Nutrition Anthropometric and Mortality Survey Among Internally Displaced Populations in Erbil and Sulaimaniyah Governorates – Kurdistan Region of Iraq

Ministry of Health / Kurdistan Region of Iraq

Nutrition Anthropometric and Mortality Survey among Internally Displaced Populations in Erbil and Sulaimaniyah Governorates – Kurdistan Region of Iraq

(November 2014)

November 2014 I

Acknowledgements

The Departments of nutrition of Directorate of health in Erbil and Sulaimaniyah would like to take the opportunity to acknowledge the efforts of individuals and organizations involved in the successful implementation of this survey.

We would like to acknowledge UNICEF Regional and Country Office for the financial and technical support for conducting this survey as part of the strong collaboration and partnership with the Kurdistan Ministry of health.

We are deeply appreciative for the helpful contributions of various individuals and organizations on the design of the survey, its implementation, data analysis and report review.

Special appreciations are expressed to survey team (supervisors, team leaders, enumerators, and drivers) for their tireless efforts to ensure that the survey was conducted professionally and on time. A special thanks to mothers caregivers and the whole community for the voluntary participation in this survey and response to the interviewers.

Table of contents Table of Contents Acknowledgements ...... 2

...... 2 Table of contents ...... 3 List of Tables and Figures ...... 4 Acronyms and abbreviations ...... 5 Executive Summary ...... 6 The CMR in Erbil was 0.09 death (0.02 – 0.39; 95% CI) per 10,000 people per day while it is 0.0 death per 10,000 children per day. The situation is the same in Sulaimaniyah. According to the Sphere project, the CMR and U5MR emergency thresholds are 0.3 and 0.5 respectively for Middle East countries. These figures demonstrate that the level of malnutrition is in within the acceptable range in both provinces...... 7 I. Introduction ...... 8 1.1. Survey Objectives ...... 9 II. Methodology ...... 9 2.1. Survey area ...... 9 2.2. Sample size ...... 10 2.3. Sampling procedure: selecting clusters, households and children ...... 10 2.4. Inclusion criteria and case definitions ...... 11 2.5. Training and supervision ...... 12 3

2.6. Data collection ...... 13 2.7. Data analysis ...... 14 III. Results ...... 14 3.1. Anthropometric results (based on WHO standards 2006): ...... 14 Anthropometric data were collected among 678 children in Erbil and 665 in Sulaimaniyah. Among these, 17 children (10 from Erbil and 7 from Sulaimaniyah) were excluded in the analysis as the one or more of the measurements (weight, height or age) were out of range...... 14 a) Prevalence of Global Acute Malnutrition (GAM); wasting ...... 16 b) Prevalence of underweight ...... 18 c) Prevalence of chronic malnutrition (Stunting) ...... 20 d) Prevalence of overweight based on WHZ ...... 21 3.2. Retrospective mortality results ...... 22 3.3. Households socio-economic characteristics ...... 22 3.4. Infant and young child feeding practices ...... 23 3.5. Vitamin A supplementation and immunization ...... 24 3.6. Prevalence of child morbidity ...... 25 3.7. Household food Security ...... 25 3.8. Water access and hygiene ...... 26 IV. Discussion ...... 26 V. Conclusions ...... 28 VI. Recommendations ...... 28 VII. References ...... 29 VIII-Annexes ...... 31 Annex 1: Calendar of events ...... 31 Annex 2: Plausibility Report ...... 32 Annex 3: Standardization test ...... 59 Annex 4: Assignment of clusters ...... 64

List of Tables and Figures Table 1: The sample size calculation parameters ...... 10 Table 2: Anthropometric and mortality indicators definition ...... 11 Table 3-a: Distribution of age and sex of sample in Erbil ...... 15 Table 4: Household food security ...... 25 Table 55: Access to safe water and household hygiene ...... 26

Figure 1-a: Distribution of the sample (678 children) within the target districts in Erbil ...... 14

Acronyms and abbreviations ARI Acute Respiratory Infection BMS Breastmilk Substitutes C4D Communication for Development CI Confidence Interval CMAM Community Management of Acute Malnutrition CMR Crude Mortality Rate DoH Directorate of Health DTM Displacement Tracking Matrix ENA Emergency Nutrition Assessment EPI Extended Program on Immunization GAM Global Acute Malnutrition HAZ Height-for-Age Z score IDP Internally Displaced Population IMCI Integrated Management of Childhood Diseases IOM International Organization for Migration IYCF infant and Young Child feeding Practices KRI Kurdistan Region of Iraq MAM Moderate Acute Malnutrition MICS Multiple Indicator Cluster Survey MUAC Mid Upper Arm Circumference

SAM Severe Acute Malnutrition SD Standard Deviation SMART Standardized Monitoring of Relief and Transitions SPSS Statistical Package for Social Sciences U5MR under five Mortality Rate UNICEF United Nations Children's Fund WASH Water Sanitation and Hygiene WAZ Weigh-for-Age Zscore WHO World Health Organization WHZ Weight-for-height Zscore

Executive Summary

The Departments of nutrition of Erbil and Sulaimaniyah - Directorate of preventive health affairs in collaboration with UNICEF carried out a nutrition survey in the districts of Erbil,Shaqlawa ,Barzan and Koya in Erbil province and in the districts of Sulaimaniyah , Dukan ,Chamchamal, Darbandikhan ,Kalar and Kefri in Sulaimaniyah province. This assessment was undertaken to increase the understanding of the nutrition situation among the Internally Displaced Population (IDPs) settled in the target districts. It also serves as baseline to gather key information that support the implementation of evidence-based interventions to tackle the contributing factors to malnutrition (triple burden of under nutrition, micronutrient deficiencies and overweight).

The proposed sampling methodology was a two-stage cluster randomized sampling with probability proportional to the size of the population. The Emergency Nutrition Assessment (ENA) software for Standardized Monitoring of Relief and Transitions (SMART) version (August 4 th, 2014) was used to calculate the required sample size. The first level of sampling identified IDPs locations (schools, unfinished buildings, camps, community centres, etc.) that were included in this survey while the second stage sampling selected households using the list of households available in each location. The data collection took 7 days in each province from November 8-14 and involved 43 trained enumerators and 8 supervisors. Four districts and over 30 IDPs locations in Erbil province and six districts and over 30 IDPs locations in Sulaimaniyah were visited. In addition to the anthropometric measurements taken from each child 6 – 59 months of age, information related to household socioeconomic characteristics, vitamin A and Measles coverage, infant and young child feeding practices, child morbidity, household food security and access to water and

sanitation were also collected. The crude mortality rate and under five mortality rate were also measured.

Overall, 678 children and 451 households in Erbil and 665children and 414 households in Sulaimaniyah were surveyed. The findings reveal that the majority of respondents (97.8%) in Erbil and (97.3%) in Sulaimaniyah were married (16.0%) and 26.3% subsequently were illiterate. The proportion of unemployed among mothers reached 91.1% in Erbil and 96.6% in Sulaimaniyah. The average number of household members is 5.21 in both provinces while the mean age of the respondents in Erbil was 29.33 year-old and in Sulaimaniyah was 29.55 year-old. Anthropometric data were analysed using WHO child growth reference and the prevalence of wasting, underweight and stunting was 0.6 % (0.2 - 1.5), 2.1% (1.2 - 3.5) and 5.7% (3.9 - 8.3) in Erbil and 0.9 % (0.4 - 2.2), 3.7% (2.2 - 5.9) and 12.2% (8.5 - 17.2) in Sulaimaniyah respectively. The prevalence of stunting does not show any significant difference between boys and girls in the two provinces but the rate is much higher in Sulaimaniyah than Erbil province. Similarly, the prevalence is also higher among girls in Erbil than Sulaimaniyah. Overall, the nutritional figures are better than the MICS4 results and are classified as “acceptable” based on WHO nutrition crisis categorization. Overweight assessed using weight for height above two standard deviation of the reference population was at6.7% (4.9 - 9.1) in Erbil and 3.6% (2.3 - 5.7) in Sulaimaniyah among the target groups. The CMR in Erbil was 0.09 death (0.02 – 0.39; 95% CI) per 10,000 people per day while it is 0.0 death per 10,000 children per day. The situation is the same in Sulaimaniyah. According to the Sphere project, the CMR and U5MR emergency thresholds are 0.3 and 0.5 respectively for Middle East countries. These figures demonstrate that the level of malnutrition is in within the acceptable range in both provinces.

The investigation on child feeding practices in Erbil indicated that over 278 children out of 451 were not exclusively breastfed (61.6%), among 291 children who were not breastfed during the survey, 26.7% never did so while in Sulaimaniyah over 308 children out of 414 were not exclusively breastfed (74.4%), among 300 children who were not breastfed during the survey, 20.6% never did so. Vitamin A supplementation coverage was at 23% in Erbil and 24.6% in Sulaimaniyah and target only children 9 – 59 months. Proportion of women who lost or misplaced the vaccination was high (56.6%) in Erbil and (53.1%) in Sulaimaniyah showing a need to improve sensitization activities on safe keeping of vaccination card and follow up on vaccination calendar. Approximately (61.1%) of the children in Erbil and (53.3%) in Sulaimaniyah were not immunized against Measles.

Up to twenty three percent children in Erbil and 21.7% in Sulaimaniyah had at least one episode of diarrhoea in the last fifteen days. ARI was dramatically high in this community and affected at least more than half of the sampled children.

Out of 451 respondents, 306 (76.8%) in Erbil and out of 414 respondents in Sulaimaniyah, 255 (61.6%) reported having food shortage in the last six weeks. However, over 57.9% in Erbil and 49.3% in Sulaimaniyah have indicated receiving food aid in the same period. Up to 98% of households reported access to safe drinking water in both provinces and the main sources are household/institution connections and tap water. Overall, in Erbil 93.1% of sampled households use flush latrines and30.7% improved latrines with slab while in Sulaimaniyah, 65.7% of sampled households use flush latrines and 30.7% improved latrines with slab. However, a high proportion of households were still sharing toilets.

This survey shows that the nutrition situation, as measured by the prevalence of acute malnutrition, underweight, stunting and overweight is not alarming. However, the caseload should raise concerns due to the high number of internally displaced population settled in both provinces. Besides, the inappropriate child feeding practices, high prevalence of ARI, diarrhoea, hygiene issue related to sharing toilets call for immediate actions to address the underlying causes of malnutrition to prevent further deterioration of the nutrition situation through the capacity building, technical assistance and provision of supply and medicines. Community based screening and breastfeeding counselling should be implemented and scaled up. The underlying causes of under nutrition identified in this survey call for an integrated approach with Communication for Development, Health WASH and Nutrition to develop a multi-sectoral interventions.

I. Introduction

The internal armed conflict in Iraq has escalated since January and triggered the displacement of millions of Iraqis across the Country. From January through October 26, there were 1,898,844 identified displaced Iraqis among which 709,494 are settled in KRI (source: IOM Iraq Displacement Tracking Matrix, http://iomiraq.net/dtm-page). This situation contributes to worsen the already overburdened system due to high number of refugees who fled the Syrian conflict, 215,387 refugees as of 30/9/2014 (source: UNHCR Iraq RRP6 Health Dashboard September 2014). Attacks on essential public facilities such as hospitals and schools are frequent and the denial of access to basic services has been employed as a weapon. In order to provide the needed services including health and nutrition to the affected populations and host communities, the humanitarian actors in close collaboration with the government has been setting the provision of services in the settlement areas.

While humanitarian organizations and local authorities continue responding to the most immediate needs, there are serious concerns about the conditions of the displaced population. Provision of food, water and sanitation and health services is somehow challenging in some areas due the high burden and limited accessibility related to security. Even though the overall population is affected, those living outside the urban areas and at the boundaries of the disputed internal territories and Children and women in particular are among the most in need.

In order to reinforce its strategic response to the humanitarian needs, UNICEF in close collaboration with the Ministry of Health planned to carry out nutrition surveys in three Governorates of Kurdistan. The purpose of these surveys was to assess the nutrition situation of the IDPs and gathered additional indicators related to health , food security and wash among internally displaced populations.

The first survey was carried out in Dohuk in September-October 2014 and the second survery carried out in two provinces Erbil and Sualimanyha and cover districts of Erbil,Shaqlawa ,Barzan and Koya in Erbil province and districts of Sulaimaniyah , Dukan ,Chamchamal, Darbandikhan ,Kalar and Kefri in Sulaimaniyah province. In addition to 2014 influx of IDPs to both provinces. The population in both provinces had shown a dramatic change since the arrival of thousands of syrian refugees which was exacerbated by several vagues of IDPs mainly fron Salahaddin and Anbar provinces.

While humanitarian organizations and local authorities continue responding to the most immediate needs, no representative health and nutrition survey targeting IDPs was carried out so far. The present survey will serve as baseline information that will inform the current program and provide evidence based information supporting further assessment on the progress.

1.1. Survey Objectives The overall objective of the survey is to assess the nutritional situation, related indicators and retrospective mortality rate among IDPs settled in Erbil and Sulaimaniyah provinces

The Specific objectives are to estimate the: Magnitude of the under nutrition (wasting, underweight and stunting) and crude and under five mortality rate among the target IDPs Infant and Young Child Feeding practices among children 0 – 23 months Coverage of measles vaccination and Vitamin A supplementation among children Diarrhoea and ARI rates among children 6 – 59 months in the 2 weeks prior to the survey Food access and household food insecurity situation Proportion of households with access to safe water and sanitation

II. Methodology 2.1. Survey area The nutrition assessment was carried out from November 8-14 in the districts of Erbil,Shaqlawa ,Barzan and Koya in Erbil province and in the districts of Sulaimaniyah , Dukan ,Chamchamal, Darbandikhan ,Kalar and Kefri in Sulaimaniyah. Anthropometric measurements (weight, height, MUAC) was taken from a representative sample of children aged 6 – 59 months while mothers and caregivers of children under five were questioned as primary respondent about the child health/nutrition and household access to food and water.

2.2. Sample size The sampling methodology was a two-stage cluster randomized sampling with probability proportional to the size of the population. The Emergency Nutrition Assessment (ENA) software for Standardized Monitoring of Relief and Transitions (SMART) version (August 4th , 2014) was used to calculate the required sample size. The sample was calculated using the nutritional status (wasting) for children 6-59 months and the Crude Mortality Rate (CMR) for the household sample. The sampling plan is designed to provide representative 9

estimates in the all districts in both provinces as a whole (Province level). Estimates for both anthropometric and mortality indicators are presented in the Table 1 below.

Table 1: The sample size calculation parameters Estimates Malnutrition Mortality rate Estimated Prevalence/death rate per 10 000/day 7% 1 Desired Precision 3% 0.5 Design effect 2 2 Recall period 90 days Average household Size 6 6 % of Children Under five 16% % of non-response Households 3% 3% Children 605 3717 Total sample size Households 722 639 In order to get a representative sample size for each province, 30 clusters of at least 21 children each for a total 605 children 6-59 months from 722 households were needed for the anthropometric data while the mortality rate requires 3,717 individuals living in 639 households. Anthropometric measurement of all eligible children 6 -59 months were selected. In the last household, all eligible children were included in the anthropometric measurement whether or not we exceeded the required target number. The estimate of acute malnutrition of 7 % was used based on MICS4.

Based on the size of the questionnaire and the travel time from one site to another, it was estimated that each team would visit 11 households a day. Thus 7 teams of three surveyors in each province (enumerators and one team leader) for 7 days will be needed to complete the data collection.

2.3. Sampling procedure: selecting clusters, households and children The overall sampling universe was only IDPs settled in the districts of Erbil,Shaqlawa ,Barzan and Koya in Erbil province and in the districts of Sulaimaniyah , Dukan ,Chamchamal, Darbandikhan ,Kalar and Kefri in Sulaimaniyah province .The target population was estimated to 277,262 as of October among which an approximate 46,202 children 6 – 59 months. The first level of sampling identified IDPs locations (rented houses , collective towns, schools, unfinished buildings, camps, community centres, etc.) that were included in this survey. It is based on Directorate of health EPI database. This database provide the list of health facilities which cover the IDPs locations (catchment areas). Prior to the survey, DoH staff visited each selected health facility to collect the list of IDPs locations in which one was randomly selected. If the selected location does not have enough children, the team was instructed to proceed to the closest one to complete the required number of children to be surveyed (a minimum of 21 per cluster).

For the second stage sampling, households were selected using the list of households available in each location. As the IDPs were scaterred in different locations which were rented houses , collective towns ,unfinished buildings, camps, schools, community centres, etc., the selection procedure was adapted to the location itself based on the type of settings. For unfinished buildings, schools, community centres and similar location, the list of rooms were counted first and ranked. Based on the list, the first room with IDPs households were randomly selected. All IDPs living in the same rooms were surveyed whether or not they had an eligible child. The next room with the closest door was selected and all eligible children included. The same process was maintained on upon completion of the target 10

children for the cluster.. For camps collective towns and similar locations, the sample selection was based on the modified EPI randmon walk as recommended by SMART methodology. First the centre of the camp or collective town was identified with the support of the communitieslike Mokhatar. Once the centre of the camp is identified survey teams spinned a pen to randomly assign the direction towards the edge of the cluster then the team walks to the boundary of the site. From that end of the location, survey team counts the number of houses until they reached the other end of the location. Once all the houses in that direction are counted and assigned consecutive numbers, survey team select a random number to identify the starting household. Consecutive households were the one with the closest door until the required number of children was reached. All eligible children 6 – 59 months ifrom selected households ncluded in the antropometric measurement. If the last household had more than the required number of children to reach the needed sample, all eligible children were included whether or not we exceeded the required target number. While anthrometric measurments target only househoilds with eligible children, mortality questionnaire was administrated to every single household whether or not their is an eligible child.

2.4. Inclusion criteria and case definitions The inclusion criteria for anthropometric measurements was children 6 – 59 months and when the age is unknown a calendar of local events were used (see Annex 1). Households without target children (6 – 59 months) were also include for mortality, food security and WASH data. In order to be able to calculate anthropometric indicators (Table 2), the following meaurement was taken from each eligible child.

Weight: It was measured using a portable mother/child electronic scale, 150kg x 100g. All children were weighted without any clothes. If not feasible, the clothes were weighted right after taking the anthropometric measurement and the weight was subtracted from the child and clothes weight. Every morning, the accuracy of the scale was checked using a 5 kg weight and no discrepancy was found between measurements during the survey.

Height: it was determined using a measuring board (precision of 0.1cm). A cut-off point of 87cm was used to select children to whom height was measured lying down (length) or standing up (height). Children less than 87cm were measured lying down, while those greater than or equal to 87cm were measured standing up.

MUAC: It was measured at mid-point of the left upper arm of every single child. It has taken to the closest millimetre using the standard coloured measurement tape.

Oedema: Bilateral pitting oedema was assessed by applying a thumb pressure on top of each of the child’s feet simultaneously for a period of three seconds (enumerators were instructed to count 101, 102, 103) and thereafter observe for the presence or absence a pit which mean presence or absence of oedema. The age of each child was identified using the existing child administrative or health documents. When the dates are not known, a calendar of event was used to approximate the child age. If there is no possibility to use the calendar of event, only child with height 65 to 130 cm were included in the survey.

The additional information including both child related data and household was collected through a questionnaire divided in modules (see Annex 5).

Table 2: Anthropometric and mortality indicators definition

Indicators Definition Cut-off points Number of children 6-59m who fall below Normal: ≥ -2SD minus 2SD from the median Moderate: ≥ -3 & < -2SD and No WHZ (wasting) weight-for-height of WHO Growth oedema Standards Severe: < -3 SD Number of children 6-59m who fall below Normal: ≥ -2SD WAZ (Underweight) minus 2SD from the median weight-for-age Moderate: ≥ -3 & < -2SD of WHO Growth Standards Severe: < -3 SD Number of children 6-59m who fall below Normal: ≥ -2SD HAZ (Stunting) minus 2SD from the median height-for-age Moderate: ≥ -3 & < -2SD of WHO Growth Standards Severe: < -3 SD Normal: ≥ 125 mm Number of children 6-59m with a Mid-upper circumference Moderate: ≥ 115 & < 125mm MUAC value below 125mm Severe: < 115mm Number of children 6 -59m with Nutritional oedema bilateral pitting oedema (depression on Yes: If any both feet after 3 seconds of thumb pressure) Number of deaths within the overall Emergency: 0.3 death/10 000 Crude retrospective mortality surveyed population during recall period persons/day

Under five crude retrospective Number of deaths within under five Emergency: 0.5 death/10 000 mortality children during recall period U5/day The crude death rate and under five death rate as well as causes of death were collected and computed using SMART recommended form. The recall period was approximately 90 days and the reference date (starting point for the recall period) was day of Sinjar attack by ISIS which falls to 3rd of August.

2.5. Training and supervision Prior to field work, three days training of enumerators (43) and supervisors (8) took place in Raparin paediatric hospital I Erbil in order to ensure accuracy and precision of collected data. The training covered an introduction to nutrition assessments, the survey objectives, anthropometric measurements, the household selection procedures, data collection and interviewing approach. The survey questionnaire was reviewed to ensure a common understanding of each question. Following the discussions with the team and Directorate of health focal person, the questionnaire was not translated into local languages.

With regard to the anthropometric measurement, each team comprising of two enumerators and one team leader went through a standardization test. The team leader and the enumerators took the weight, height and MUAC of 10 children twice. These measurements were checked against the surveyor’s one for accuracy and precision. The accuracy i.e. differences between the enumerator values and the Supervisor’s values and the precision (differences between the two measurements from the same enumerator) was computed using ENA software “evaluation of enumerators”. Standardization measurements (see Annex 3 ) were repeated to ensure that all enumerators have the acceptable level of accuracy and precision prior to data collection. Supervisors were trained how to control the quality of data before leaving the area. They were instructed to check the completeness and accuracy of information taking into consideration the link between questions and sign at the first page for quality assurance.

2.6. Data collection Data collection was carried out from November 8-14 in the target districts. Anthropometric, mortality and key child health and household variables were collected using a standardized questionnaire. In addition to the team of three who were collecting the data, eight

supervisors (from Dohuk , Erbil and Sulaimaniyah DoHs and UNICEF) oversaw the overall the data collection and monitor data completeness and quality. Prior to the field visit, each team received a list of locations already randomly selected (see Annex 4 ). In each location, the team leaders randomly select the first household to be interviewed using the aforementioned standardized protocol.

With regard to the anthropometric measurements, data were collected from all children in the selected households within the eligible age range (6 - 59 months) using anthropometric questionnaire. Weight was measured using a portable mother/child electronic scale, 150kg x 100g. All children were weighted without any clothes. If not feasible, the clothes weight was taken and subtracted from the child and clothes weight. Height was determined using a measuring board (precision of 0.1cm). A cut-off point of 87cm was used to select children to be measured lying down or standing up. Children less than 87cm were measured lying down, while those greater than or equal to 87cm were measured standing up. The age of each child was identified using administrative or health documents (birth certificate, vaccination card etc.). The calendar of events was not used even though the enumerators were trained on how to use it if needed. For the accuracy of collected data, the weight scales were calibrated every 2 days against 5kg weight. No discrepancy was observed all along the survey.

In order to ensure the quality and validity of the information, the addition measures described below were taken • Children should be selected by using the house-to-house method and teams were not allowed to gather all children at a central location for measurement • If the team runs out of houses to measure, they were instructed to go to the next nearest IDPs location not included in the selected list to completed the required sample • No Household substitution can be made for any reason • If two eligible children are found in a household, both were included, even if they are twins • if there are no children under the age of five in a household, this house should neglected • If a child lives in the house but is not present at the time of the survey, The team should continue to look him by re-visiting the household until they left the survey area • Disabled children should be included where possible. If weight or height can be measured, it should be recorded as missing Data entry for the anthropometric measurements were conducted and the data quality ascertained by supervision before leaving the area. Morining meetings were set with the teams to provide feedback on their data quality and solve any issues that were raised before the following day.

2.7. Data analysis

Anthropometric and mortality data were analysed using ENA software 2011 (last updated August 4th, 2014). All the remaining child related-data and household variables were entered and analysed using SPSS 16.0. Prior to analysis collected anthropometric data were double entered and cleaned while the other data were checked using SPSS and any consistent information were double checked and corrected accordingly. Telephone number of the respondents were collected in order to be able to call back if needed. Anthropometric variables were analysed against World Health Organization 2006 growth standards. 13

Extreme z-score values were further investigated and appropriately excluded in the final analysis if deviating from the observed mean (SMART flags). Anthropometric indices are flagged when they are out the ranges below:

- Weight for Height: -3 Z-Scores WHZ < 3 Z-Scores - Weight for Age: -3 Z-Scores WAZ < 3 Z-Scores - Height for Age: -3 Z-Scores HAZ < 3 Z-Scores

III. Results

3.1. Anthropometric results (based on WHO standards 2006): Anthropometric data were collected among 678 children in Erbil and 665 in Sulaimaniyah. Among these, 17 children (10 from Erbil and 7 from Sulaimaniyah) were excluded in the analysis as the one or more of the measurements (weight, height or age) were out of range. The distribution of the selected children (n = 678) in Erbil and(n = 665) in Sulaimaniyah are summarized below (Figure 1-a&b).

Figure 1-a: Distribution of the sample (678 children) within the target districts in Erbil

3% 3% 10%

Erbil Shaqlawa Barzan Koya

83%

Figure 1-b: Distribution of the sample (665 children) within the target districts in Sulaimaniyah

24% Sulaimaniyah 48% Dukan Chamchamal Kalar 14% Kifri

10%

Table 3-a&b below summarizes the age and sex distribution of the surveyed children. The distribution of the sample by age and sex for children the sampled population revealed that the overall sex ratio was 0.9 in Erbil and 1.0 in Sulaimaniyah, which is expected for a normally distributed populations especially for <5 years. The distribution of boys and girls within the different age groups did not show any major discrepancies and ranges from 47.1% to 47.7% and from 52.9 to 52.3% for boys and girls in Erbil and ranges from 52.6% to 50.1% and from 47.4 to 49.9% for boys and girls in Sulaimaniyah respectively.

Table 3-a: Distribution of age and sex of sample in Erbil Age group Boys Girls Total Ratio (months) No. % No. % No. % Boy:girl 6-17 74 47.1 83 52.9 157 23.2 0.9

18-29 72 47.1 81 52.9 153 22.6 0.9

30-41 68 45.9 80 54.1 148 21.9 0.9

42-53 74 48.1 80 51.9 154 22.7 0.9

54-59 31 47.7 34 52.3 65 9.6 0.9

Total 319 47.1 358 52.9 677 100.0 0.9

Table 3-b: Distribution of age and sex of sample in Sulaimaniyah

Age group Boys Girls Total Ratio (months) No. % No. % No. % Boy:girl 15

6-17 70 52.6 63 47.4 133 20.0 1.1

18-29 70 47.0 79 53.0 149 22.4 0.9

30-41 86 56.6 66 43.4 152 22.9 1.3

42-53 72 47.4 80 52.6 152 22.9 0.9

54-59 35 44.3 44 55.7 79 11.9 0.8

Total 333 50.1 332 49.9 665 100.0 1.0

a) Prevalence of Global Acute Malnutrition (GAM); wasting The global acute malnutrition rate or wasted (WHZ) was estimated using weight for height index expressed in z-score and or bilateral pitting oedema. Weight for height index are calculated based on WHO 2006 growth standards. Proportion (%) of affected children disaggregated by sex are presented in Table with the total number (n ), and 95% Confidence interval after exclusion of SMART flags. The Global Acute Malnutrition (GAM) rate was 0.6% (95% CI: 0.2 – 1.5) in Erbil and 0.9% (95% CI: 0.4 – 2.2) in Sulaimaniyah. No cases of Severe Acute Malnutrition (SAM) or bilateral pitting oedema were diagnosed. There were no significant different between boys and girls. These results indicate that the prevalence is far below the emergency threshold of15% as defined by WHO categorization of acute malnutrition. The acute malnutrition rate among these children is classified as acceptable.

Table 4: Prevalence of Global Acute Malnutrition (GAM) by sex after exclusion of SMART flags Erbil

Variables All (n = 668) Boys (n = 314) Girls (n = 354) Prevalence of Global Acute Malnutrition (GAM) (n = 4) 0.6 % (n = 2) 0.6 % (n -= 2) 0.6 % (<-2 z-score and/or oedema) (0.2 - 1.5) (0.2 - 2.6) (0.1 - 2.3) Prevalence of Moderate Acute Malnutrition (n = 4) 0.6 % (n = 2) 0.6 % (n = 2) 0.6 % (MAM)(<-2 z-score and ≥-3 z-score, no oedema) (0.2 - 1.5 (0.2 - 2.6) (0.1 - 2.3) Prevalence of Severe Acute Malnutrition (SAM) (n = 0) 0.0 % (n = 0) 0.0 % (n = 0) 0.0 % (<-3 z-score and/or oedema) (0.0 - 0.0) (0.0 - 0.0) (0.0 - 0.0) Sulaimaniyah Variables All (n = 658) Boys (n = 329) Girls (n = 329) Prevalence of Global Acute Malnutrition (GAM) (n = 6) 0.9 % (n = 2) 0.6 % (n = 4) 1.2 % (<-2 z-score and/or oedema) (0.4 - 2.2) (0.1 - 2.6) (0.5 - 3.2) Prevalence of Moderate Acute Malnutrition (n = 6) 0.9 % (n = 2) 0.6 % (n = 4) 1.2 % (MAM)(<-2 z-score and ≥-3 z-score, no oedema) (0.4 - 2.2) (0.1 - 2.6) (0.5 - 3.2) Prevalence of Severe Acute Malnutrition (SAM) (0) 0.0 % (0) 0.0 % (0) 0.0 % (<-3 z-score and/or oedema) (0.0 - 0.0) (0.0 - 0.0) (0.0 - 0.0) The prevalence of oedema is 0.0%

The distribution curve of sampled children as presented in Figure 22 a&b are even shows a slight shift to the right compared to WHO population of reference.. This shows that the level of acute malnutrition is in the accepatble range and is not a public health problem in this community 16

Figure 2-a: Z-Score Distribution of Weight for Height for the sample-Erbil

Figure 2-b: Z-Score Distribution of Weight for Height for the sample-Sulaimaniyah

Mid-upper arm circumference (MUAC) was used as a proxy of wasting. It is also known as a good predictor of acutely malnourished children (6 – 59 months) most at risk of death. Nutrition status was classified as severe, moderate or normal based on WHO cut-off point 17

(Table 5). Overall, the prevalence of moderate wasting based on MUAC measurements was 0.6% in Erbil and 0.9% in Sulaimaniyah. There were no cases of severely wasted children. This indicator did not show any alarming situation within these communities.

Table 5: Prevalence of acute malnutrition by age, based on MUAC cut offs Severe Moderate wasting Normal wasting Age in months Total children (≥115 & < 125mm) (≥ 125mm) (< 115mm) % (n) % (n) % (n) Erbil 6 – 17 155 0.0 (n = 0) 0.0 (n = 0) 100.0(n = 155) 18 – 29 151 0.0 (n = 0) 0.7 (n = 1) 99.3(n = 150) 30 – 41 147 0.0 (n = 0) 0.0 (n = 0) 100.0 (n = 147) 42 – 53 151 0.0 (n = 0) 2.0 (n = 3) 98.0 (n = 148) 54 – 59 64 0.0 (n = 0) 0.0 (n = 0) 100.0 (n = 164) Total 668 0.0 (n = 0) 0.6 (n = 4) 99.4 (n = 664) Sulaimaniyah 6 – 17 131 0.0 (n = 0) 0.0 (n = 0) 100.0 (n = 131) 18 – 29 148 0.0 (n = 0) 1.4 (n = 2) 98.6 (n = 146) 30 – 41 151 0.0 (n = 0) 1.3 (n = 2) 98.7 (n = 149) 42 – 53 150 0.0 (n = 0) 1.3 (n = 2) 98.7 (n = 148) 54 – 59 78 0.0 (n = 0) 0.0 (n = 0) 100.0 (n = 78) Total 658 0.0 (n = 0) 0.9 (n = 6) 99.1 (n = 652) b) Prevalence of underweight Underweight (WAZ) is defined as weight for age below minus 2 SD of WHO 2006 growth standards. Underweight is a combination of wasting and stunting and often used for child growth monitoring programs.

The results showed that 2.1% (95% CI: 1.2 – 3.5) of target children are underweight and there is no significant difference between boys and girls in Erbil. Similarly, the prevalence of underweight was 3.7% (95% CI: 2.2 – 5.9). No significant difference is observed between boys and girls. The underweight was also below the emergency threshold as defined by WHO and classified as low.

Table 6: Prevalence of underweight by sex and after exclusion of SMART flags Erbil Variables All (n = 674) Boys (n = 318) Girls (n = 356) Prevalence of underweight 2.1% (n = 14) 1.9% (n = 6) 2.2% (n = 8) (<-2 z-score) (1.2 - 3.5) (0.9 - 4.0) (1.1 - 4.5) Prevalence of moderate underweight 2.1%( n = 14) 1.9% ( n = 6) 2.2% (n = 8) (<-2 z-score and >=-3 z-score) (1.2 - 3.5) (0.9 - 4.0) (1.1 - 4.5 Prevalence of severe underweight 0.0 %(n = 0) 0.0 % (n = 0) 0.0% (n = 0) (<-3 z-score) (0.0 - 0.0) (0.0 - 0.0) (0.0 - 0.0) Sulaimaniyah Variables All (n = ) Boys (n = ) Girls (n = ) Prevalence of underweight 3.7% (n = 24) 2.5% (n = 8) 4.8% (n = 16) (<-2 z-score) (2.2 - 5.9) (1.2 - 5.0) (2.9 - 8.0) Prevalence of moderate underweight 3.7% (n = 24) 2.5% (n = 8) 4.8% (n = 16) (<-2 z-score and >=-3 z-score) (2.2 - 5.9) (1.2 - 5.0) (2.9 - 8.0) Prevalence of severe underweight 0.0% (n = 0) 0.0% (n = 0) 0.0% (n = 0) (<-3 z-score) (0.0 - 0.0) (0.0 - 0.0) (0.0 - 0.0)

WHO classifies the severity of underweight as low when the prevalence is below 10%, medium 10% – 19%, high 20% – 29% and very high when it is equal or above 30%. Based on these cut-off point, the prevalence of underweight which is at 2.1% in Erbil and 3.7% in Sulaimaniyah is not a public health problem in this community. The distribution curve of sampled children as presented Figure 2a&b in are practically the same that WHO distribution curve for the population of reference. These findings revealed a public health issue even minor that need to be address while developing prevention strategy.

Figure 3-a: Z-Score Distribution of Weight for Age for the sample-Erbil

Figure 3-b: Z-Score Distribution of Weight for Age for the sample-Sulaimaniyah

c) Prevalence of chronic malnutrition (Stunting) Chronic malnutrition or stunting is defined by height-for-age (HAZ) and emergency threshold is set at minus two standard deviations (WHO growth standards). As the other 19

form of undernutrition described above, it is a direct of cause of inadequate dietary intake and frequent diseases. It is often seen as a long term consequence of food deprivation and frequent disease in opposition to wasting which is seen as a short-term consequence. The survey findings summarized in Table 7 revealed that 5.7% (95% CI: 3.9 – 8.3) of the children have impaired linear growth in Erbil Governorate among which 1.7% (95% CI: 0.8 - 3.3) are severe. In Sulaimaniyah, the prevalence of stunting is 12.2% (95% CI: 8.5 – 17.2) among which 1.9% are severe. The prevalence of stunting does not show any significant difference between boys and girls in the two Governorate but the rate is much higher in Sulaimaniyah than Erbil provinces. Similarly, the prevalence is also higher among girls in Erbil than Sulaimaniyah. Based on WHO classification of the severity of stunting in a given community, the situation with regard to chronic malnutrition is “low” as the cut-off point for emergency is above 30%. Table 7: Prevalence of stunting by sex and location after exclusion of SMART flags Erbil Variables All (n = 661) Boys (n = 312) Girls (n = 349) 6.4 % (n = 20) 5.2 % (n = 18) Prevalence of stunting 5.7% (n = 38) (4.0 - 10.2 95% (3.2 - 8.1 95% (<-2 z-score) (3.9 - 8.3) C.I.) C.I.) Prevalence of moderate stunting 4.1% (n = 27) 3.5% (n = 11) 4.6% n = 16) (<-2 z-score and >=-3 z-score) (2.4 - 6.8) (1.7 - 7.3) (2.7 - 7.7) Prevalence of severe stunting 1.7% (n = 11) 2.9% (n = 9) 0.6% (n = 2) (<-3 z-score) (0.8 - 3.3) (1.4 - 5.9) (0.1 - 2.3) Sulaimaniyah Variables All (n = 647) Boys (n =322) Girls (n = 325) Prevalence of stunting 12.2% (n = 79) 13.0% (n = 42) 11.4% (n = 37) (<-2 z-score) (8.5 - 17.2) (9.5 - 17.6) (6.8 - 18.5) Prevalence of moderate stunting 10.4% (n = 67) 11.2% (n = 36) 9.5% (n = 31) (<-2 z-score and >=-3 z-score) (7.3 - 14.4) (8.1 - 15.3) (6.2 - 14.3) Prevalence of severe stunting 1.9% (n = 12) 1.9% (n = 6) 1.8% (n = 6) (<-3 z-score) (0.9 - 4.0) (0.9 - 4.0) (0.4 - 7.3)

The distribution curve of stunting shows a deviation to the left in comparison to WHO child growth reference population in both provinces.(Figure 44 a&b). Figure 4-a: Z-Score Distribution Height for Age for the sample of Height for -Erbil

Figure 4-b: Z-Score Distribution of Height for Age for the sample-Sulaimaniyah

d) Prevalence of overweight based on WHZ Overweight is defined as weight for height above 2 standard deviations without oedema of WHO growth standard. It is a predictor of malnutrition among the target children and has to be addressed as under nutrition should be. In Erbil, it was found ( Table 8) that the prevalence of overweight was 6.7% (95% CI: 4.9 – 9.1) with no significant difference between boys and girls while it was 3.6% (95% CI: 2.3 – 5.7) in Sulaimaniyah.

Table 8: Prevalence of overweight by sex

Erbil Variables All (n = 668) Boys ( n = 314) Girls ( n = 354) Prevalence of overweight 6.7% (n = 45) 6.1% (n = 19) 7.3% (n = 26) (WHZ > 2) (4.9 - 9.1) (3.9 - 9.3) (4.9 - 10.9) Prevalence of severe 0.6% (n = 4) 1.0% (n = 3) 0.3% (n = 1) overweight (WHZ > 3) (0.2 - 1.5) (0.3 - 2.9) (0.0 - 2.2) Sulaimaniyah Variables All (n = 658) Boys ( n = 329) Girls ( n = 329) Prevalence of overweight 3.6% (n = 24) 4.0% (n = 13) 3.3% (n = 11) (WHZ > 2) (2.3 - 5.7) (2.1 - 7.5) (1.8 - 6.2) Prevalence of severe 0.3% (n = 2) 0.3% (n = 1) 0.3% (n = 1) overweight (WHZ > 3) (0.1 - 1.2) (0.0 - 2.3) (0.0 - 2.2)

3.2. Retrospective mortality results Mortality rate is expressed as the number of death per 10,000 people among the target population (or among children under five) per day. The crude mortality rate (CMR) measures the death rate in the overall population while the under-five death rate (U5MR) is specific to this age group. Death rate is a crucial indicator particularly in emergency where an elevation of mortality can occur due to the crisis and overwhelming unmet needs. Erbil results presented in Table 9 show 0.09 death (0.02 – 0.39; 95% CI) per 10,000 people per day while it is 0.0 death per 10,000 children per day. The situation is the same in Sulaimaniyah. According to the Sphere project, the CMR and U5MR emergency thresholds 21

are 0.3 and 0.5 respectively for Middle East countries. These figures demonstrate that the level of mortality is within the acceptable range in both provinces.

Among the 4 reported deaths in the overall population (2 from each province) all of them were adults. The main causes of death were heart attack (50.0%) and killing (50.0%).

Table 9: Crude and under five mortality rates Erbil Sulaimaniyah

Total deaths (95% CI) Total deaths (95% CI) Crude mortality rate 0.09 (0.02 – 0.39; 95% CI) 0.09 (0.02 – 0.37; 95% CI) Under five mortality rate 0.00 (0.00 – 0.00; 95% CI) 0.00 (0.00 – 0.00; 95% CI)

3.3. Households socio-economic characteristics As summarized in Table 10, out of 451 persons questioned in Erbil, more than 97.8% are married followed by widowed 1.3%, single 0.4% and divorced 0.4%. There was no orphan among the participants While in Sulaimaniyah, out of 414 persons questioned in Erbil, more than 97.3% are married followed by widowed 1.9%, and divorced 0.7%. There was no orphan or single among the participants. The education levels among respondent in Erbil are illiterate 16.0 % , read alone 2.4% , read and write 8.9% , primary level 39.0% , secondary level 16.4% and above secondary 17.3% , In Sulaimaniyah the education levels are illiterate 26.3 % , read alone 1.4% , read and write 27.3% , primary level 32.6% , secondary level 7.2% and above secondary 5.1%. . As main respondents were women, this show somehow the overwhelming number of respondents (91.1%) in Erbil and (96.6%) in Sulaimaniyah are unemployed. The mean age of mothers or primary caregivers in both provinces is 29 years. The distribution of age among interviewed women revealed that 75.7% in Erbil and 78.5% in Sulaimaniyah are between 15 to 35 years older. Approximately the average household size is 5 persons. Average number of under five years among families is 1.73 in Erbil and 1.62 in Sulaimaniyah.

Table 10: Respondent background information and households socioeconomic characteristics % or mean ± SD Variables Erbil Sulaimaniyah (n = 451) (n- 414 ) Respondent marital status 97.8% Married 97.3% .4% Single 0.0% .4% Divorced 0.7% 1.3% Widowed 1.9% 0.0% Orphan (under 18 years old) 0.0% Respondent level of education Illiterate 16.0% 26.3% Read alone 2.4% 1.4% Read & Write 8.9% 27.3% Primary level 39.0% 32.6% Secondary level 16.4% 7.2% Above secondary 17.3% 5.1% Respondent main occupation Business 0.0% 0.7% Vocational skills 0.6% 0.7% 22

Casual labour 0.0% 0.0% Wage employment 0.1% 0.0% Government employment 8.6% 1.9% Unemployment 91.1% 96.6% Retired 0.0% 0.0% Mean age of respondents 29.33 ± 7.1 29.55 ±7.37 Distribution of the age of the respondents (Years) 15 – 25 35.0% 37.5% 26 – 35 42.7% 41.0% 36 – 45 15.5% 19.8% 46 and older 1.8% 1.7% Number of household members 5.21 ± 1.754 5.21 ± 1.74 (n = 678) (n = 665) Number of children under five 1.73 ± 0.851 1.62 ± 0.690

3.4. Infant and young child feeding practices Infant and young child feeding practices was assessed even though the sample was not specifically designed to investigate these questions. Though, the findings were derived from a sub sample of 451 and 414 children under 24 months of age with represents approximately 66.57% and 62.2% of the target group (children 6 – 59 months) sample in this survey in Erbil and Sulaimaniyah respectively. As summarized in 11, the proportion of children being breastfed based on mothers recall was35.33% and 27.55 in Erbil and Sulaimaniyah respectively. There is no significant difference between boys and girls (p > 0.05). Among the 291 children in Erbil and 300 children in Sulaimaniyah were not currently breastfed, approximately, 26.0 % and 15.2% were never breastfed in both provinces respectively. The disaggregation of these results by sex shows no significant difference between boys and girls (p > 0.05). In order to assess the exclusive breastfeeding rate among the target community, the early introduction of food or liquid other than breast milk was investigated. The findings revealed that over (61.47%) in Erbil and (74.9%) in Sulaimaniyah of the children have received food or liquid in the first three days after child birth. There were no significant difference between boys and girls.

Table 11: Infant and young child feeding practices % Variables Erbil Sulaimaniyah Children under 24 months currently breastfed (n = 449) (n = 414) Total sample 35.33% 27.5% Male (n = 225) 32.4% (n = 66) 15.94% Female (n =224) 37.9% (n = 48) 10.62% Children under five that have never breastfed (n = 294) (n = 294) Total sample 38.9% 38.9% Male (n = 153) 43.2% (n = 153) 43.2% Female (n = 141 ) 38.4 % (n = 141) 38.4% Children U5 that received food or liquid in the first three days (n = 450) (n = 414) Total sample 61.7% 74.9% Male (n = 255) 68.47% (n = 223)73.9% Female (n = 255) 58.6% (n = 191) 71.7%

3.5. Vitamin A supplementation and immunization

It well known that micronutrient deficiencies are among the most widespread health public problem worldwide and vitamin A supplementation has a positive impact on reducing child morbidity and mortality. Based on this, WHO has recommended countrywide supplementation of vitamin A targeting children 6 – 59 months at least twice a year.

In Iraq, vitamin A supplementation is part of the immunization calendar but target only children from 9 – 59 months. In this survey, we measured the coverage of vitamin A supplementation campaign; it was found the coverage of vitamin A supplementation is very low among these children ( Table 12 . The results showed that over 23% among 499 children 9 – 59 months in Erbil and 24.6 % among 394 children in Sulaimaniyah have received vitamin A supplementation within the last six months prior to the survey. There is no significant difference between boys and girls (p > 0.05). Besides, a little proportion of children had vaccination cards during the home visits (27.3%) in Erbil and (38.4%) in Sulaimaniyah while most of them have received one but it was either lost or misplaced. Mothers reported that 61.1% of the children in Erbil and 53.3% in Sulaimaniyah were vaccinated against Measles.

Table 12 : Vitamin A and Measles coverage % Variables Erbil Sulaimaniyah Vitamin A supplementation coverage among children 9- 59 months (n = 499 ) (n = 394) Total Sample 23% 24.6% Boys (n = 224) 28.57% (n = 213) 25.35% Girls (n = 225) 22.66% (n = 181) 23.75% Children having vaccination card (n = 451) (n = 414) Yes, seen by interviewer 27.3% 38.4% Not available/ lost/misplaced 56.6% 53.1% Never had a card 6% 8.2% Don’t know 1.1% 0.2% Measles vaccine coverage (N = 450) (N = 414) Total sample 61.1% 53.3% Boys ( (n = 225) 59.6% (n = 223) 54.7% Girls (n = 250) 50.8% (n = 191) 56%

3.6. Prevalence of child morbidity The vicious cycle infections and malnutrition impairs the life and well-being on millions of children worldwide. In this survey, we have assessed the frequency of the diarrhoea and Acute Respiratory Infection (ARI) in the last two weeks before the survey. As presented in Mothers reported 23% of children in Erbil and 21.7% of children in Sulaimaniyah had at least one episode of diarrhoea in the last fifteen days. These proportions were not significantly different. Similarly, ARI is dramatically high in this community with at least up to 50% of the sample in both provinces are affected in the last two weeks (Table ).

Table 13: Prevalence of diarrhea and ARI % Variables Erbil Sulaimaniyah Children with diarrhoea in the last 2 weeks before the (N = 450) (N = 414) survey 23% 21.7% Total sample (n=225)22 .2% (n=223) 21% Boys (n=225) 22% (n=191) 22.5% 24

Girls

Children with ARI the last 2 weeks before the survey (N = 450) (N = 414) Total Sample 54.6% 47.8%

(n=225)48% (n=223)50.2% Boys (n=225)50.4% (n=191) 45% Girls

3.7. Household food Security Due to its impact on household diet diversity and under nutrition, food security was investigated and the main findings were summarized in Table 4. In Erbil 76.8% and 61.6% in Sulaimaniyah were reported having food shortage in the last six weeks. However, only up to 50% in both provinces % have also indicated receiving food aid in the same period. Observation data during the data collection corroborated these findings as foods from diverse organizations were found in most of the visited households. Among 261 households in Erbil and 204 household in Sulaimaniyah that have received food aid, 25.7% were provisioned three time or more, 14.2% twice and 17.5% once and 18.6% were provisioned three time or more, 10.9% twice and 20.8% once in Sulaimaniyah respectively within six weeks. This is in line with the reported number of meals. Almost, the overall selected households have at least three meals a day. Even though the frequency of meals looks like adequate, the dietary diversity and quality were not investigated.

Table 4: Household food security % Variables Erbil (n=451) Sulaimaniyah(n=414) Reported household food shortage the last 6 76.8% 61.6% weeks Household that have received food aid the 57.9% 49.3% last 6 weeks Average number of food aid received Once 17.5% 20.8% Twice 14.2% 10.9% Three or more 25.7% 18.6% Don’t know 7.8% 8.9% Average number of meals per day the last 6 weeks Once 0.7% 0.7% Twice 1.3% 4.8% Three or more 98.0% 94.4%

3.8. Water access and hygiene Lack of potable water and poor hygiene has detrimental consequences on child morbidity and survival. Access to safe water and household hygiene was explored and Table 55 summarized the main outcomes. With regard to drinking water, up to 98% of the households in both provinces have access to safe drinking water which is mainly household/institution connections and tap water. As shown in the table below, In Erbil 93.1% of households use flush latrines, 6.0% improved latrines with slab while in Sulaimaniyah 65.71% of 25

households use flush latrines, 30.7% improved latrines with slab.. Besides, 72.9 % of the sample in Erbil and 51.2% in Sulaimaniyah share the toilets.

Table 55: Access to safe water and household hygiene % Variables Erbil Sulaimaniyah Household main source of drinking water Safe Water Source (household connection, tap water, public standpipe, 99.8% 98.3% borehole, protected dug well, protected spring, tanker truck water, mineral water) Type of toilet facility Flush latrine 93.1% 65.71% Improved latrine with cement slab 6.0% 30.7% Open air 0.9 % 1.9 %

Households sharing toilets 25.9% 45.7% Not shared 72.9% 51.2% Shared households 0.2% 0.2% Public toilet

IV. Discussion

The survey was carried out under the lead of the Department of nutrition of MOH/Erbil - Directorate of preventive health affairs in Erbil and Sulaimaniyah and target Internally Displaced Population settled in both provinces. The data collection took 7 days from November 8-14 and involved 43 trained enumerators and 8 supervisors. Nine districts and over 60 IDPs locations were visited. Participation in the survey was on a volunteer basis and verbal consent was asked to all respondents prior to any interviews or anthropometric measurements.

Following the influx of high number of refugees and IDPs in the region and the potential burden on the existing resources, it was expected critical nutrition situation among the target children. Though, the sample size was calculated based on this assumption and using SMART methodology as a standardized method to derive representative data from the target community. Overall, the anthropometric measurements were taken from 678 children in Erbil and 665 children in Sulaimaniyah were used for final analysis. Nutrition status was calculated using Emergency Nutrition Assessment software and against WHO 2006 child growth references.

The anthropometric findings revealed that the levels of wasting, underweight and stunting were 0.6 %, 2.1% and 5. 7% in Erbil and 0.9%, 3.7% and 12.2% in Sulaimaniyah respectively. These values are below the emergency threshold as defined by the World Health Organisation. Besides, there were no significant difference between boys and girls. Taking into consideration the lack of nutritional information on the target population in their governorate of origin (Ninewa , Salahaddin and Anbar), the present result was compared to the last MICS4 survey which was carried out in 2011. MICS results showed that a prevalence of wasting at 6.9%, underweight 8.4% and stunting 22.3%. These findings revealed a significant higher prevalence of wasting and stunting in the Iraq population compared to IDPs population. Even though, the nutrition status of the IDPs was much better, the lack of information on any seasonal variation of the level of under nutrition does not allow any further conclusion. Similarly, the level of overweight based on weight for height above two standard deviation of the reference population was higher that was found 26

among IDPs in Duhok (1.3%) and it was (6.7) in Erbil and (3.6%) in Sulaimaniyah while it reached 11.1% among the overall population in 2011.

This survey shows that the nutrition situation, as measured by the prevalence of acute malnutrition, underweight, stunting or overweight was not alarming. However, the caseload should raise a major concern due to the high number of internally displaced population settled in the region. As of October 2014, it was estimated that over 277,262 IDPs live in Erbil and Sulaimaniyah. Based on these figures approximately 79 children are wasted, 276 underweight and 748 stunting in Erbil and approximately 131 children are wasted, 540 underweight and 1780 stunting in Sulaimaniyah. The wasting cases were particularly an issue due to the lack of community-based screening to identify and refer malnourished children and the low coverage of nutrition rehabilitation services. This situation calls for immediate action to strengthen the management of acute malnutrition to ensure early identification of malnourished child for treatment. This is particularly important as it is well established the severely wasted children are at higher risk of death compared to those who are not wasted. The risk is again higher when the child is both wasted and stunted. Besides, its short-term consequences on child morbidity and mortality, stunting has also long-term consequences that can jeopardize the future of affected children. The proposed actions should be integrated into the overall Integrated Management of Childhood diseases combined with raising awareness of key family practices.

The survey investigated the child feeding practices, vitamin A supplementation and measles coverage and level of child morbidity. Caregivers were questioned about breastfeeding practices and early introduction of food and liquid in the first three days after birth in particular. It was found that 61.7% in Erbil and 74.9% in Sulaimaniyah received food or liquid in the first three days after birth. This shows that most of the target children were not exclusively breastfed. In Erbil among 291 children who were not breastfed during the survey, 26.7% never did so while in Sulaimaniyah, among 300 children who were not breastfed during the survey, 20.6% never did so. These results were in line with the MICS4 finding with an exclusive breastfeeding rate at 18.6% and revealed widespread inappropriate child feeding practices among this community. It supports also the need to introduce community and facility based infant and young child feeding capacity building to raise awareness and provide counselling support to women in need. Breastfeeding is the most effective way to protect infants and children from common childhood diseases. It is well established that suboptimal breastfeeding play a critical role on child morbidity and mortality. In addition to these findings, it was noted in several occasions that partners were distributing breast milk substitutes to IDPs without any control or specific support to mothers and caregivers. This is a real concern and need immediate actions from the humanitarian actors to implement mechanism to control the procurement, management and distribution of breast milk substitutes.

Providing vitamin A supplements to children 6 – 59 every 4 to 6 months is recommended by the World Health Organization as a public health approach to improve child survival and health. In this survey, it was notable that vitamin A Coverage was very low (23%) in Erbil and (24.6%) in Sulaimaniyah. Measles coverage was in opposite higher (61.1%) in Erbil and (53.3%)in Sulaimaniyah. In comparison to MICS results which were 64.2%, there is an improvement on the coverage but need to be scaled up to 90% at least. Vitamin A supplementation could be used to integrate activities and raise awareness on key family practices (IYCF, hand washing, using iodized salt, etc.)

The high prevalence of diarrhoea up to 23% and acute respiratory infection near 50% were among the issues that need to be addressed by humanitarian actors due to their contribution on child morbidity including malnutrition and mortality.

With regard to food security, it was reported over 76.8% of the interviewed households in Erbil and 61.6% in Sulaimaniyah have food shortage during the last 6 weeks prior to the survey. Also the proportions of household having food aid are not high, so they need continuous support and the partners should have use fortified food for the general food distribution. These actions may support the reduction of micronutrient deficiency.

V. Conclusions

This survey shows that the nutrition situation, as measured by the prevalence of acute malnutrition, underweight, stunting or overweight is not alarming in both Erbil and Sulaimaniyah provinces. The death rates were also very low and did not show any urgent actions. Even though the overall situation is low, the higher level of chronic malnutrition among IDPs settled in Sulaimaniyah in comparison to those in Erbil province call for multi sectoral prevention activities to Support child growth and wellbeing.

VI. Recommendations

Although the nutrition situation as measured by the rates of wasting, underweight, stunting and overweight is not alarming, the nutrition sector should reinforce the preventive activity and work closely with other sectors such as health, C4D and WASH to develop integrated approach to respond to the multifactorial causes of malnutrition. Meanwhile, specific actions should be taken to treat existing cases. In order to respond to the issues identified in this survey, the following actions should be implemented. - Strengthen the nutrition rehabilitation centres as part of the Integrated Management of Childhood Illnesses (IMCI) to ensure provision of services to the exiting cases - Develop a nutrition surveillance system based on the routine data as the growth monitoring activities which is already in place in many health facilities - Trained Health professional on Infant and young child feeding practices and support the implementation of IYCF activities at both health facilities and community level. - Develop guidance for integrated management at community and health facility level addressing ARI, diarrhea and malnutrition - Develop guidance on BMS & advocate for the use of fortified food in both blanket and target distribution - Conduct an integrated vitamin A supplementation and advocate for the inclusion of children from 6 months of age. Use every opportunity especially related to immunization (Measles, polio..) to integrate Vitamin A supplementation - Set up an integrated action plan between nutrition and other sectors such as C4D, WASH and Health to develop a multisectoral approach to address the underlying causes of under nutrition.

VII. References

1. SMART. Measuring Mortality, Nutritional Status, and Food Security in Crisis Situations: SMART Methodology, Version 1 (April 2006); 129 pages 2. IOM Iraq Displacement Tracking Matrix (DTM), January 1 to September 28, 2014 3. Iraq Multiple Indicator Cluster Survey 2011. Preliminary Report (April 2012); 68 pages 4. UNICEF. Rapid Assessment Sampling in Emergency Situations. 2010; 44 pages 5. Tanya Khara & Carmel Dolan, technical Briefing paper: The relationship between wasting and stunting, policy, programming and research implications: Emergency Nutrition Network (ENN); July 2014 39 pages 6. Robert E Black, Lindsay H Allen, Zulfi qar A Bhutta & al for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371: 243-60 7. Zulfi qar A Bhutta, Jai K Das, Arjumand Rizvi, & al for the Maternal and Child Undernutrition Study Group. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet June 6, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60996-4 8. Maaike Bruins and Klaus Kraemer. Public health programmes for vitamin A deficiency control. Community Eye Health Journal 2013; 26 (84): 69 – 70 9. WHO. Guideline: Vitamin A supplementation in infants and children 6-59 months of age. Geneva, World Health Organization, 2011 10. WHO. Malnutrition: Quantifying the health impact at national and local levels. Environmental Burden of Disease Series, 2005; No. 12: 51 pages 11. Francesco Checchi and Les Roberts. Interpreting and using mortality data in humanitarian emergencies: A primer for non-epidemiologists. Humanitarian Practice Network 2005; 54: 41 pages 12. The Sphere Project. Humanitarian Charter and Minimum Standards in Humanitarian Response, 2011: 203 pages 13. Helen Young, Annalies Borrel & al. Public nutrition in complex emergencies. Lancet 2004; 364: 1899–909 14. WHO. WHO child growth standards and the identification of severe acute malnutrition in infants: A Joint Statement by the World Health Organization and the United Nations Children’s Fund, 2009: 12 pages 15. Ma del Carmen Casanovas, Chessa K. Lutter & al. Multi-sectoral interventions for healthy growth. Maternal and Child Nutrition (2013), 9 (Suppl. 2), pp. 46–57 16. IFE Core Group. Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. IFE 2007; Version2.1: 28 pages 17. Save the Children UK. Infant and Young Child Feeding in Emergencies: Why are we not delivering at scale? A review of global gaps, challenges and ways forward. Save the Children 2012; 52 pages 18. Jehangir Khan, Linda Vesel & al. Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: Effects on neonatal mortality and morbidity—A Systematic Review and Meta-analysis. Matern Child Health 2014 Jun 4 doi 10.1007/s10995-014-1526-8 19. Shams Arifeen, Robert E. Black & al. Exclusive Breastfeeding Reduces Acute Respiratory Infection and Diarrhea Deaths Among Infants in Dhaka Slums. Pediatrics 2001; 108(4): e67 29

20. WHO. The WHO Child Growth Standards. http://www.who.int/childgrowth/en/ . September 2014 21. WFP. Measuring and interpreting malnutrition and mortality, 2005: 222 pages 22. WHO. Guidelines: Updates on the management of severe acute malnutrition in infants and children. WHO 2013: 123 pages 23. John Hoddinott, Harold Alderman & al. The economic rationale for investing in stunting reduction. Maternal and Child Nutrition (2013), 9 (Suppl. 2), pp. 69.

VIII-Annexes Annex 1: Calendar of events Months 2009 2010 2011 2012 2013 2014 January 57 45 33 21 9 56 Chella 44 Chella 32 Chella 20 Chella 8 February Zivastany (2 Zivastany (2 Zivastany (2 of Zivastany (2 of Chella Zivastany of February) of February) February) February) (2 of February) 55 43 31 19 7 March Nawroz (21 of Nawroz (21 of Nawroz (21 of Nawroz (21 of Nawroz (21 of march) march) march) march) march) 54 Red 42 Red 30 Red 18 Red 6 Red Wednesday April Wednesday Wednesday Wednesday Wednesday (mid April) (mid April) (mid April) (mid April) (mid April) May 53 41 29 17 5 52 40 28 16 4 June Mossul Attack (June 20) July 51 39 27 15 3 50 Chella 38 Chella 26 14 2 August Haveny (2 of Haveny (2 of Chella Haveny Chella Haveny Chella Haveny August) August) (2 of August) (2 of August) (2 of August) September 49 37 25 13 1 48 Sheikh Hadi 36 Sheikh Hadi 24 12 0 October visit (6-13 visit (6-13 Sheikh Hadi Sheikh Hadi Sheikh Hadi visit Oct) Oct) visit (6-13 Oct) visit (6-13 Oct) (6-13 Oct) November 59 47 35 23 11

58 46 34 22 10 December Fasting Eid Fasting Eid Fasting Eid Fasting Eid Fasting Eid (11-12 Dec) (11-12 Dec) (11-12 Dec) (11-12 Dec) (11-12 Dec)

Annex 2: Plausibility Report

Plausibility check for: 1_Erb_AnthropoData.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

Missing/Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of in-range subjects) 0 5 10 20 0 (1.3 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.134)

Overall Age distrib Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.885)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (10)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 10 (26)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 4 (14)

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 2 6 20 0 (0.96)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 1 (0.26)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.02)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.625)

Timing Excl Not determined yet 0 1 3 5

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 17 %

The overall score of this survey is 17 %, this is acceptable.

There were no duplicate entries detected.

Percentage of children with no exact birthday: 1 %

Age/Height out of range for WHZ:

MONTHS: Line=474/ID=1: 5.13 mo 32

Anthropometric Indices likely to be in error (-3 to 3 for WHZ, -3 to 3 for HAZ, -3 to 3 for WAZ, from observed mean - chosen in Options panel - these values will be flagged and should be excluded from analysis for a nutrition survey in emergencies. For other surveys this might not be the best procedure e.g. when the percentage of overweight children has to be calculated):

Line=5/ID=1: WHZ (-3.811) , Weight may be incorrect Line=49/ID=1: HAZ (-3.452), Age may be incorrect Line=136/ID=2: HAZ (-3.945), Age may be incorrect Line=139/ID=1: HAZ (3.114), Age may be incorrect Line=198/ID=2: WHZ (-2.684) , Weight may be incorrect Line=298/ID=2: HAZ (3.062), Age may be incorrect Line=319/ID=1: WHZ (4.324) , WAZ (5.041), Weight may be incorrect Line=363/ID=1: WHZ (-3.016) , HAZ (2.814), Height may be incorrect Line=370/ID=2: HAZ (-4.321), Age may be incorrect Line=382/ID=2: HAZ (-3.648), WAZ (-3.311), Age may be incorrect Line=384/ID=4: HAZ (2.667), Height may be incorrect Line=463/ID=1: WHZ (-2.635) , HAZ (3.423), Height may be incorrect Line=499/ID=1: HAZ (-4.617), Age may be incorrect Line=506/ID=1: HAZ (-3.731), Height may be incorrect Line=524/ID=1: WHZ (-2.685) , Weight may be incorrect Line=532/ID=2: HAZ (-3.463), Height may be incorrect Line=585/ID=1: HAZ (3.811), Height may be incorrect Line=598/ID=1: WHZ (3.686) , Weight may be incorrect Line=611/ID=3: WHZ (3.722) , WAZ (3.850), Weight may be incorrect Line=621/ID=1: HAZ (3.589), Age may be incorrect Line=630/ID=2: WHZ (3.947) , Weight may be incorrect Line=664/ID=1: HAZ (4.163), Age may be incorrect Line=671/ID=2: HAZ (5.416), Age may be incorrect

Percentage of values flagged with SMART flags:WHZ: 1.3 %, HAZ: 2.4 %, WAZ: 0.4 %

Age distribution:

Month 5 : # Month 6 : ################ Month 7 : ############ Month 8 : ############## Month 9 : ############# Month 10 : ############# Month 11 : ######## Month 12 : ############# Month 13 : #################### Month 14 : ############ Month 15 : ######### Month 16 : ############ Month 17 : ######## Month 18 : ############# 33

Month 19 : ########### Month 20 : ############ Month 21 : ############ Month 22 : ########### Month 23 : #### Month 24 : ############# Month 25 : ################# Month 26 : ################### Month 27 : #################### Month 28 : ############# Month 29 : ############ Month 30 : ########### Month 31 : ############# Month 32 : ################ Month 33 : ############### Month 34 : #################### Month 35 : ######## Month 36 : ########### Month 37 : ############# Month 38 : ############ Month 39 : ########## Month 40 : ####### Month 41 : ########### Month 42 : ########### Month 43 : ########## Month 44 : ########### Month 45 : ########### Month 46 : ################## Month 47 : ######## Month 48 : ############# Month 49 : ################# Month 50 : ########### Month 51 : ######### Month 52 : ################### Month 53 : ############# Month 54 : ################# Month 55 : ######### Month 56 : ####### Month 57 : ####### Month 58 : ############## Month 59 : ########### Month 60 : #######

Age ratio of 6-29 months to 30-59 months: 0.84 (The value should be around 0.85).

Statistical evaluation of sex and age ratios (using Chi squared statistic):

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 74/74.0 (1.0) 83/83.1 (1.0) 157/157.1 (1.0) 0.89 18 to 29 12 72/72.2 (1.0) 81/81.0 (1.0) 153/153.1 (1.0) 0.89 30 to 41 12 68/69.9 (1.0) 80/78.5 (1.0) 148/148.4 (1.0) 0.85 42 to 53 12 74/68.8 (1.1) 80/77.2 (1.0) 154/146.1 (1.1) 0.93 34

54 to 59 6 31/34.0 (0.9) 34/38.2 (0.9) 65/72.3 (0.9) 0.91 ------6 to 59 54 319/338.5 (0.9) 358/338.5 (1.1) 0.89

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.134 (boys and girls equally represented) Overall age distribution: p-value = 0.885 (as expected) Overall age distribution for boys: p-value = 0.949 (as expected) Overall age distribution for girls: p-value = 0.964 (as expected) Overall sex/age distribution: p-value = 0.471 (as expected)

Digit preference Weight:

Digit .0 : ############################################################## Digit .1 : ############################## Digit .2 : ################################ Digit .3 : ############################## Digit .4 : ################################ Digit .5 : ################################### Digit .6 : ############################## Digit .7 : ################################## Digit .8 : ############################## Digit .9 : ########################

Digit preference score: 10 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.000 (significant difference)

Digit preference Height:

Digit .0 : ###################################################### Digit .1 : ######## Digit .2 : ########### Digit .3 : ############### Digit .4 : ########## Digit .5 : ########################## Digit .6 : ################ Digit .7 : ############ Digit .8 : ############ Digit .9 : ######

Digit preference score: 26 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.000 (significant difference)

Digit preference MUAC:

Digit .0 : ############################################################ 35

Digit .1 : ############################ Digit .2 : ################################ Digit .3 : ############################ Digit .4 : ########################################## Digit .5 : ########################################################### Digit .6 : ##################### Digit .7 : ######################## Digit .8 : #################### Digit .9 : ########################

Digit preference score: 14 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.000 (significant difference)

Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures

. no exclusion exclusion from exclusion from . reference mean observed mean . (WHO flags) (SMART flags) WHZ Standard Deviation SD: 1.03 1.03 0.96 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 1.3% 1.3% calculated with current SD: 0.9% 0.9% calculated with a SD of 1: 0.8% 0.8%

HAZ Standard Deviation SD: 1.20 1.20 1.06 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 6.6% 6.6% 5.7% calculated with current SD: 8.8% 8.8% 6.4% calculated with a SD of 1: 5.2% 5.2% 5.3%

WAZ Standard Deviation SD: 1.01 0.99 0.97 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 2.2% calculated with current SD: 1.9% calculated with a SD of 1: 1.8%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.004 HAZ p= 0.000 p= 0.000 p= 0.134 WAZ p= 0.000 p= 0.009 p= 0.023 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)

Skewness WHZ 0.17 0.17 0.26 HAZ 0.17 0.17 -0.08 WAZ 0.21 0.06 0.04 If the value is: -below minus 0.4 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 0.4 and minus 0.2, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 0.2 and plus 0.2, the distribution can be considered as symmetrical. -between 0.2 and 0.4, there may be an excess of obese/tall/overweight subjects in the sample. -above 0.4, there is an excess of obese/tall/overweight subjects in the sample

Kurtosis WHZ 0.97 0.97 -0.02 HAZ 1.53 1.53 -0.09 WAZ 1.22 0.60 0.32 36

Kurtosis characterizes the relative size of the body versus the tails of the distribution. Positive kurtosis indicates relatively large tails and small body. Negative kurtosis indicates relatively large body and small tails. If the absolute value is: -above 0.4 it indicates a problem. There might have been a problem with data collection or sampling. -between 0.2 and 0.4, the data may be affected with a problem. -less than an absolute value of 0.2 the distribution can be considered as normal.

Test if cases are randomly distributed or aggregated over the clusters by calculation of the Index of Dispersion (ID) and comparison with the Poisson distribution for:

WHZ < -2: ID=0.90 (p=0.625) GAM: ID=0.90 (p=0.625) HAZ < -2: ID=1.25 (p=0.168) HAZ < -3: ID=1.22 (p=0.193) WAZ < -2: ID=1.00 (p=0.473)

Subjects with SMART flags are excluded from this analysis.

The Index of Dispersion (ID) indicates the degree to which the cases are aggregated into certain clusters (the degree to which there are "pockets"). If the ID is less than 1 and p > 0.95 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p value is between 0.05 and 0.95 the cases appear to be randomly distributed among the clusters, if ID is higher than 1 and p is less than 0.05 the cases are aggregated into certain cluster (there appear to be pockets of cases). If this is the case for Oedema but not for WHZ then aggregation of GAM and SAM cases is likely due to inclusion of oedematous cases in GAM and SAM estimates.

Are the data of the same quality at the beginning and the end of the clusters? Evaluation of the SD for WHZ depending upon the order the cases are measured within each cluster (if one cluster per day is measured then this will be related to the time of the day the measurement is made).

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.84 (n=30, f=0) ## 02: 1.09 (n=30, f=0) ############ 03: 0.74 (n=30, f=0) 04: 0.89 (n=30, f=0) #### 05: 1.38 (n=30, f=1) ######################## 06: 1.24 (n=30, f=0) ################## 07: 1.14 (n=30, f=2) ############## 08: 0.87 (n=30, f=0) ### 09: 1.49 (n=30, f=2) ############################# 10: 1.17 (n=30, f=1) ################ 11: 0.99 (n=30, f=0) ######## 12: 0.89 (n=30, f=0) #### 13: 0.94 (n=30, f=0) ###### 14: 0.73 (n=30, f=0) 15: 0.79 (n=30, f=0) 16: 1.15 (n=30, f=0) ############### 17: 0.93 (n=30, f=0) ##### 18: 1.05 (n=30, f=1) ########### 19: 0.84 (n=29, f=0) ## 20: 1.10 (n=29, f=1) ############# 21: 1.27 (n=27, f=1) #################### 22: 0.70 (n=16, f=0) 23: 0.76 (n=09, f=0) 24: 0.71 (n=07, f=0) 25: 1.26 (n=05, f=0) ~~~~~~~~~~~~~~~~~~~ 37

26: 0.69 (n=04, f=0) 27: 0.56 (n=04, f=0) 28: 1.13 (n=03, f=0) ~~~~~~~~~~~~~~ 29: 1.21 (n=03, f=0) ~~~~~~~~~~~~~~~~~ 30: 0.34 (n=02, f=0)

(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)

Analysis by Team

Team 1 2 3 4 5 6 7 n = 82 77 106 108 93 108 104 Percentage of values flagged with SMART flags: WHZ: 2.4 0.0 2.8 0.0 2.2 0.0 1.9 HAZ: 2.4 2.6 0.9 0.9 5.4 2.8 1.9 WAZ: 1.2 0.0 0.9 0.0 0.0 0.9 0.0 Age ratio of 6-29 months to 30-59 months: 0.91 1.03 0.89 0.95 0.50 1.04 0.73 Sex ratio (male/female): 0.91 1.08 0.89 1.00 0.94 0.66 0.89 Digit preference Weight (%): .0 : 16 34 18 15 13 23 13 .1 : 6 5 5 11 15 6 12 .2 : 9 10 9 9 5 9 13 .3 : 10 8 7 7 12 11 8 .4 : 16 5 13 6 10 5 13 .5 : 6 12 8 12 9 12 13 .6 : 7 9 6 10 12 9 9 .7 : 11 6 12 12 9 13 6 .8 : 7 8 13 10 10 6 9 .9 : 12 3 9 7 6 6 5 DPS: 12 28 13 9 9 17 10 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference Height (%): .0 : 17 97 25 16 31 34 16 .1 : 6 0 5 8 2 6 7 .2 : 7 0 10 6 4 6 9 .3 : 11 1 14 8 14 4 9 .4 : 5 0 3 11 5 4 12 .5 : 21 0 27 14 16 18 10 .6 : 5 0 5 19 14 9 11 .7 : 11 0 3 13 3 5 13 .8 : 13 1 8 2 4 9 10 .9 : 4 0 1 2 5 6 5 DPS: 18 97 29 18 29 30 10 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference MUAC (%): .0 : 32 27 23 9 11 11 16 .1 : 1 5 4 15 8 13 9 .2 : 10 13 13 10 4 6 11 38

.3 : 5 6 7 8 12 9 10 .4 : 5 12 16 13 19 13 9 .5 : 26 14 21 11 22 16 14 .6 : 2 3 4 9 6 6 12 .7 : 7 6 6 6 6 11 6 .8 : 9 9 5 4 3 4 10 .9 : 4 4 3 14 9 11 5 DPS: 33 23 24 11 19 12 11 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Standard deviation of WHZ: SD 1.24 0.94 1.02 1.01 1.12 0.94 0.96 Prevalence (< -2) observed: % 2.4 0.9 0.0 3.2 Prevalence (< -2) calculated with current SD: % 2.0 1.1 0.8 1.6 Prevalence (< -2) calculated with a SD of 1: % 0.5 1.0 0.7 0.8 Standard deviation of HAZ: SD 1.26 1.29 1.08 0.97 1.42 1.21 1.15 observed: % 7.3 5.2 1.9 10.8 11.1 4.8 calculated with current SD: % 12.0 8.9 3.8 14.1 11.8 5.5 calculated with a SD of 1: % 7.0 4.2 2.8 6.2 7.5 3.3

Statistical evaluation of sex and age ratios (using Chi squared statistic) for:

Team 1:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 9/9.0 (1.0) 8/10.0 (0.8) 17/19.0 (0.9) 1.13 18 to 29 12 8/8.8 (0.9) 14/9.7 (1.4) 22/18.5 (1.2) 0.57 30 to 41 12 8/8.6 (0.9) 6/9.4 (0.6) 14/18.0 (0.8) 1.33 42 to 53 12 12/8.4 (1.4) 10/9.3 (1.1) 22/17.7 (1.2) 1.20 54 to 59 6 2/4.2 (0.5) 5/4.6 (1.1) 7/8.8 (0.8) 0.40 ------6 to 59 54 39/41.0 (1.0) 43/41.0 (1.0) 0.91

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.659 (boys and girls equally represented) Overall age distribution: p-value = 0.535 (as expected) Overall age distribution for boys: p-value = 0.598 (as expected) Overall age distribution for girls: p-value = 0.462 (as expected) Overall sex/age distribution: p-value = 0.158 (as expected)

Team 2:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 8/9.3 (0.9) 13/8.6 (1.5) 21/17.9 (1.2) 0.62 18 to 29 12 9/9.0 (1.0) 9/8.4 (1.1) 18/17.4 (1.0) 1.00 30 to 41 12 9/8.8 (1.0) 4/8.1 (0.5) 13/16.9 (0.8) 2.25 39

42 to 53 12 13/8.6 (1.5) 7/8.0 (0.9) 20/16.6 (1.2) 1.86 54 to 59 6 1/4.3 (0.2) 4/3.9 (1.0) 5/8.2 (0.6) 0.25 ------6 to 59 54 40/38.5 (1.0) 37/38.5 (1.0) 1.08

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.732 (boys and girls equally represented) Overall age distribution: p-value = 0.491 (as expected) Overall age distribution for boys: p-value = 0.298 (as expected) Overall age distribution for girls: p-value = 0.340 (as expected) Overall sex/age distribution: p-value = 0.049 (significant difference)

Team 3:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 14/11.6 (1.2) 13/13.0 (1.0) 27/24.6 (1.1) 1.08 18 to 29 12 8/11.3 (0.7) 15/12.7 (1.2) 23/24.0 (1.0) 0.53 30 to 41 12 9/11.0 (0.8) 12/12.3 (1.0) 21/23.2 (0.9) 0.75 42 to 53 12 13/10.8 (1.2) 12/12.1 (1.0) 25/22.9 (1.1) 1.08 54 to 59 6 6/5.3 (1.1) 4/6.0 (0.7) 10/11.3 (0.9) 1.50 ------6 to 59 54 50/53.0 (0.9) 56/53.0 (1.1) 0.89

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.560 (boys and girls equally represented) Overall age distribution: p-value = 0.933 (as expected) Overall age distribution for boys: p-value = 0.671 (as expected) Overall age distribution for girls: p-value = 0.896 (as expected) Overall sex/age distribution: p-value = 0.447 (as expected)

Team 4:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 13/12.3 (1.1) 14/12.5 (1.1) 27/24.8 (1.1) 0.93 18 to 29 12 19/12.0 (1.6) 6/12.2 (0.5) 25/24.2 (1.0) 3.17 30 to 41 12 7/11.6 (0.6) 16/11.8 (1.4) 23/23.5 (1.0) 0.44 42 to 53 12 6/11.4 (0.5) 11/11.7 (0.9) 17/23.1 (0.7) 0.55 54 to 59 6 8/5.7 (1.4) 7/5.8 (1.2) 15/11.4 (1.3) 1.14 ------6 to 59 54 53/53.5 (1.0) 54/53.5 (1.0) 0.98

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.923 (boys and girls equally represented) Overall age distribution: p-value = 0.566 (as expected) Overall age distribution for boys: p-value = 0.049 (significant difference) Overall age distribution for girls: p-value = 0.277 (as expected) Overall sex/age distribution: p-value = 0.006 (significant difference)

Team 5:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 10/10.4 (1.0) 9/11.1 (0.8) 19/21.6 (0.9) 1.11 18 to 29 12 8/10.2 (0.8) 4/10.9 (0.4) 12/21.0 (0.6) 2.00 30 to 41 12 7/9.9 (0.7) 19/10.5 (1.8) 26/20.4 (1.3) 0.37 40

42 to 53 12 15/9.7 (1.5) 11/10.4 (1.1) 26/20.1 (1.3) 1.36 54 to 59 6 5/4.8 (1.0) 5/5.1 (1.0) 10/9.9 (1.0) 1.00 ------6 to 59 54 45/46.5 (1.0) 48/46.5 (1.0) 0.94

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.756 (boys and girls equally represented) Overall age distribution: p-value = 0.112 (as expected) Overall age distribution for boys: p-value = 0.379 (as expected) Overall age distribution for girls: p-value = 0.020 (significant difference) Overall sex/age distribution: p-value = 0.003 (significant difference)

Team 6:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 9/10.0 (0.9) 18/15.1 (1.2) 27/25.1 (1.1) 0.50 18 to 29 12 11/9.7 (1.1) 17/14.7 (1.2) 28/24.4 (1.1) 0.65 30 to 41 12 13/9.4 (1.4) 11/14.3 (0.8) 24/23.7 (1.0) 1.18 42 to 53 12 6/9.3 (0.6) 16/14.0 (1.1) 22/23.3 (0.9) 0.38 54 to 59 6 4/4.6 (0.9) 3/6.9 (0.4) 7/11.5 (0.6) 1.33 ------6 to 59 54 43/54.0 (0.8) 65/54.0 (1.2) 0.66

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.034 (significant excess of girls) Overall age distribution: p-value = 0.640 (as expected) Overall age distribution for boys: p-value = 0.583 (as expected) Overall age distribution for girls: p-value = 0.382 (as expected) Overall sex/age distribution: p-value = 0.019 (significant difference)

Team 7:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 11/11.4 (1.0) 8/12.8 (0.6) 19/24.1 (0.8) 1.38 18 to 29 12 9/11.1 (0.8) 16/12.4 (1.3) 25/23.5 (1.1) 0.56 30 to 41 12 15/10.7 (1.4) 12/12.1 (1.0) 27/22.8 (1.2) 1.25 42 to 53 12 9/10.6 (0.9) 13/11.9 (1.1) 22/22.4 (1.0) 0.69 54 to 59 6 5/5.2 (1.0) 6/5.9 (1.0) 11/11.1 (1.0) 0.83 ------6 to 59 54 49/52.0 (0.9) 55/52.0 (1.1) 0.89

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.556 (boys and girls equally represented) Overall age distribution: p-value = 0.742 (as expected) Overall age distribution for boys: p-value = 0.675 (as expected) Overall age distribution for girls: p-value = 0.574 (as expected) Overall sex/age distribution: p-value = 0.230 (as expected)

Evaluation of the SD for WHZ depending upon the order the cases are measured within each cluster (if one cluster per day is measured then this will be related to the time of the day the measurement is made).

Team: 1

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.54 (n=05, f=0) 02: 1.21 (n=03, f=0) ################# 03: 0.76 (n=03, f=0) 05: 1.31 (n=04, f=0) ##################### 06: 1.37 (n=03, f=0) ######################## 07: 0.91 (n=04, f=0) ##### 08: 0.86 (n=03, f=0) ### 09: 2.47 (n=05, f=1) ################################################################ 10: 1.43 (n=05, f=0) ########################## 11: 1.09 (n=05, f=0) ############ 12: 0.79 (n=04, f=0) 13: 1.33 (n=04, f=0) ###################### 14: 0.53 (n=03, f=0) 15: 0.40 (n=03, f=0) 16: 2.44 (n=03, f=1) ################################################################ 17: 1.29 (n=04, f=0) ##################### 18: 2.03 (n=04, f=1) #################################################### 19: 0.84 (n=03, f=0) ## 20: 1.42 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOO 21: 0.19 (n=02, f=0)

Team: 2

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.96 (n=06, f=0) ####### 02: 0.98 (n=05, f=0) ####### 03: 0.38 (n=05, f=0) 04: 0.46 (n=03, f=0) 05: 0.48 (n=04, f=0) 06: 0.52 (n=04, f=0) 07: 1.70 (n=04, f=0) ###################################### 08: 0.18 (n=02, f=0) 09: 0.77 (n=04, f=0) 10: 0.39 (n=03, f=0) 11: 1.31 (n=05, f=0) ##################### 12: 0.68 (n=03, f=0) 13: 0.82 (n=02, f=0) O 14: 0.31 (n=02, f=0) 15: 0.49 (n=02, f=0) 16: 0.81 (n=02, f=0) 17: 0.53 (n=04, f=0) 18: 0.30 (n=03, f=0) 19: 1.08 (n=04, f=0) ############ 20: 1.20 (n=03, f=0) ################# 21: 1.37 (n=03, f=0) ######################## 22: 0.06 (n=02, f=0)

Team: 3

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.97 (n=08, f=0) ####### 02: 0.81 (n=06, f=0) 03: 0.47 (n=06, f=0) 04: 1.32 (n=05, f=0) ###################### 05: 0.94 (n=05, f=0) ###### 06: 1.09 (n=05, f=0) ############ 07: 1.96 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 08: 0.21 (n=05, f=0) 09: 1.94 (n=06, f=1) ################################################ 10: 0.52 (n=04, f=0) 42

11: 0.91 (n=05, f=0) ##### 12: 1.01 (n=06, f=0) ######### 13: 0.99 (n=04, f=0) ######## 14: 0.55 (n=04, f=0) 15: 0.69 (n=05, f=0) 16: 0.28 (n=04, f=0) 17: 0.69 (n=04, f=0) 18: 1.43 (n=07, f=1) ########################## 19: 0.54 (n=03, f=0) 20: 0.48 (n=04, f=0) 21: 0.53 (n=04, f=0) 22: 0.53 (n=02, f=0)

Team: 4

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.06 (n=07, f=0) ########### 02: 0.79 (n=06, f=0) 03: 1.40 (n=04, f=0) ######################### 04: 0.96 (n=05, f=0) ####### 05: 1.15 (n=06, f=0) ############### 06: 1.64 (n=07, f=0) ################################### 07: 0.41 (n=06, f=0) 08: 0.72 (n=05, f=0) 09: 1.12 (n=07, f=0) ############# 10: 0.74 (n=06, f=0) 11: 0.16 (n=04, f=0) 12: 0.73 (n=06, f=0) 13: 1.54 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 14: 1.40 (n=05, f=0) ######################### 15: 0.98 (n=05, f=0) ######## 16: 1.41 (n=05, f=0) ######################### 17: 1.30 (n=04, f=0) ##################### 18: 0.99 (n=06, f=0) ######## 19: 0.46 (n=04, f=0) 20: 0.62 (n=03, f=0) 21: 0.67 (n=03, f=0)

Team: 5

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.88 (n=07, f=0) ### 02: 1.82 (n=04, f=0) ########################################### 03: 1.23 (n=03, f=0) ################## 04: 1.00 (n=03, f=0) ######## 05: 1.30 (n=04, f=0) ##################### 06: 1.63 (n=05, f=0) ################################### 07: 2.05 (n=06, f=1) ##################################################### 08: 1.25 (n=05, f=0) ################### 09: 0.58 (n=06, f=0) 10: 0.68 (n=06, f=0) 11: 0.82 (n=06, f=0) # 12: 0.54 (n=03, f=0) 13: 0.62 (n=04, f=0) 14: 0.18 (n=04, f=0) 15: 0.68 (n=03, f=0) 16: 1.40 (n=03, f=0) ######################### 17: 0.75 (n=04, f=0) 18: 2.23 (n=03, f=1) ############################################################ 19: 0.58 (n=03, f=0) 20: 1.42 (n=04, f=0) ########################## 21: 1.17 (n=03, f=0) ################

(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found 43

in the different time points)

Team: 6

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.59 (n=06, f=0) 02: 1.35 (n=06, f=0) ####################### 03: 0.97 (n=04, f=0) ####### 04: 0.49 (n=02, f=0) 05: 1.65 (n=04, f=0) #################################### 06: 1.55 (n=04, f=0) ############################### 07: 0.54 (n=05, f=0) 08: 0.69 (n=04, f=0) 09: 0.55 (n=03, f=0) 10: 1.63 (n=03, f=0) ################################### 11: 0.16 (n=03, f=0) 12: 1.36 (n=05, f=0) ######################## 13: 0.35 (n=04, f=0) 14: 0.65 (n=04, f=0) 15: 0.40 (n=04, f=0) 16: 1.60 (n=03, f=0) ################################## 17: 1.01 (n=05, f=0) ######### 18: 0.27 (n=05, f=0) 19: 0.55 (n=03, f=0) 20: 1.08 (n=05, f=0) ############ 21: 0.84 (n=06, f=0) ## 22: 1.39 (n=04, f=0) ######################### 23: 0.52 (n=04, f=0) 24: 0.54 (n=04, f=0) 25: 0.63 (n=02, f=0) 26: 0.73 (n=02, f=0) 27: 0.69 (n=02, f=0)

Team: 7

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.29 (n=07, f=1) ##################### 02: 0.41 (n=04, f=0) 03: 0.48 (n=04, f=0) 04: 0.50 (n=04, f=0) 05: 1.12 (n=04, f=0) ############## 06: 0.18 (n=04, f=0) 07: 0.51 (n=04, f=0) 08: 0.67 (n=05, f=0) 09: 1.20 (n=05, f=0) ################# 10: 1.62 (n=05, f=1) ################################### 11: 1.08 (n=05, f=0) ############ 12: 1.01 (n=06, f=0) ######### 13: 1.13 (n=06, f=0) ############## 14: 0.90 (n=06, f=0) #### 15: 0.81 (n=04, f=0) 16: 0.79 (n=06, f=0) 17: 0.73 (n=04, f=0) 18: 1.23 (n=06, f=0) ################## 19: 0.30 (n=04, f=0) 20: 0.78 (n=03, f=0) 21: 1.04 (n=03, f=0) OOOOOOOOOO 22: 0.02 (n=02, f=0)

(for better comparison it can be helpful to copy/paste part of this report into Excel)

Plausibility check for: 1_Sul_Compil_All.as

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Missing/Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of in-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=0.969)

Overall Age distrib Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.328)

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 10 (24)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 4 (14)

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 2 6 20 0 (0.96)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.02)

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=0.239)

Timing Excl Not determined yet 0 1 3 5

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

The overall score of this survey is 14 %, this is good.

Duplicate Entries in the database:

Line=404/ID=1 with Line=403/ID=1

Percentage of children with no exact birthday: 2 %

Line=26/ID=2: HAZ (3.077), Age may be incorrect Line=27/ID=3: HAZ (3.658), Age may be incorrect Line=61/ID=1: WHZ (-5.588) , WAZ (-4.007), Weight may be incorrect Line=63/ID=2: WAZ (-3.243), Age may be incorrect Line=159/ID=1: WHZ (-4.587) , HAZ (3.474), Height may be incorrect Line=168/ID=1: HAZ (3.563), Age may be incorrect Line=188/ID=1: WHZ (-3.817) , Weight may be incorrect Line=203/ID=4: HAZ (-3.881), Age may be incorrect Line=229/ID=3: HAZ (-5.415), WAZ (-3.271), Age may be incorrect Line=230/ID=1: HAZ (-4.165), Age may be incorrect Line=251/ID=1: HAZ (-4.144), Age may be incorrect Line=255/ID=3: HAZ (4.560), Age may be incorrect Line=257/ID=2: HAZ (3.083), Age may be incorrect Line=258/ID=1: HAZ (-4.260), Age may be incorrect Line=281/ID=1: HAZ (3.383), Height may be incorrect Line=282/ID=1: WHZ (-3.198) , Weight may be incorrect Line=348/ID=1: HAZ (-4.911), WAZ (-3.240), Age may be incorrect Line=412/ID=1: WHZ (3.874) , Height may be incorrect Line=427/ID=1: HAZ (3.211), WAZ (2.840), Age may be incorrect Line=467/ID=1: HAZ (2.469), Age may be incorrect Line=472/ID=2: HAZ (-5.704), WAZ (-4.418), Age may be incorrect Line=475/ID=1: HAZ (2.416), Age may be incorrect Line=516/ID=1: WHZ (-2.741) , Weight may be incorrect Line=529/ID=2: WAZ (2.848), Age may be incorrect Line=553/ID=2: WHZ (-3.599) , WAZ (-3.585), Weight may be incorrect Line=578/ID=1: WAZ (-3.316), Age may be incorrect Line=591/ID=1: HAZ (2.408), Age may be incorrect Line=621/ID=1: WAZ (3.076), Age may be incorrect

Percentage of values flagged with SMART flags:WHZ: 1.1 %, HAZ: 2.7 %, WAZ: 1.5 %

Age distribution:

Month 6 : ## Month 7 : ########## Month 8 : ######### Month 9 : ############# Month 10 : ########## Month 11 : ######### Month 12 : ############ Month 13 : ########## Month 14 : ################ Month 15 : ################## Month 16 : ######### Month 17 : ############ Month 18 : ########## Month 19 : ########### Month 20 : ###### 46

Month 21 : ############### Month 22 : ################### Month 23 : ################### Month 24 : ######### Month 25 : ############ Month 26 : ############ Month 27 : ########### Month 28 : ################ Month 29 : ######### Month 30 : ######## Month 31 : ######### Month 32 : ############## Month 33 : ################## Month 34 : ############# Month 35 : ######### Month 36 : ############### Month 37 : ################## Month 38 : ########### Month 39 : ############# Month 40 : ####### Month 41 : ############## Month 42 : ############ Month 43 : ############### Month 44 : ########### Month 45 : ########### Month 46 : ################## Month 47 : ############ Month 48 : ######### Month 49 : ####################### Month 50 : ######### Month 51 : ############ Month 52 : ############# Month 53 : ########## Month 54 : ############ Month 55 : ########## Month 56 : ########### Month 57 : ############ Month 58 : ################### Month 59 : ######### Month 60 : #########

Age ratio of 6-29 months to 30-59 months: 0.74 (The value should be around 0.85).

Statistical evaluation of sex and age ratios (using Chi squared statistic):

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 70/77.3 (0.9) 63/77.0 (0.8) 133/154.3 (0.9) 1.11 18 to 29 12 70/75.3 (0.9) 79/75.1 (1.1) 149/150.4 (1.0) 0.89 30 to 41 12 86/73.0 (1.2) 66/72.8 (0.9) 152/145.8 (1.0) 1.30 42 to 53 12 72/71.9 (1.0) 80/71.6 (1.1) 152/143.5 (1.1) 0.90 54 to 59 6 35/35.5 (1.0) 44/35.4 (1.2) 79/71.0 (1.1) 0.80 ------6 to 59 54 333/332.5 (1.0) 332/332.5 (1.0) 1.00 47

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.969 (boys and girls equally represented) Overall age distribution: p-value = 0.328 (as expected) Overall age distribution for boys: p-value = 0.497 (as expected) Overall age distribution for girls: p-value = 0.169 (as expected) Overall sex/age distribution: p-value = 0.044 (significant difference)

Digit preference Weight:

Digit .0 : #################################### Digit .1 : ############################## Digit .2 : ##################################### Digit .3 : ################################ Digit .4 : ################################## Digit .5 : #################################### Digit .6 : ##################### Digit .7 : ################################ Digit .8 : #################################### Digit .9 : ######################################

Digit preference score: 5 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.164

Digit preference Height:

Digit .0 : ################################################################ Digit .1 : ################## Digit .2 : ################### Digit .3 : ##################### Digit .4 : ###################### Digit .5 : ###################################### Digit .6 : ########## Digit .7 : ########## Digit .8 : ########## Digit .9 : ###########

Digit preference score: 24 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.000 (significant difference)

Digit preference MUAC:

Digit .0 : ############################################ Digit .1 : ################### Digit .2 : #################### Digit .3 : ################# 48

Digit .4 : ################### Digit .5 : #################################### Digit .6 : ################## Digit .7 : ############## Digit .8 : ################### Digit .9 : ################

Digit preference score: 14 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.000 (significant difference)

Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures

. no exclusion exclusion from exclusion from . reference mean observed mean . (WHO flags) (SMART flags) WHZ Standard Deviation SD: 1.05 1.03 0.96 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 1.8% 1.7% calculated with current SD: 1.5% 1.3% calculated with a SD of 1: 1.1% 1.1%

HAZ Standard Deviation SD: 1.27 1.27 1.10 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 12.9% 12.9% 12.2% calculated with current SD: 14.8% 14.8% 11.8% calculated with a SD of 1: 9.2% 9.2% 9.6%

WAZ Standard Deviation SD: 1.06 1.06 0.99 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 4.7% 4.7% calculated with current SD: 4.4% 4.4% calculated with a SD of 1: 3.5% 3.5%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.386 HAZ p= 0.000 p= 0.000 p= 0.362 WAZ p= 0.019 p= 0.019 p= 0.514 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)

Skewness WHZ -0.54 -0.32 -0.02 HAZ 0.11 0.11 -0.02 WAZ -0.19 -0.19 0.00 If the value is: -below minus 0.4 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 0.4 and minus 0.2, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 0.2 and plus 0.2, the distribution can be considered as symmetrical. -between 0.2 and 0.4, there may be an excess of obese/tall/overweight subjects in the sample. -above 0.4, there is an excess of obese/tall/overweight subjects in the sample

Kurtosis WHZ 2.33 1.26 -0.04 HAZ 1.47 1.47 -0.15 WAZ 0.60 0.60 -0.23 Kurtosis characterizes the relative size of the body versus the tails of the distribution. Positive kurtosis indicates relatively large tails and small body. Negative kurtosis indicates relatively large body and small tails. If the absolute value is: -above 0.4 it indicates a problem. There might have been a problem with data collection or 49

sampling. -between 0.2 and 0.4, the data may be affected with a problem. -less than an absolute value of 0.2 the distribution can be considered as normal.

Test if cases are randomly distributed or aggregated over the clusters by calculation of the Index of Dispersion (ID) and comparison with the Poisson distribution for:

WHZ < -2: ID=1.17 (p=0.239) GAM: ID=1.17 (p=0.239) HAZ < -2: ID=2.32 (p=0.000) HAZ < -3: ID=1.66 (p=0.015) WAZ < -2: ID=1.33 (p=0.112)

Subjects with SMART flags are excluded from this analysis.

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.85 (n=30, f=0) ## 02: 0.98 (n=30, f=0) ######## 03: 1.27 (n=30, f=0) #################### 04: 0.89 (n=30, f=0) #### 05: 1.21 (n=30, f=1) ################# 06: 0.85 (n=30, f=0) ## 07: 1.47 (n=30, f=2) ############################ 08: 1.66 (n=30, f=2) #################################### 09: 1.17 (n=30, f=1) ################ 10: 0.88 (n=30, f=0) ### 11: 1.09 (n=30, f=0) ############ 12: 0.76 (n=30, f=0) 13: 0.93 (n=30, f=0) ##### 14: 0.72 (n=30, f=0) 15: 0.87 (n=30, f=0) ### 16: 0.96 (n=30, f=0) ####### 17: 1.00 (n=30, f=0) ######## 18: 0.90 (n=30, f=0) #### 19: 1.05 (n=30, f=0) ########## 20: 1.07 (n=29, f=0) ########### 21: 0.99 (n=27, f=0) ######## 22: 0.90 (n=19, f=0) OOOO 23: 1.33 (n=11, f=0) OOOOOOOOOOOOOOOOOOOOOO 24: 2.31 (n=04, f=1) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 25: 0.71 (n=03, f=0) 26: 0.28 (n=02, f=0)

Analysis by Team

Team 1 2 3 4 5 6 7 9 n = 100 72 114 75 80 111 111 2 Percentage of values flagged with SMART flags: WHZ: 2.0 0.0 0.9 2.7 1.3 0.9 0.0 0.0 HAZ: 4.0 1.4 2.6 2.7 2.5 3.6 1.8 0.0 WAZ: 0.0 1.4 1.8 1.3 1.3 3.6 0.9 0.0 Age ratio of 6-29 months to 30-59 months: 0.69 0.85 0.70 0.79 0.90 0.66 0.71 0.00 Sex ratio (male/female): 0.89 1.18 1.15 1.14 1.00 0.85 0.95 1.00 Digit preference Weight (%): .0 : 13 11 12 7 3 18 9 50 .1 : 10 7 10 11 13 5 10 0 .2 : 9 11 10 21 10 5 15 0 .3 : 8 8 12 4 6 12 14 0 .4 : 13 11 11 8 9 12 8 0 .5 : 10 13 11 7 14 10 12 0 .6 : 6 7 7 7 6 8 4 0 .7 : 9 11 8 9 18 7 8 50 .8 : 10 8 11 13 11 10 13 0 .9 : 12 13 10 13 11 14 8 0 DPS: 7 7 5 16 14 13 11 67 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference Height (%): .0 : 25 17 38 15 19 65 11 50 .1 : 9 14 5 11 8 0 14 0 .2 : 14 7 7 8 15 3 8 0 .3 : 8 7 8 19 10 2 16 0 .4 : 11 15 9 5 16 3 13 0 .5 : 15 19 19 20 9 24 12 0 .6 : 6 4 2 7 6 0 7 0 .7 : 2 7 6 8 0 0 9 0 .8 : 6 1 4 5 6 3 5 0 .9 : 4 8 3 3 11 1 5 50 DPS: 21 19 35 19 18 65 11 67 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference MUAC (%): .0 : 18 15 39 17 11 20 14 0 .1 : 7 11 4 9 20 2 10 0 .2 : 8 7 5 9 8 12 13 0 .3 : 9 3 6 12 6 8 8 0 .4 : 7 8 2 9 14 9 13 50 .5 : 24 8 29 8 5 20 13 0 .6 : 7 15 2 9 15 5 9 0 .7 : 9 11 2 8 6 5 5 50 .8 : 7 11 7 7 6 19 3 0 51

.9 : 4 10 4 11 9 1 14 0 DPS: 19 12 41 9 15 23 12 67 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Standard deviation of WHZ: SD 0.98 1.06 0.98 1.24 1.02 1.10 0.92 0.46 Prevalence (< -2) observed: % 1.4 2.7 1.3 3.6 Prevalence (< -2) calculated with current SD: % 1.8 2.8 1.3 4.5 Prevalence (< -2) calculated with a SD of 1: % 1.3 0.9 1.1 3.1 Standard deviation of HAZ: SD 1.50 1.27 1.18 1.29 1.11 1.37 1.12 0.39 observed: % 20.0 15.3 4.4 20.0 6.3 15.3 11.7 calculated with current SD: % 20.4 17.3 9.4 16.9 10.2 16.8 12.7 calculated with a SD of 1: % 10.7 11.5 6.0 10.8 7.9 9.5 10.1

Statistical evaluation of sex and age ratios (using Chi squared statistic) for:

Team 1:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 13/10.9 (1.2) 9/12.3 (0.7) 22/23.2 (0.9) 1.44 18 to 29 12 8/10.6 (0.8) 11/12.0 (0.9) 19/22.6 (0.8) 0.73 30 to 41 12 12/10.3 (1.2) 9/11.6 (0.8) 21/21.9 (1.0) 1.33 42 to 53 12 8/10.1 (0.8) 14/11.4 (1.2) 22/21.6 (1.0) 0.57 54 to 59 6 6/5.0 (1.2) 10/5.7 (1.8) 16/10.7 (1.5) 0.60 ------6 to 59 54 47/50.0 (0.9) 53/50.0 (1.1) 0.89

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.549 (boys and girls equally represented) Overall age distribution: p-value = 0.501 (as expected) Overall age distribution for boys: p-value = 0.740 (as expected) Overall age distribution for girls: p-value = 0.243 (as expected) Overall sex/age distribution: p-value = 0.091 (as expected)

Team 2:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 13/9.0 (1.4) 7/7.7 (0.9) 20/16.7 (1.2) 1.86 18 to 29 12 7/8.8 (0.8) 6/7.5 (0.8) 13/16.3 (0.8) 1.17 30 to 41 12 11/8.6 (1.3) 6/7.2 (0.8) 17/15.8 (1.1) 1.83 42 to 53 12 7/8.4 (0.8) 10/7.1 (1.4) 17/15.5 (1.1) 0.70 54 to 59 6 1/4.2 (0.2) 4/3.5 (1.1) 5/7.7 (0.7) 0.25 ------6 to 59 54 39/36.0 (1.1) 33/36.0 (0.9) 1.18

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.480 (boys and girls equally represented) Overall age distribution: p-value = 0.648 (as expected) Overall age distribution for boys: p-value = 0.245 (as expected) Overall age distribution for girls: p-value = 0.775 (as expected) Overall sex/age distribution: p-value = 0.090 (as expected)

Team 3:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 9/14.2 (0.6) 10/12.3 (0.8) 19/26.5 (0.7) 0.90 18 to 29 12 13/13.8 (0.9) 15/12.0 (1.3) 28/25.8 (1.1) 0.87 30 to 41 12 14/13.4 (1.0) 7/11.6 (0.6) 21/25.0 (0.8) 2.00 42 to 53 12 21/13.2 (1.6) 11/11.4 (1.0) 32/24.6 (1.3) 1.91 54 to 59 6 4/6.5 (0.6) 10/5.7 (1.8) 14/12.2 (1.2) 0.40 ------6 to 59 54 61/57.0 (1.1) 53/57.0 (0.9) 1.15

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.454 (boys and girls equally represented) Overall age distribution: p-value = 0.246 (as expected) Overall age distribution for boys: p-value = 0.108 (as expected) Overall age distribution for girls: p-value = 0.173 (as expected) Overall sex/age distribution: p-value = 0.006 (significant difference)

Team 4:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 7/9.3 (0.8) 8/8.1 (1.0) 15/17.4 (0.9) 0.88 18 to 29 12 12/9.0 (1.3) 6/7.9 (0.8) 18/17.0 (1.1) 2.00 30 to 41 12 13/8.8 (1.5) 8/7.7 (1.0) 21/16.4 (1.3) 1.63 42 to 53 12 4/8.6 (0.5) 11/7.6 (1.5) 15/16.2 (0.9) 0.36 54 to 59 6 4/4.3 (0.9) 2/3.7 (0.5) 6/8.0 (0.7) 2.00 ------6 to 59 54 40/37.5 (1.1) 35/37.5 (0.9) 1.14

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.564 (boys and girls equally represented) Overall age distribution: p-value = 0.691 (as expected) Overall age distribution for boys: p-value = 0.194 (as expected) Overall age distribution for girls: p-value = 0.581 (as expected) Overall sex/age distribution: p-value = 0.050 (as expected)

Team 5:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 9/9.3 (1.0) 5/9.3 (0.5) 14/18.6 (0.8) 1.80 18 to 29 12 10/9.0 (1.1) 14/9.0 (1.5) 24/18.1 (1.3) 0.71 30 to 41 12 10/8.8 (1.1) 7/8.8 (0.8) 17/17.5 (1.0) 1.43 42 to 53 12 6/8.6 (0.7) 12/8.6 (1.4) 18/17.3 (1.0) 0.50 54 to 59 6 5/4.3 (1.2) 2/4.3 (0.5) 7/8.5 (0.8) 2.50 ------6 to 59 54 40/40.0 (1.0) 40/40.0 (1.0) 1.00

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 1.000 (boys and girls equally represented) Overall age distribution: p-value = 0.498 (as expected) Overall age distribution for boys: p-value = 0.877 (as expected) Overall age distribution for girls: p-value = 0.109 (as expected) Overall sex/age distribution: p-value = 0.067 (as expected)

Team 6:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 8/11.8 (0.7) 13/13.9 (0.9) 21/25.8 (0.8) 0.62 18 to 29 12 11/11.5 (1.0) 12/13.6 (0.9) 23/25.1 (0.9) 0.92 30 to 41 12 12/11.2 (1.1) 16/13.2 (1.2) 28/24.3 (1.2) 0.75 42 to 53 12 14/11.0 (1.3) 11/12.9 (0.8) 25/24.0 (1.0) 1.27 54 to 59 6 6/5.4 (1.1) 8/6.4 (1.2) 14/11.8 (1.2) 0.75 ------6 to 59 54 51/55.5 (0.9) 60/55.5 (1.1) 0.85

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.393 (boys and girls equally represented) Overall age distribution: p-value = 0.728 (as expected) Overall age distribution for boys: p-value = 0.699 (as expected) Overall age distribution for girls: p-value = 0.818 (as expected) Overall sex/age distribution: p-value = 0.352 (as expected)

Team 7:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 11/12.5 (0.9) 11/13.2 (0.8) 22/25.8 (0.9) 1.00 18 to 29 12 9/12.2 (0.7) 15/12.9 (1.2) 24/25.1 (1.0) 0.60 30 to 41 12 13/11.8 (1.1) 13/12.5 (1.0) 26/24.3 (1.1) 1.00 42 to 53 12 12/11.7 (1.0) 10/12.3 (0.8) 22/24.0 (0.9) 1.20 54 to 59 6 9/5.8 (1.6) 8/6.1 (1.3) 17/11.8 (1.4) 1.13 ------6 to 59 54 54/55.5 (1.0) 57/55.5 (1.0) 0.95

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 0.776 (boys and girls equally represented) Overall age distribution: p-value = 0.540 (as expected) Overall age distribution for boys: p-value = 0.562 (as expected) Overall age distribution for girls: p-value = 0.778 (as expected) Overall sex/age distribution: p-value = 0.309 (as expected)

Team 8:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 0/0.2 (0.0) 0/0.2 (0.0) 0/0.5 (0.0) 18 to 29 12 0/0.2 (0.0) 0/0.2 (0.0) 0/0.5 (0.0) 30 to 41 12 1/0.2 (4.6) 0/0.2 (0.0) 1/0.4 (2.3) 42 to 53 12 0/0.2 (0.0) 1/0.2 (4.6) 1/0.4 (2.3) 0.00 54 to 59 6 0/0.1 (0.0) 0/0.1 (0.0) 0/0.2 (0.0) ------6 to 59 54 1/1.0 (1.0) 1/1.0 (1.0) 1.00

The data are expressed as observed number/expected number (ratio of obs/expect)

Overall sex ratio: p-value = 1.000 (boys and girls equally represented) Overall age distribution: p-value = 0.627 (as expected) Overall age distribution for boys: p-value = 0.469 (as expected) Overall age distribution for girls: p-value = 0.458 (as expected) Overall sex/age distribution: p-value = 0.126 (as expected)

Team: 1

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.62 (n=05, f=0) 02: 1.22 (n=05, f=0) ################## 03: 1.12 (n=04, f=0) ############# 04: 0.41 (n=05, f=0) 05: 0.95 (n=05, f=0) ###### 06: 1.12 (n=05, f=0) ############## 07: 1.90 (n=04, f=1) ############################################## 08: 1.08 (n=04, f=0) ############ 09: 1.54 (n=05, f=0) ############################### 10: 1.01 (n=05, f=0) ######### 11: 1.31 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOO 12: 0.09 (n=04, f=0) 13: 0.79 (n=04, f=0) 14: 0.51 (n=05, f=0) 15: 0.68 (n=05, f=0) 16: 0.33 (n=04, f=0) 17: 1.08 (n=05, f=0) ############ 18: 0.83 (n=05, f=0) # 19: 1.19 (n=04, f=0) ################ 20: 0.53 (n=05, f=0) 21: 1.17 (n=05, f=0) ################ 22: 0.81 (n=03, f=0)

Team: 2

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.84 (n=06, f=0) ## 02: 1.12 (n=02, f=0) OOOOOOOOOOOOO 03: 0.85 (n=02, f=0) OO 04: 1.45 (n=03, f=0) ########################### 05: 0.27 (n=03, f=0) 06: 0.57 (n=05, f=0) 07: 1.79 (n=04, f=0) ########################################## 08: 1.25 (n=03, f=0) ################### 09: 0.89 (n=04, f=0) #### 10: 1.03 (n=04, f=0) ########## 11: 1.39 (n=04, f=0) ######################### 12: 0.65 (n=03, f=0) 13: 0.77 (n=04, f=0) 14: 1.06 (n=04, f=0) ########### 15: 0.45 (n=02, f=0) 16: 0.65 (n=03, f=0) 17: 0.97 (n=04, f=0) ####### 18: 1.87 (n=03, f=0) ############################################# 19: 0.44 (n=02, f=0) 20: 0.19 (n=02, f=0) 21: 0.95 (n=03, f=0) ######

(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found 55

in the different time points)

Team: 3

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.54 (n=06, f=0) 02: 0.39 (n=04, f=0) 03: 1.39 (n=04, f=0) ######################### 04: 0.91 (n=05, f=0) ##### 05: 0.54 (n=05, f=0) 06: 0.68 (n=06, f=0) 07: 0.86 (n=05, f=0) ### 08: 1.80 (n=04, f=1) ########################################## 09: 0.75 (n=06, f=0) 10: 0.22 (n=04, f=0) 11: 1.57 (n=05, f=0) ################################ 12: 0.83 (n=05, f=0) # 13: 0.59 (n=05, f=0) 14: 0.98 (n=05, f=0) ######## 15: 0.93 (n=04, f=0) ##### 16: 1.51 (n=04, f=0) ############################## 17: 0.92 (n=05, f=0) ##### 18: 0.41 (n=06, f=0) 19: 1.88 (n=04, f=0) ############################################## 20: 0.61 (n=06, f=0) 21: 1.14 (n=04, f=0) ############## 22: 0.86 (n=04, f=0) ### 23: 0.75 (n=04, f=0) 24: 0.58 (n=02, f=0)

Team: 4

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.11 (n=06, f=0) ############# 02: 0.19 (n=02, f=0) 03: 0.67 (n=04, f=0) 04: 0.50 (n=05, f=0) 05: 2.13 (n=05, f=1) ######################################################## 06: 1.01 (n=03, f=0) ######### 07: 1.62 (n=03, f=0) ################################## 08: 1.76 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 09: 2.17 (n=03, f=0) ########################################################## 10: 0.99 (n=03, f=0) ######## 11: 1.45 (n=03, f=0) ########################### 12: 1.03 (n=03, f=0) ########## 13: 0.99 (n=03, f=0) ######## 14: 0.78 (n=03, f=0) 15: 1.00 (n=03, f=0) ######### 16: 1.48 (n=05, f=0) ############################ 17: 1.84 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 18: 0.63 (n=04, f=0) 19: 0.35 (n=04, f=0) 20: 0.69 (n=04, f=0) 21: 0.41 (n=02, f=0)

Team: 5

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.04 (n=06, f=0) ########## 02: 1.04 (n=04, f=0) ########## 03: 0.44 (n=02, f=0) 04: 0.87 (n=04, f=0) ### 05: 1.24 (n=04, f=0) ################### 56

06: 0.51 (n=03, f=0) 07: 2.14 (n=05, f=1) ######################################################## 08: 0.69 (n=03, f=0) 09: 1.18 (n=04, f=0) ################ 10: 0.26 (n=03, f=0) 11: 0.91 (n=04, f=0) ##### 12: 0.74 (n=05, f=0) 13: 0.93 (n=03, f=0) ##### 14: 0.84 (n=05, f=0) ## 15: 0.57 (n=03, f=0) 16: 0.62 (n=04, f=0) 17: 0.32 (n=03, f=0) 18: 1.49 (n=05, f=0) ############################# 19: 0.06 (n=02, f=0) 20: 1.78 (n=03, f=0) ######################################### 21: 0.75 (n=03, f=0) 22: 0.02 (n=02, f=0)

Team: 6

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.76 (n=07, f=0) 02: 1.06 (n=06, f=0) ########### 03: 1.42 (n=05, f=0) ########################## 04: 1.38 (n=05, f=1) ######################## 05: 0.55 (n=05, f=0) 06: 0.88 (n=04, f=0) ### 07: 3.06 (n=05, f=1) ################################################################ 08: 0.73 (n=06, f=0) 09: 1.01 (n=06, f=0) ######### 10: 0.93 (n=05, f=0) ###### 11: 1.11 (n=04, f=0) ############# 12: 0.99 (n=05, f=0) ######## 13: 0.86 (n=04, f=0) ### 14: 0.25 (n=05, f=0) 15: 1.11 (n=04, f=0) ############# 16: 1.10 (n=05, f=0) ############# 17: 0.66 (n=04, f=0) 18: 0.48 (n=05, f=0) 19: 1.60 (n=05, f=0) ################################## 20: 0.89 (n=04, f=0) #### 21: 0.41 (n=05, f=0) 22: 0.92 (n=04, f=0) #####

Team: 7

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.72 (n=07, f=0) 02: 0.67 (n=05, f=0) 03: 0.69 (n=04, f=0) 04: 0.59 (n=05, f=0) 05: 0.57 (n=06, f=0) 06: 1.39 (n=04, f=0) ######################### 07: 1.29 (n=07, f=1) ##################### 08: 1.00 (n=06, f=0) ######## 09: 1.14 (n=06, f=0) ############## 10: 1.15 (n=05, f=0) ############### 11: 0.83 (n=05, f=0) # 12: 0.35 (n=05, f=0) 13: 0.72 (n=05, f=0) 14: 0.55 (n=06, f=0) 15: 0.96 (n=05, f=0) ####### 16: 0.49 (n=05, f=0) 17: 1.16 (n=03, f=0) OOOOOOOOOOOOOOO 18: 0.46 (n=04, f=0) 57

19: 0.70 (n=04, f=0) 20: 0.54 (n=04, f=0) 21: 1.15 (n=05, f=0) ############### 22: 0.65 (n=03, f=0) 23: 1.36 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOO

Team: 8

Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

(for better comparison it can be helpful to copy/paste part of this report into Excel).

Annex 3: Standardization test Preci Standardisation test results sion Accuracy OUTCOME

subj me S Technical TEM/ Coef of Bias from Bias from res Weight ects an D max error mean reliability superv median ult k TEM TEM # Kg g kg (kg) (%) R (%) Bias (kg) Bias (kg) Supervisor R value good Enumerator R value 1 good Bias good Enumerator R value 2 good Bias good Enumerator R value 3 good Bias good Enumerator R value 4 good Bias good Enumerator R value 5 good Bias good Enumerator R value 6 good Bias good Enumerator R value 7 acceptable Bias good Enumerator R value 8 good Bias good Enumerator R value 9 good Bias good Enumerator R value 10 acceptable Bias good

enum inter 1st R value good enum inter 2nd R value acceptable inter enum + sup R value good TOTAL R value intra+inter acceptable Bias good TOTAL+ sup R value acceptable

Height

Supervisor R value good Enumerator R value 1 good Bias good Enumerator R value 2 good Bias good Enumerator R value 3 good Bias good Enumerator R value 4 good Bias good Enumerator R value 5 good Bias good Enumerator R value 6 acceptable Bias good Enumerator R value 7 good Bias good Enumerator R value 8 reject Bias good

Enumerator R value 9 acceptable Bias good Enumerator R value 10 good Bias good enum inter 1st R value acceptable enum inter 2nd R value reject inter enum + sup R value reject TOTAL R value intra+inter reject Bias good TOTAL+ sup R value reject

MUAC

Supervisor R value good Enumerator R value Bias 1 acceptable reject Enumerator R value Bias 2 reject reject Enumerator R value 3 reject Bias good Bias Enumerator R value acceptabl 4 good e Enumerator R value Bias 5 reject reject Enumerator R value Bias

6 reject reject Enumerator R value Bias 7 reject reject Enumerator R value 8 reject Bias poor Enumerator R value Bias 9 reject reject Enumerator R value Bias 10 poor reject enum inter 1st R value reject enum inter 2nd R value reject inter enum + sup R value reject TOTAL R value Bias intra+inter reject reject TOTAL+ sup R value reject

Parameter individual good TEM acceptable (intra) poor reject Team TEM good (intra+inter) acceptable and Total poor

reject R value good acceptable poor reject Bias good From sup if good acceptable outcome, otherwise poor from median reject

Annex 4: Assignment of clusters

Nutritional survey for IDPs -Erbil 2014

Number of Sub Sub Name of Health No. of District District U5 IDPs Population Cluster No. district district Centre children code Children code Tayrawa 479 2874 1 1 Zhyan 189 1134 1 21 1 1 Koran/ ankawa 241 1446 1 1 Azady 264 1584 2 21 1 1 akray Nafaa 182 1092 1 1 bajalan Mohammes 68 408 1 1 Shaheedan 305 1830 1 1

Erbil haydar Najdi 238 1428 3 21 1 1 bamarney Nazdazr 233 1398 1 1 Nawroz 283 1698 4 21 1 1

Erbil Kurdistan 621 3726 5 21 1 1

Mala afandi 264 1584 1 1 Sarwaran 474 2844 6 21 1 1 Brayaty 235 1410 1 1 Ainkawa malih Habeeb 3083 18498 7,8,9,10,11 105 1 2 Toraq 239 1434 1 1 Sarkarez 363 2178 12 21 1 1 Erbil Hawkari 824 4944 13 21 1 1 Hasarook 139 834 1 1 Shadi 335 2010 14 21 1 1

Betwata 89 534 1 1 binsalawa 1050 6300 15,16 42 1 1 Kasnazan Kasnazan 1590 9538 17,18 42 1 3 Daratoo Daratoo 1045 6272 19,RC 21 1 4 Qushtapa Qushtapa 740 4439 RC 1 5 Erbil Shawes 1358 8147 20,21 42 1 1 Kasnazan Lawan collective 2742 16449 22,23,24,25 84 1 3 Erbil Girdarasha 190 1138 1 1 Shaqlawa shaqlawa center 1526 9156 26,27,28 63 2 1 Harer Harer 260 1560 2 2 Heran Hera n 77 464 2 3 Basirma Basirma 98 589 RC 2 4 Shaqlawa Balesan Balesan 2 12 2 5 Soran Soran Soran 1237 7422 RC 3 1 Barzan Barzan Barzan 47 282 29 21 4 1 Choman Choman Choman 25 150 5 1 Koya Koya Koya 748 4488 30 21 6 1 Total 21882 131294 630

Nutritional survey for IDPs -Sulaimanya 2014

District Subdsitrict No. of District Sub district Name of Health Centre code code Children Cluster No. Cluster Sarchnar 1 21 Fayaqi Hagi Ali Shakraka Shaheed Jaza 2 21 Kani Kurda Farmanbaran Hawari Shar Shaeed M.Esmael 3 21 Sarwary Suleimanya 01 Suleimanya 01 Kurdsat(Shaheed Baqhi) 1 1 Shaheed Rebaz Awbara Costay Cham Rapareen 4 21 Chwderi Rapareen Centre Babagurgur 5 21 Khbat(Sh.Hasan Khawe Hajiawa Zerinok

Qaradadagh Woluba 6 21 Azadei Ali Kamal Shaheed Sardar 7 21 Ibraheem Pasha Ibraheem Ahmed Qaiwan Rozhalat Chwarbagh 8 21 Shaheed hama Rash Sh.RafiqHama Jan Kareza Wishik 9 21 Rezgari Bakhtiary Mamostayan Sh. Shamal 10 21 Shaheed Bakhtiar Ali Nagei Zargata 11 21 Arbat Tanjaro Tanjaro 2 Suleimanya Birth Centre 12 1 21 Suleimanya Bazyan Glazarda 13 3 21

Bardaqharaman+Tainal Tasluja 14 21 Saidsadiq Sharazoor Sharazoor Shanadary 2 1 Penjwen Zimnako RC Zamnako Zamnako 3 3 Shaheed Dr Chia Halabja Halabja Halabja 4 4 Dukan Dukan 15 1 21 Khalakan Khalakan 2 Dukan 05 5 Peramagro Peramagro 16 3 21 Surdash Surdash 17 4 21 Kewa Rash Rania+Sarkapkan 1 Cometan Raparen 2 Bingrd 3 Ranai 06 Chwar Qurna+Khadran RC 6 4 Hajiawa 5 Saruchawa 6 Shkarta 7 Everia+Hero+Halsho 1 Qaladiza Qaladiza Raparen Qaladza 7 2 Sangasar+Zurkan 3 Chamchamal Chamchamal Charmoo 18,19 8 1 42

Shorash Sagirma 20,21 2 42 Takya Takya 3 Darbandikhan Darbandikhan 22 1 21 Darbandikhan 9 Pebaz Pebaz 2 Kalar Sherwana 23,24,RC 1 42 Kalar Garmian Garmian 25 11 2 21 Kulajo Kalar RC,27,28,29,30 3 84 Kifiri Kifiri Kifiri 26 10 1 Total

Annex 5: Questionnaire NUTRITION SURVEY HOUSEHOLD DATA COLLECTION FORM

Consent: My name is ______and I am working with the Ministry of health. We are conducting a survey on the nutrition and health status of your family. I would like to ask you few questions about your family and we will also weigh and measure your children who are younger than 5 years of age. The survey usually takes about 30 minutes to complete. Any information that you provide will be kept strictly confidential and will not be shown to other people. Your name or any of the family members will not be mentioned to any document and report. This is voluntary and you can choose not to answer any or all of the questions if you want; however we hope that you will participate since your views are important.

Do you have any questions? Questionnaire cleared by:______Section A : Household identification

Date: /______/______/ 2014 : Team number: /__/__/

Governorate: ______/___/ District: ______/__/__/

Sub district: ______/__/__/ Cluster number: /____/____/

Household number: Respondent number: /__/__/__/__/ /__/__/__/__/__/__/__/__/__/__/__/__/__/ IDP location: ______Type of settlement: ______District of origin______Duration in the site: /______/

Section B : Socio economic Characteristics Q 1 . Respondent name : ______

Phone Number ( if possible) : Q 2 . Respondent age (in completed year) ? /___/___/ Q 3. Respondent marital status? 1. Married 2. Single /___/ 3. Divorced 4. Widowed 5. Orphan (under 18 years old) Q 4. What was the highest level of education did you (respondent) reach 1. Illiterate /___/ 2. Read Alone 3. Read And Write 4. Primary Level 5. Secondary Level 6. Above Secondary Q. 5. What do you do for a living nowadays 1. Business /___/ 2. Vocational skills 3. Casual labour 4. Wage employment 5. Government employment ______70

6. Unemployment 7. Other (Specify) Q. 6. How many persons living in this household? /___/___/ Q.7. How many children living in this household are under age five? /___/___/ Q 8 . Can you please tell me the name of the Youngest?

How old is (name of the youngest) /___/____/ /___/____/ /____/_____/ (day/month/year) if not known age in months/____/____/ Sex: Male: /___/ Female: /____/

Read to Respondent: The following questions below refer to “Child’s name” Section C : Infant and Young child feeding & health status Q 1. Are you currently breastfeeding (NAME)? 1. Yes /___/ 2. No If yes go to Q3 Q 2. Did you ever breastfeed (NAME)? 1. Yes /___/ 2. No Q 3. Du ring the first three days after delivery did you give (NAME) any food or liquid other than your breast milk? 1. Yes /___/____/ 2. No 99. Don’t know Q 4. Did (NAME) take a vitamin A dose like this during the last 6 months? SHOW CAPSULE /___/____/ 1. Yes 2. No 99. Don’t know Q 5. Do you have a card where (NAME) vaccinations are written down? May I see it please? 1. Yes, seen by interviewer /___/____/ 2. Not available/ lost/misplaced 3. Never had a card 99. Don’t know If Yes, please report all vaccines and dates (interviewer to derive the information from the card) If Yes, please report all vaccines and dates

BCG------OPV0 ------Hep B------Penta– 1------OPV1------Rota 1------Tetra– 1------OPV2------Rota 2------Penta– 2------OPV3------Rota 3------Measles------MMR1------Tetra– 2------OPV1-Booster------Tetra-3-Boos ter------OPV2Booster------MMR2 ------

Q 6. Has (NAME) had diarrhea in the last 2 weeks? 1. Yes 2. No /___/____/ 99. Don’t know Q 6. Has (NAME) had ARI in the last 2 weeks? 1. Yes /___/____/ 2. No Don’t know 71

Read to Respondent: The following question refer to the household Section D : Household food security, water access and hygiene Q 1. Did you experience food shortages during the past 6 weeks? 1. Yes /___/____/ 2. No 99. Would not tell Q 2. Have you received food aid during any of the last 6 weeks? 1. Yes /___/____/ 2. No 99. Not aware Q3. In the past 6 weeks, How many times have you received food aid? 1. Once 2. Two time /___/____/ 3. Three time or more 99. Don’t know Q4. In the past 6 weeks, How many meals do you often have? 1. Once /___/____/ 2. Two

3. Three or more 99. Don’t know Q 5 . What is the main source of drinking water for your household at the moment? 1. Safe Water Source (household connection, tap water, public standpipe, /____/ borehole, protected dug well, protected spring, tanker truck water, mineral water) 2. Unsafe water source (unprotected spring, unprotected well, rivers or ponds) Q 7 . What kind of toilet facility does your household use? 1. Flush latrine /____/ 2. Improved latrine with cement slab 3. Open air (corner place in the compound) ______4. Other (specify) Q 8: How many households share this toilet? (observant) /___/____/ 1. Not shared 2. Shared households (with how many) /____/ or don’t know /____/ 3. Public toilet 99. Don’t know

Section E: Anthropometric data for children aged 6 -59 months Birth date Child Sex Œdema Weight height MUAC Child name (dd/mm/yyyy) or no. (F/M) (Y/N) (00.0kg) (00.0cm) (000mm) age in month

Section F: Mortality questionnaire Joined Left Born Died Date on or on or on or on or Cause of after after later later of death Household members Sex birth/ or No name (F/M) age Start date of the recall period : reason in 01/08/2014 for years Write Y for yes and leave blank leaving if No a) List all the household members that are currently living in the Household 1 2 3 4 5 6 7 8 9 10 11 12 b) List all the household members that have left this household (out migrants) since the start of the recall period 1 2 3 4 5 6 7 8 c) List all the household members who died since the start of the recall period 1 2 3 4