-3 SD)

(6) 1.2% (0.6- 2.4 95% CI)

(4) 1.6% (0.6- 3.9 95% CI)

(2) 0.8% (0.2- 3.2 95% CI)

4.3.1. 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 Shaidayee camp and Shahrak Sabz & Shahrak Satar Pahlawan camp

of Herat IDP camp were 20.4% (15.9-25.8 95% C.I) and 20.0% (13.9-28.0 95% C.I.), respectively as

indicated in table 5-16 and 5-17.

Table 5 16: Prevalence of underweight based on weight-for-age z-scores by sex., Herat IDP camps

Table 5 17: Prevalence of underweight based on weight-for-age z-scores by sex, Herat IDP camps

Shaidayee camp

All

n = 602 Boys

n = 318 Girls

n = 284

Prevalence of underweight (<-2 z-score) (123) 20.4 %

(15.9 - 25.8 95% C.I.)

(68) 21.4 % (15.8 - 28.3 95%

C.I.)

(55) 19.4 % (14.4 - 25.5 95%

C.I.)

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

(97) 16.1 % (12.5 - 20.5 95% C.I.)

(52) 16.4 % (11.8 - 22.2 95%

C.I.)

(45) 15.8 % (11.7 - 21.0 95%

C.I.)

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

(26) 4.3 % (2.9 - 6.4 95% C.I.)

(16) 5.0 % (3.4 - 7.5 95% C.I.)

(10) 3.5 % (1.7 - 7.1 95% C.I.)

Shahrk Sabz & Shaharak Satar pahlawan camp

All

n = 505 Boys

n = 251 Girls

n = 254

Prevalence of underweight (<-2 z-score) (101) 20.0 %

(13.9 - 28.0 95% C.I.)

(55) 21.9 % (15.5 - 30.0 95%

C.I.)

(46) 18.1 % (11.3 - 27.8 95%

C.I.)

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

(81) 16.0 % (11.4 - 22.2 95% C.I.)

(44) 17.5 % (12.4 - 24.2 95%

C.I.)

(37) 14.6 % (9.4 - 21.9 95%

C.I.)

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

(20) 4.0 % (2.0 - 7.8 95% C.I.)

(11) 4.4 % (2.1 - 8.8 95% C.I.)

(9) 3.5 % (1.3 - 9.0 95% C.I.)

4.3.2. 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 Herat IDPs camps were

35.9% (28.1-44.5 95% C.I.) in Shaidayee camp and 40.5% (29.3-51.5 95% C.I.) in Shahrak Sabz &

Shahrak Satar Pahlawan camp as indicated in tables 5-18 and 5-19.

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

Table 5 19: Prevalence of stunting based on height-for-age z-scores and by sex., Herat IDP camps

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

The overall score for the current Rapid SMART surveys was categorized as a good (12% for Shaidayee and 13% for Sharhak Sabz. Meanwhile the SD was in limited range (0.8-1.20) for more plausibility check see Annex 1 & 2)

Shaidayee Camp

All

n = 582 Boys

n = 307 Girls

n = 275

Prevalence of stunting (<-2 z-score)

(209) 35.9 % (28.1 - 44.5 95%

C.I.)

(114) 37.1 % (28.1 - 47.2 95%

C.I.)

(95) 34.5 % (27.1 - 42.9 95%

C.I.)

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

(124) 21.3 % (16.7 - 26.8 95%

C.I.)

(75) 24.4 % (18.2 - 32.0 95%

C.I.)

(49) 17.8 % (13.6 - 22.9 95%

C.I.)

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

(85) 14.6 % (10.4 - 20.2 95%

C.I.)

(39) 12.7 % (8.1 - 19.3 95% C.I.)

(46) 16.7 % (12.5 - 22.0 95%

C.I.)

Shahrk Sabz & Shaharak Satar pahlawan

All

n = 459 Boys

n = 229 Girls

n = 230

Prevalence of stunting (<-2 z-score)

(186) 40.5 % (30.5 - 51.5 95% C.I.)

(93) 40.6 % (29.3 - 53.1 95% C.I.)

(93) 40.4 % (29.9 - 51.9

95% C.I.)

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

(92) 20.0 % (14.8 - 26.6 95% C.I.)

(48) 21.0 % (13.5 - 31.1 95% C.I.)

(44) 19.1 % (14.2 - 25.3

95% C.I.)

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

(94) 20.5 % (14.4 - 28.3 95% C.I.)

(45) 19.7 % (12.9 - 28.7 95% C.I.)

(49) 21.3 % (14.6 - 30.0

95% C.I.)

Table 5-20 and 5-21 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 4.03 and 5.08 respectively, for HAZ for both IDPs, the sample population showed

some degree of heterogeneity for chronic malnutrition for more information refer to Annex 1 and 2

plausibility check.

Table 5 20: Mean z-scores, design effect and excluded subjects, Shaidayee camp Indicator N Mean z-

scores ± SD Design Effect (z-score < -2)

z-scores not available*

z-scores out of range

Weight-for-Height 608 -0.39±1.11 1.14 0 7

Weight-for-Age 602 -1.04±1.10 2.12 0 13

Height-for-Age 582 -1.49±1.35 4.03 0 33 * contains for WHZ and WAZ the children with edema.

Table 5 21: Mean z-scores, design effect and excluded subjects, Shahrak Sabz & Shahrak Satar Pahlawan camp Indicator N Mean z-scores ±

SD Design Effect (z-

score < -2) z-scores not

available* z-scores out of

range

Weight-for-Height 504 -0.31±1.14 1.23 0 11

Weight-for-Age 505 -1.04±1.13 3.68 0 10

Height-for-Age 459 -1.64±1.43 5.08 0 56

* contains for WHZ and WAZ the children with oedema

4.4. Child morbidity

High prevalence of diarrhea was recorded in both Shaidayee and Shahrak Sabz & Shahrak Satar

Pahlawan camps of Herat (Table 5-22 and 5-23). Nearly one out of two surveyed children were

reported as suffering from diarrhea in the past two weeks prior to the assessment.

Table 5 22: Morbidity among children 6-59 months, Herat IDP camps

Table 5 23: Morbidity among children 6-59 months, Herat IDP camps

Shaidayee camp

(N=615)

n %

Diarrhea 6-59 months, two weeks recall 276 44.9%

Shahrak Sabz & Shahrak Satar Pahlawan camp

(N=515)

N %

4.5. Maternal nutritional status

The nutritional status of pregnant and lactating women was analyzed by MUAC. From the survey

findings, 25.1% and 24.2% of women were found to be acutely malnourished in Shaidayee and in

Shahrak Sabz & Satar Pahlawan camps, respectively as indicated in table 5-24 and 5-25.

Table 5 24: Maternal nutritional status based on MUAC cut-off points for PLW, Herat IDP camps.

Table 5 25: Maternal nutritional status based on MUAC cut-off points for PLW, Herat IDP camps.

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

The number of children enrolled in the nearby OPD-SAM program was only 8.8 % and 9.1% in

Shaidayee and Shahrak Sabz & Shahrak Satar Pahlawan camps, respectively. Overall, of children

identified as acutely malnourished by the survey teams only 32.4% in Shaidayee and 42.4% in Shahrak

Sabz & Shahrak Satar Pahlawan camp were enrolled in a program at the time of survey (Table 5-26).

The low coverage of nutrition services is seen as a gap in response needs in the camps. All acutely

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

health center with OPD-SAM and OPD-MAM program. Some of the teams could not use the WHZ -

score chart properly in the field and missed passive screening.

Diarrhea 6-59 months, two weeks recall

249 48.3%

Shaidayee IDPs camp (N=223)

n %

Global Acute Malnutrition (GAM) MUAC < 230 mm

56 25.1%

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

53 23.8 %

Severe Acute Malnutrition (SAM) MUAC < 185 mm

3 1.3%

Shahrak Sabz & Satar Pahlawan IDPs camp

(N=227)

N %

Global Acute Malnutrition (GAM) MUAC < 230 mm

55 24.2%

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

53 23.3%

Severe Acute Malnutrition (SAM) MUAC < 185 mm

2 0.9%

Table 5 26: 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=34) in Shaidayee camp

(3) 8.8% (8) 23.5% (0) 0.0% (23) 67.6%

Acutely malnourished children 6-59 months by WHZ, MUAC, or oedema (N=33) in Shahrak Sabz & Shahrak Satar Pahlawan

camp

(3) 9.1% (11) 33.3% (0) 0.0% (19)57.6%

5. DISCUSION

The GAM prevalence based on weight-for-height <-2 z-scores was classified as medium level of

severity for both IDPS, {Shaidayee camp was at 8.7% (6.5-11.6 95% CI), Shaharak Sabz & Shahrak

Satar Pahlawan was at 7.1% (4.9-10.3 95% CI)}, according to UNICEF-WHO severity classification.

If MUAC and WHZ criteria are combined, the overall prevalence of children likely to be eligible for

SAM and MAM management in the camps were Shaidayee 10.9% (8.2-14.2 95% CI), Shahrak Sabz &

Shahrak Satar Pahlawan 10.5% (7.5-14.6 95% CI. Combined WHZ (<-3 z-score) and MUAC (<115 mm)

illustrates that SAM prevalence was at (Shaidayee 2.1% (1.3- 3.4 95% CI), Shahrak Sabz & Shahrak

Satar Pahlawan 1.2% (0.6- 2.4 95% CI). This suggests a high 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

acutely malnourished children 6-59 months, and may inform better the estimation of SAM and MAM

caseloads in the camp, ultimately, strengthening planning and programming.

Figure 1: GAM children captured by WHZ, MUAC and combined

By considering the combined GAM rate, it is estimated that 3,308 children are acutely malnourished

in the Shaidayee camp as today (out of 175,440 population with combined GAM rate 10.9%), and

1,876 children acutely malnourished in the Shahrak Sabz & Shahrak Satar Pahlawan camp as today (

out of 103,292 population, with combined GAM 10.5%), with 17.3% under-five population estimation.

Stunting prevalence was at (35.9% (28.1-44.5 95% CI) in Shaidayee camp and 40.5% (30.5-51.5 95%

CI) in Shahrak Sabz & Shahrak Satar Pahlawan camp. High stunting levels are usually seen in contexts

with very low access to health services, low sanitation levels and low maternal nutritional status,

High stunting rates are in line with the compromised nutritional status of women in childbearing age

(15-49 years). From the survey findings it shows pregnant and lactating women (PLWs) malnutrition

status was at 25.1% in Shaidayee % and was at 24.2% in Shahrak Sabz & Shahrak Satar Pahlawan

based on MUAC < 230 mm.

From the direct observation of the Rapid SMART survey teams shows that the poor awareness about

the available health and nutrition services, weak Health Education and weak awareness of use of safe

drinking water soureces were the biggest limitations during the survey period. The proportion of

children (6-59 months) reported having diarrhea based on two-week recall period was very high for

both camps : Shaidayee 44.9 %, Shahrak Sabz & Shahrak Satar Pahlawan 48.3%/ It means that 1 in 2

children are reported to be suffering from diarrhea. The burden of diseases among under-five increases

the SAM and MAM caseloads, as disease is an immediate cause to under-nutrition.

10.9%

8.7%

5.2%

11%

7.1%

5.6%

GAM COMBINED

GAM ONLY WHZ

GAM ONLY MUAC

GAM COMBINED

GAM ONLY WHZ

GAM ONLY MUAC

Shahrak Sabz & Shahrak Satar Palwan camp

Shaidayee camp

21

6. RECOMMENDATIONS

Increasing IHNMT numbers in the camps; as per the SMART technical team observations

from the IDP camps, it is recommended to keep the number of existing integrated health

and nutrition mobile “IHNMT teams in the area.

Expending active case finding in the camps; during the assessments in Shaidayee, Shahrak

Sabz and Satar Pahlawan Camps, 67 active SAM cases were recorded, out of them 32 cases

were not admitted in the program, which shows low nutrition program coverage in the

camps. So, it is highly recommended to conduct an exhaustive Active-Adaptive case finding

in the targeted area to have most of the malnourished children in the program.

Expanding TSFP Program, PLW malnutrition in both Rapid SMART assessments was 24.5

%, which indicate an inadequate nutrition status of current pregnant and lactating women

To improve the situation and to get rid of the PLW malnutrition, it is needed to expand the

existing TSFP program in the camps and to make the services available for all malnourished

children and PLWs.

Launching food demonstration program in the IDPs community to increase knowledge of

women on proper using of nutritious locally available foods to prevent the maternal

nutrition .

Advocacy for health program and enhancing Health Education; Poor awareness about the

available health and nutrition services and weak Health Education were the biggest

limitations during the assessment, to make the program implementation smooth and to

make the existing services accessible for all people conducting public awareness, personal

& environmental hygiene and health education sessions are needed and highly

recommended.

Provide WASH community mobilization to increase access to safe drinking water and

hygiene to decrease the high burden of diarrhea.

21

7. ANNEXES

Annex 1: Plausibility check for: Herat_IDP camps ( Shaidayee) _April_2019_Afghanistan.as Standard/Reference used for z-score calculation: WHO standards 2006 (If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility report are more for advanced users and can be skipped for a standard evaluation) 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 (1.1 %) Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.116) Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.908) Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (5) Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 4 (17) Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (11) 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 5 (1.11) Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 1 (-0.28) Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.11) Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.214) OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 12 % The overall score of this survey is 12 %, this is good. Annex 2: Plausibility check for: Herat_IDP_camps ( HSharak Sabz) _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 (2.4 %) Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.895) Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 4 (p=0.001) Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (5) Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (11) Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (10)

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 5 (1.13) Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.05) Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.04) Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.185) OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 13 % The overall score of this survey is 13 %, this is good

Annex 3: Selected clusters Herat IDPs Shaidayee camp

Enumerations area Total Population Cluster Number

Street 1: Chief /Malik 01 8000 1,2

Street 1: Chief /Malik 02 6300 3


Street 3:Chief /Malik 01 8400 5

Street 3:Chief /Malik 02 9800 6,7


Street 4:Chief /Malik 02 4200










Street 6:Chief /Malik 02 3920 RC

















Annex 4: Selected clusters Herat IDPs Shahrak Sabz & Shahrak Satar Pahlawan

Shaharak Sabz 1:Chief /Malik 01 18011 1,2,RC,3,4

Shaharak Sabz 2:Chief /Malik 01 3388

Regristion :Chief /Malik 01 5173 5,6

Shaharak Satar Palawan :Chief /Malik 03 3500 7

Shaharak Satar Palawan:Chief /Malik 04 5600 8

Shaharak Satar Palawan :Chief /Malik 05 6300 9,10

Shaharak Satar Palawan :Chief /Malik 06 2800 RC

Shaharak Satar Palawan: Chief /Malik 07 3500 11




Shaharak Satar Palawan :Chief /Malik 11 2800 RC



Sofi Qudos :Chief /Malik 01 5600 17,18

Sofi Qudos :Chief /Malik 02 4900 19


Sofi Qudos :Chief /Malik 04 4550 21,22




Annex 5. Herat IDPs camps field Map.

25

3

161,140

Street 1

باغ وحش

End of IDPs

Street 2

Resurved Clusters

Total IDPs Households

Stre

et 6

Stre

et 7

Stre

et 8

Herat Rapid SMARTs Field Plan

ShahrakSabz 1 Shahrkasabz2 Regration

This area will be covered by first Rapid SMART

This area will be covered by Second Rapid SMART

Health and Nutrition Team

Total Clusters

Stre

et 1

Stre

et 2

Pediatric Hopstial

Prot

ecte

d ID

PS

Stre

et 5

Stre

eet 3

Stre

et 4

Shah

rak

Sabz

Str

eet

Shai

daye

Gar

den

Police Check

Point

Canal West

North

East

South Sofi Qodus Garden

Herat Karokh Highway

Sata

r Pah

law

an S

hahr

ak

Behind of Sofi Qodus Garden

RNA2

Total Clusters 25

Reserve Clusters 3Total IDPs Population 103,292

RNA1

Annex 6: 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 6-59 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 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

1=yes

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 (6-59 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)

Annex 7: Event calendar

اسم ماه ماه 1393 ماه 1394 ماه 1395 ماه 1396 ماه 1397 ماه 1398

حمل

شروع مکاتب. چهار شنبه اول

سال . 13 بدر. گل های الله . وقت

کاهوها . زاده ولد گسفندها .

سماروق . روز نوروز وقت

سیالبها . گل دختر

49


سال . 13 بدر. گل های الله .

وقت کاهوها . زاده ولد گسفندها

. سماروق . روز نوروز وقت


37






25






13






1






فصل کاهو. 8 ثور. پیروزی

مجاهدین. فصل میوه هایی

نارسیده . وقت غوره

اخکوک.رواشک و نیش زدن

تاریاک





تاریاک





تاریاک





تاریاک





تاریاک

شروع درو گندم ابی . کندن کرابیه

. پیله ابریشم . پخته شدن زردالو .

14 جوزا روز مادر . وقت پشها .

وقت جوجها . پخته شدن زردالو.

کشت زعفران. سیب شکره . وقت

خوشه زدن. رمضان

شروع درو گندم ابی . کندن

کرابیه . پیله ابریشم . پخته شدن

زردالو . 14 جوزا روز مادر .

وقت پشها . وقت جوجها . پخته

شدن زردالو. کشت زعفران.

سیب شکره . وقت خوشه زدن.

رمضان







رمضان







رمضان







رمضان

سرطان 58

باد 120 روزه. کندم درو. وقت

میوه های تابستانی ) انگور و

شفتالو( رخضتی چهار نیم ماه .

کشت شالی.

46




کشت شالی.

34




کشت شالی.

22




کشت شالی.

10




کشت شالی.

اسد 57

وسط بادها 120 روزه . 28 اسد )

ازادی اقغانستان ( امدن مالدارها

به قریه . وقت جمعه واری ماش

مشنگ کنجت

45

وسط بادها 120 روزه . 28 اسد

) ازادی اقغانستان ( امدن

مالدارها به قریه . وقت جمعه

واری ماش مشنگ کنجت

33





21





9





سنبله 56

وقت جمع واری پسته . جمع

واری تخم زاعفران . شروع فراه

باد . وقت زخیره ایزوم

44




32




20




8




میزان 55برگ ریزی یا خزان . کشت تیرماه

. جمعه واری علوفه . وفت انار .43

برگ ریزی یا خزان . کشت

تیرماه . جمعه واری علوفه .

وفت انار .

31



وفت انار .

19



وفت انار .

7



وفت انار .

بعقر 54

جشن گل زعفران . اماده نمودن

الندی . وقت چهار مغز42








الندی . وقت چهار مغز

شروع بادخزانی. گذاشتن بهاری و

کرسی . شروع امتحان هایی

مکاتب .

شروع بادخزانی. گذاشتن بهاری

و کرسی . شروع امتحان هایی

مکاتب .



مکاتب .



مکاتب .



مکاتب .

یجد 52

6 جدی . چله کالن . سر زمستان .

شب یالدا . وقت الندی ها وقت

اماد کردن غذاهایی محلی . ساه

باد .

40

6 جدی . چله کالن . سر زمستان

. شب یالدا . وقت الندی ها وقت


باد .

28




باد .

16




باد .

4




باد .

دلوه 51برف باری . چله خورد. جنگ چله

ها.39

برف باری . چله خورد. جنگ

چله ها.27


چله ها.15


چله ها.3


چله ها.

تحو 50

امادگی نوروز. 24) قیام مردم

هرات ( کشت پالیزها . کشت گندم .

کوچ کردن کوچیها. پتک .

مندوالق. مخ و فت . امن بمن

38


هرات ( کشت پالیزها . کشت گندم

. کوچ کردن کوچیها. پتک .


26





14





2





ثورجوزا 3559

سقو 529 1754

122436

41

48

47 1123

Documents

Rapid SMART Assessment Report Herat IDPs Camps, Herat … · 2020. 4. 30. · Executive summary In April 2019, Action Against Hunger (AAH) in collaborations with the Ministry of Public