Afghanis T An

Rapid SMART Assessment Report Qala-e-Naw IDP Camps, Badghis province Date: 4-11 April 2019

AFGHANISTAN

Lead by: Dr: Shafiullah Samim, Dr. M. Khalid Zakir and Dr. Nazir Sajid Author: Beka Teshome and Dr. Sayed Rahim Rastkar

Funded by: AHF-OCHA

Action Contre la Faim

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

TABLE OF CONTENTS

AKNOWLEDGMENT ...... 4 ACRONYMS AND ABBREVIATIONS ...... 5 EXECUTIVE SUMMARY ...... 7 1. BACKGROUND ...... 9 2. Objectives...... 10 2.1. General objective ...... 10 2.2. Specific objectives ...... 10 3. METHODOLOGY ...... 10 3.1. Geographic target area and population group ...... 10 3.2. Survey period ...... 11 3.3. Survey design ...... 11 3.4. Sample size ...... 11 3.5. Sampling procedures ...... 12 3.5.1. First stage sampling: selection of clusters ...... 12 3.5.2. Second stage sampling: selection of households ...... 12 3.6. Organization of the Survey ...... 13 3.6.1. Survey Coordination...... 13 3.6.2. Survey Teams ...... 13 3.6.3. Training of the Survey Teams ...... 13 3.7. Data collection and field work ...... 14 3.7.1. Children anthropometric survey ...... 14 3.7.2. Maternal nutritional status ...... 15 3.7.3. Child Morbidity ...... 15 3.8. Data quality assurance ...... 15 4. Data management and Analysis ...... 15 5. Results ...... 15 5.1. Mean z-scores, Design Effects and excluded subjects ...... 15 5.2. General characteristics of study population and households ...... 16 5.2.1. Households and children 6-59 months ...... 16 5.2.2. Pregnant and Lactating Women ...... 17 5.3. Anthropometric results ...... 17 5.3.1. Distribution by sex and age ...... 17 5.3.2. Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex ...... 18 5.3.3. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema 19 5.3.4. Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) ...... 20 5.3.5. Prevalence of underweight based on weight-for-age z-scores ...... 21 5.3.6. Prevalence of stunting based on height-for-age z-scores and by sex ...... 22 5.4. Child morbidity ...... 22 5.5. Maternal nutritional status ...... 23

5.6. Prevalence of Combined Acute Malnutrtion based on WHZ and/or MUAC ...... 23 5.7. Proportion of acutely malnourished children enrolled in & referred to a nutrition program ... 23 6. DISCUSSION ...... 24 6.1. Nutritional status ...... 24 6.2. Child health indicators ...... 26 7. Recommendations ...... 26 Annexes ...... 27 Annex 1: Plausibility check for: Badghis_IDP_camps_segment A _April_2019_Afghanistan.as ...... 28 Annex 2: Plausibility check for: Badghis_IDP_camps_Segment B _April_2019_Afghanistan.as ...... 28 Annex 3: Selected clusters, segment A, Qala-e-Naw IDP camp ...... 29 Annex 4: Selected clusters, segment B, Qala-e-Naw IDP camp ...... 30 Annex 5: Rapid SMART Assessment questionnaires for children and pregnant and lactating women . 32 Annex 6: Event calendar ...... 34

AKNOWLEDGMENT

This survey would not have been possible without the financial support provided by Afghanistan Humanitarian Fund (AHF). Action Against Hunger (AAH) would also like to thank all stakeholders and partners who provided support to the Rapid SMART Assessment teams in Qala-e-Naw city IDP Camps, Badghis province:

 Public Nutrition Department (PND), Nutrition cluster and Afghanistan Information Management Working Group (AIM-WG) for their support in methodological review and validation.  Badghis Provincial Public Health Directorate (PPHD) and currently Badghis Provincial Nutrition officer (PNO) for the support provided in the authorization of the survey.  All the community members for welcoming and supporting the survey teams during the data collection process.  All health stakeholders who are currently providing health and nutrition services in the IDP camps  Afghan Youth Services Organization (AYSO) especially Dr. Anasul Haq Rahimi, Dr. Abdullah Qarizada and Dr. Amanullah Saqeb for the smooth implementation of the assessments in Qala-e- Naw city IDP camps in Badghis province.  Survey teams composed of enumerators and supervisors for making the whole process smooth.  AAH teams at Kabul and Paris for technical, logistics and administrative support.

Statement on Copyright

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

Unless otherwise indicated, reproduction is authorized on condition that the source is credited. If reproduction or use of texts and visual materials (sound, images, software, etc.) is subject to prior authorization, such authorization was render null and void the above-mentioned general authorization and was clearly indicate any restrictions on use.

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

ACRONYMS AND ABBREVIATIONS

AAH Action Against Hunger AfDHS Afghanistan Demographic Health Survey AHF Afghanistan Humanitarian Fund AIM-WG Assessment Information Management Working Group AYSO Afghan Youth Services Organization cGAM Combined Global Acute Malnutrition CI Confidence Interval cSAM Combined Severe Acute Malnutrition CSO Central Statistics Organization DD Date ENA Emergency Nutrition Assessment GAM Global Acute Malnutrition HAZ Height for Age Z score HH Households IDP Internally Displaced People IMAM Integrated Management of Acute Malnutrition IPD-SAM Inpatient Department for Severe Acute Malnutrition MAM Moderate Acute Malnutrition MHT Mobile Health Team MM Month MoPH Ministry of Public Health MUAC Mid-Upper Arm Circumference NGO Non-Governmental Organisation NRC Norwegian Refugee Council OPD-MAM Outpatient Department for Moderate Acute Malnutrition OPD-SAM Outpatient Department for Severe Acute Malnutrition PLW Pregnant and Lactating Women PND Public Nutrition Department PNO Public Nutrition Officer PPHD Provincial Public Health Directorate PPS Probability Proportional to Size RC Reserve Cluster RUSF Ready-to Use Supplementary Food RUTF Ready-to-use Therapeutic Food SAM Severe Acute Malnutrition SD Standard Deviation SMART Standardized Monitoring of Assessment of Relief and Transition TSFP Targetted Supplementary Feeding Program UNICEF United Nations Children's Fund UNOCHA United Nations Office for Coordination and Humanitarian Affairs

WASH Water Sanitation and Hygiene WAZ Weight for Age Z score WHO World Health Organization WHZ Weight for Height Z score WVI World Vision International YYYY Year

EXECUTIVE SUMMARY

In April 2019, AAH) in collaborations with Ministry of Public Health (MoPH) of Badghis province, conducted two nutrition assessments in Qala-e-Naw IDP Camps. This was done in response to the need to determine the malnutrition levels and to inform the intervention response for the camps.

The main objective of the surveys was to assess the current nutrition situation among children 0-59 months of age and Pregnant and Lactating Women (PLW) in Qala-e-Naw IDP Camps of Badghis province and provide key recommendations.

The surveys applied a two-stage cluster sampling using the SMART methodology based on probability proportional to population size (PPS). Stage one sampling involved the sampling of the clusters to be included in the survey while the second stage sampling involved the selection of the households from the sampled clusters. The smallest geographical unit in Qala-e-Naw IDP Camps i.e. a Chief/Malik defined a cluster. A total of 866 children aged 6-59 months (418 from segment A and 448 children from segment B) were assessed.

Data collection took place from 4th to 11th of April, 2019, in two phases. The first phase rapid nutrition assessment conducted in segment A (Kharistan, Jar Khoshk, Jar Haji Sakhi, Chakaran between 4-7 April) while the second phase rapid nutrition assessment was conducted in segement B (Zaimati, Sanjidak, Baghlar, Shamal Darya between 8-11 April 2019). In segment A, out of 250 households planned, 234 were assessed and in segment B, all planned households were surveyed.

The survey results indicated a Global Acute Malnutrition (GAM) rate for children 6-59 months old based on WHZ and oedema of 7.5 % (5.6 – 10.0 95% C.I.) and 8.3% (5.8-11.8 95% CI) in segment A and segment B of Qala-e-Naw city IDP camp, respectively. The results also indicated a very high rates of chronic malnutrition of 40.0% (35.3 – 44.9 95%C.I.) and 47.5% (40.2-55.0 95% CI) in segment A and segment B, respectively. Undernutrition among Pregnant Women based on Middle Upper Arm Circumference (MUAC) <230 mm was 28.4% and 39.3% in segment A and segment B, respectively.

SUMMARY OF KEY SURVEY FINDINGS: Child Health and Nutrition Status Indicators Segment A Qala-e-Naw Segment B Qala-e-Naw city IDP camps Result city IDP camps Result

GAM rate among children aged 6-59 months based 7.5 % 8.3% on Weight for Height- Z- Score <-2 SD and/or Oedema (5.6 – 10.0 95% C.I.) (5.8-11.8 95% CI)

SAM rate among children aged 6-59 months based on 1.9 % 1.6 % Weight for Height Z-Score <-3 SD and/or Oedema (1.0 – 3.9 95% C.I.) (0.6- 4.1 95% CI)

GAM rate among children aged 6-59 months based 8.1 % 8.7% on MUAC <125 mm and/or Oedema ( 5.6 – 11.7 95% C.I) (6.4-11.8 95% CI)

SAM rate among children aged 6-59 months based on 2.4 % 1.6% MUAC <115 mm and/or Oedema (1.3 – 4.4 95% C.I.) (0.7- 3.5 95% CI)

GAM rate among children aged 6-59 months based 10.9 % 13.1 % on combined criteria (WHZ <-2 SD and/or MUAC <125 (8.4-14.0 95% C.I.) (10.7-15.8 95 % CI) mm and/or Oedema)*

SAM rate among children aged 6-59 months based on 3.4 % 2.9 % combined criteria (WHZ <-3 SD and/or MUAC <115 (2.0- 5.8 95% C.I.) (1.6- 5.3 95% CI) mm and/or Oedema)*

Stunting or chronic malnutrition among children aged 40.0 % 47.5 % 6-59 months based on Height for Age Z-Score <-2 SD (35.3 – 44.9 95%C.I.) (40.2-55.0 95% CI)

Underweight among children aged 6-59 months 21.6 % 26.6 % based on Weight for Age Z-Score <-2SD (17.7 – 26.1 95% C.I) (22.3-31.4 95 % C.I)

Children aged 6-59 months that reported of having Diarrhea during the past 14 days of the survey (based 31.6 % 33.9 % on two weeks recall method)

Women Nutrition Status Indicators Segment A Qala-e-Naw Segment B Qala-e- city IDP camps Result Naw city IDP camps Result

Undernutrition among Pregnant Women based on 25.0% 41.7 % MUAC <230 mm

Undernutrition among only Lactating Women based on 30.3% 36.7 MUAC < 230 mm

Undernutrition among Pregnant and Lactating Women 28.4 % 39.3 % based on MUAC <230mm

1. BACKGROUND

Badghis is one of the thirty-four provinces of Afghanistan, located in the isolated hills of northwestern Afghanistan. Badghis is bordered with Turkmenistan to the north, Faryab to the east, Ghor to the southeast, and Herat to the south. More than two-thirds of the province’s area (69%) is mountainous or semi mountainous terrain, while more than one-fifth of the area (22%) is made up of plain land and the remaining is semi-plain land (9%). The province is divided into six districts (Ab Kamari, Jawand, Muqur, Qadis, Bala Murghab, and Qala-e-Now).

The province was carve out of portions of Herat Province and Meymaneh (current Faryab Province) in 1964 and has a total area of 20,591 km. The province comprises 1,182 villages, with estimated population of 530,574 people (CSO’s 2018/19). Agriculture is the province’s primary economic activity. It is considered as one of the most underdeveloped province in the country. It has multiethnic groups such as Tajik, Pashtun, Uzbek, Turkmen, and Baloch representing 62%, 28%, 5%, 3%, and 2% respectively. The population is mostly Sunnis. The province has two rivers namely, Murghab River in the North and the Hari- Ruud River in the South.

Badghis is one of the provinces most affected by drought in 2018. Followingthe drought, internally displaced persons (IDP) started arriving in Qala-e-Naw IDP Camps from all districts in Badghis province . According to UNOCHA & PPHD in Badghis, the population of the IDP in Qala-e-Naw IDP Camps in April 2019 was 133,000 individuals, with 19,000 households. According to the Badghis Multi-Sector Rapid Assessment1, the humanitarian situation in the IDP camps was alarming with women and children being among the most affected in terms of health, nutrition and general living conditions. The MUAC measurement results show a GAM rate of 32.8% (24.8 - 42.0 95% C.I.); Moderate Acute Malnutrition (MAM) rate of 16.9% (10.7 - 22.8 95% C.I.); and Severe Acute Malnutrition (SAM) of 15.9% (10.9 - 25.4 95% C.I.) indicating a crtitical serious nutrition situation in the area. The finding of this assessment also show that communities have been facing a critical food security crisis and drinking water shortage as a result of the drought. The drought situation remains dynamic with fluctuating numbers of displaced people as some return back to their origin place while some new IDP arrive in the temporary settlements. Back in July 2018, Action Against Hunger conducted a rapid assessment in the selected hotspot locations and the finding revealed GAM rate of 10.0% and Severe Acute Malnutrition (SAM) rate of 2.7% in Badghis. To mitigate the deteriorating situation in Qala-e-Naw IDP Camps, World Vision International (WVI) has been implementing various interventions in the IDP camps namely food security, water, sanitation and hygiene (WASH), nutrition and health.

In order to rapidly collect reliable nutrition data and to address the current nutritional problems of the community in the IDP camps, the Nutrition Cluster along with the Assessment and Information Management Working Group/PND/MoPH recommended two assessments using Rapid SMART methodology in Qala-e-Naw IDP Camps. AAH conducted the assessments in partnership with Afghan Youth Services Organization (AYSO).

1Badghis Multi-Sector Rapid Assessment Summary June 2018.

2. OBJECTIVES

2.1. General objective

The overall objective of the rapid SMART assessments was to estimate the current prevalence of acute malnutrition among children 6-59 months of age and PLW in Qala-e-Naw city IDP camps, Badghis province

2.2. Specific objectives

The specific objectives included the following:

 To estimate the prevalence of global and severe acute malnutrition in children aged 6-59 months.  To estimate the prevalence of acute malnutrition among PLW using MUAC.  To estimate the prevalence of diarrhea among children 6-59 months in the last two weeks prior to the survey dates.  To estimate prevalence of chronic malnutrition and underweight among children aged 6-59 months.

3. METHODOLOGY

3.1. Geographic target area and population group

The two Rapid SMART assessments were carried out in in segment A (Kharistan, Jar Khoshk, Jar Haji Sakhi, Chakaran) and segment B (Zaimati, Sanjidak, Baghlar, Shamal Darya) of Qala-e-Naw IDP Camps. The IDP arrived to Qala-e-Naw IDP Camps from all districts of Badghis province. The IDP has multi ethnics origin such us Tjik, Pashtoon, Aimaq, and Uzbek. Dari was more spoken than Pashto in the IDP population. All the 115 Chief/Malik2 (62 in segment A & 53 in segment B) were included in the sampling frame. The study population was children from the age of 6 to 59 months and PLW.

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

Qala-e-Naw IDP Camps location, Badghis province

3.2. Survey period

A four-days training was organized between 31 March to 3rd April 2019 and data collection took place from 4th to 11th of April, 2019, in two phases. The first phase data collection was conducted in segment A between 4-7 April) while the second phase data collection was conducted in segment B between 8-11 April 2019.

3.3. Survey design

The two rapid nutrition assessmenst (Segment A & Segment B) in Qala-e-Naw IDP Camps were cross- sectional with two-stage cluster samplings based on the SMART methodology.

3.4. Sample size

A pre-determined sample size of 25 clusters with 10 households (250 households) was chosen for the each rapid assessment and was expected to be enough to ensure representativeness with acceptable precision3. To reach required sample, the rapid SMART methodology4 proposes to use a simplified rule to convert children into households:

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

A. When the percentage of children under age of 5 is below 15%, 25 clusters of 12 households would be enough to estimate GAM prevalence. B. When the percentage of children under age of 5 is above 15%, 25 clusters of 10 households would be enough to estimate GAM prevalence.

As the reference percentage of under-5 population for Afghanistan is 17.3% (Afghanistan Updated Population CSO 2018-19), the option B was applied. 25 Cluster of 10 households were selected randomly using PPS by ENA software (2015 updated version) out of the total list of population living in the IDP camps near to Qala-e-Naw city in the different camps.

3.5. Sampling procedures

The surveys applied a two-stage cluster sampling method referring to the SMART methodology based on probability proportional to population size (PPS). Stage one sampling involved the sampling of the clusters to be included in the survey while the second stage sampling involved the selection of the households from the sampled clusters. The smallest geographical unit in Qala-e-Naw IDP Camps i.e. a Chief/Malik defined a cluster.

3.5.1. First stage sampling: selection of clusters

List of Chief/Malik with their respective population was obtained from the national NGO AYSO and community leaders. Chief/Malik in the IPD camps were considered as clusters and the sampled clusters were selected with probability proportional to population size (PPS). All the 115 villages of Qala-e-Naw IDP Camps (62 in segment A & 53 in segment B) along with their respective populations were entered into ENA software and clusters were selected automatically to be included in the survey (annex 3 & 4). There was no inaccessible clusters for both rapid assessments. In Chief/Malik where more than one cluster was assigned, segmentation was done and the required number of clusters selected randomly. Segmentation was done in chief/malik 34 of segment B. Upon arrival to the cluster, the teams mapped the area and used water tankers, static mobile health sites and hills as landmarks.

3.5.2. Second stage sampling: selection of households

Household definition: Group of people living under same roof and sharing food from the same pot. In households with multiple wives, those living and eating in different houses were considered as separate Households (HHs). Wives living in different houses and eating from same pot were considered as one HH.

The second stage of sampling was the selection of households within the selected clusters (Chief/Malik) using a systematic random method as described below.

On arrival at the Chief/Malik:

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

 In collaboration with the Chief/Malik leader, the team prepared a list of all households in the Chief/Malik. Abandoned households were not listed.  The required number of households were selected using systematic random sampling.  The sampling interval was determined by: Sampling interval = Total number of sampling units in the population Number of sampling units in the sample (10)  Selection of the first sampling unit: A number between 1 and the sampling interval was randomly chosen.  Selection of the following sampling units: Number of the 1st sampling unit + sampling interval; etc.

In cases where there was no eligible child but having PLW, a household was still considered part of the sample, where only anthropometric data of PLW was collected. If a respondent was absent during the time of household visit, the teams left a message and re-visited later to collect data, with no substitution of households.

Each team was assisted by a Chief/Malik guide (Chief/Malik leader) to lead and guide the survey team within the Chief/Malik and locating the selected households.

3.6. Organization of the Survey

3.6.1. Survey Coordination

With the lead of Action Against Hunger Afghanistan, communication was done of survey objectives to all the relevant administrative authorities, community leaders as well as stakeholders such as MoPH, PND, PPHD and other partners.

3.6.2. Survey Teams

Eight teams each comprising two enumerators (1 male & 1 female) were deployed to collect data in all the selected clusters from 4th to 11th April 2019. Four supervisors were assigned to supervise the survey teams (1 supervisor per 2 survey teams).

3.6.3. Training of the Survey Teams

Training was carried out by AAH’s survey manager and was conducted in the local language5. Four supervisors (1 supervisor per 2 teams), were responsible for ensuring the recording of all data collected as well as ensuring accuracy of measurements taken, methodology and any other technical issues raised while in the field. Candidates with prior experience in nutrition survey were given preference. Training

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

13 was conducted for four days from 31st March to 3rd April 2019, and training covered survey objectives, basic malnutrition, concept of sampling and SMART survey methodology followed by anthropometric measurements, recognition of the signs and symptoms of malnutrition including nutritional bi-lateral oedema and interview techniques.

As a mean to verify anthropometric skills of enumerators and to detect differences among measurers a standardization test was conducted during the fourth day of the training. Ten children were measured once by the survey supervisor and then each of the 16 enumerators were allowed to measure the children’s weight, height and MUAC twice with a time interval between individual measures. Observations of errors in the performance of each team with regards to undertaking measurements and completing the questionnaires were identified, discussed and corrected with all team members by the team supervisors and the survey manager.

3.7. Data collection and field work

3.7.1. Children anthropometric survey

Structured questionnaires (annex 5) were used to collect anthropometric and morbidity data from all children within the eligible age range (6-59 months) using anthropometric questionnaire. Once measured, visible small mark on the left upper arm or on the fingernails of the child was made in order to avoid measuring the same child several times. The collected data were:

Age: The age of children was estimated based on using birth certificate record, vaccination card or parent records of exact birth dates or ages in completed months. In case the above-mentioned documents were not available, local event calendar was used (annex 6). The calendar of local events was jointly developed with the survey assistants and camp leaders. All the birth dates were collected in accordance with Hijri Calendar – Afghanistan Official Calendar and were converted to Georgian format using date converter.

Sex: Male or female

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

Height/length: Children were measured using wooden UNICEF measuring boards (precision of 0.1cm). Children less than 87 cm were measured lying down, while those greater than or equal to 87 cm were measured standing up.

Mid-upper arm circumference: MUAC measurements were taken at the mid-point of the left upper arm using child tapes (precision of 0.1cm).

Bilateral pitting oedema: Assessed by the application of normal thumb pressure on both feet for 3 seconds. Occurrence of pitting oedema on both feet upon release of the fingers indicated nutritional oedema classified as severely malnourished.

3.7.2. Maternal nutritional status

The nutritional status of pregnant and lactating women was assessed based on MUAC measurements. MUAC measurements were taken at the mid-point of the left upper arm using adult tapes.

3.7.3. Child Morbidity

Two-weeks retrospective morbidity data was collected from mothers/caregivers of all children (6-59 months) included in the anthropometric measurement. The mother/caregiver was asked whether or not the child had diarrhea in the two weeks preceding the survey.

3.8. Data quality assurance

Assurance of data quality was insured through conducting high quality training for survey teams coupled with standardization test, practical field exercise (pre - test survey) and close supervision of survey teams during data collection. The survey supervisors were in charge of the data quality control as they ensured that HH selection was done correctly, interviews were done correctly and consistently from one household to the other and anthropometric measurements were correctly taken. All the filled questionnaires were reviewed in the field by the survey supervisors for accuracy and completeness before the teams left the given clusters. The survey supervisors reported daily and submitted all the verified completed forms to the survey manager for review and feedback given every evening. Field visits were also done by the survey manager during the survey period to ensure quality during data collection. Daily data entry and regular plausibility checks were done and feedback given to survey team.

4. DATA MANAGEMENT AND ANALYSIS

The anthropometric data were analyzed using ENA software 2011 version (updated 9 July 2015). The indices were compared to the World health Organization (WHO) Standards 2006 to determine the levels of wasting, underweight and stunting. SMART flags: WHZ -3 to 3; HAZ -3 to 3; WAZ -3 to 3 were used in final analysis to exclude zscores with extreme values from observed mean. Morbidity and PLW data were analyzed on excel.

5. RESULTS

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

Table 5-1 and 5-2 shows the distribution of the sample statistics for the surveys. The standard deviations (SD) for WHZ, WAZ & HAZ were within the acceptable range of 0.8-1.2. However, with design effect of 2.32, for HAZ in segment B, the sample population showed some degree of heterogeneity for chronic malnutrition.

The overall data quality was scored as excellent (score of 5% for segment A, score of 8% for segement B). For more information, see the plausibility check in Annex 1 & 2.

Table 5-1: Mean z-scores, design effect and excluded subjects, Qala-e-Naw city IDP camp (Segment A) Indicator N Mean z- Design Effect z-scores not z-scores out of scores ± SD (z-score < -2) available* range Weight-for-Height 411 -0.33±1.09 1.00 0 7 Weight-for-Age 412 -1.16±1.05 1.03 0 6 Height-for-Age 410 -1.75±1.17 1.00 0 8 * contains for WHZ and WAZ the children with edema.

Table 5-2: Mean z-scores, design effect and excluded subjects, Qala-e-Naw city IDP camp (Segment B) Indicator N Mean z-scores Design Effect (z- z-scores not z-scores out of ± SD score < -2) available* range

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

Weight-for-Age 447 -1.46±0.93 1.13 0 1 Height-for-Age 444 -1.93±1.05 2.32 0 4 * contains for WHZ and WAZ the children with edema

5.2. General characteristics of study population and households

5.2.1. Households and children 6-59 months

In segment A, out of 250 households planned, data was collected from a total of 234 households (94%) and in segment B, all the 250 planned households were surveyed (100%). In Segment A, 16 households were recorded as non-response households. Further, about 216.5% of the sample size of children 6-59 months of age was met without resulting to visit the 4 reserve clusters (RCs). A total of 866 children aged 6-59 months (418 children from segment A and 448 children from segment B) were assessed for their nutritional status using anthropometric measurements.

Table 5-3: Summary of households and children 6-59 months planned and those surveyed Qala-e-Naw city IDP camp 250 Segment A Number of HH planned Qala-e-Naw city IDP camp 250 Segment B

Qala-e-Naw city IDP camp 234 Segment A Number of HH surveyed Qala-e-Naw city IDP camp 250 Segment B Qala-e-Naw city IDP camp 200 Number of children 6-59 months Segment A planned Qala-e-Naw city IDP camp 200 Segment B Qala-e-Naw city IDP camp 418 Number of children 6-59 months Segment A surveyed Qala-e-Naw city IDP camp 448 Segment B

5.2.2. Pregnant and Lactating Women

In these assessments, a total of 556 pregnant & lactating women (275 in segment A, 281 in segment B) were screened for malnutrition by MUAC.

5.3. Anthropometric results

5.3.1. Distribution by sex and age

The age and sex distribution of the sample population in the two surveys are illustrated in Table 5-4 and 5-5. Among the surveyed children, 453 (52.3%) were boys while 413 (47.7%) were girls. The overall sex ratio of the surveyed children in both segments was 1.1 indicating that both sexes were equally represented within the sample. Similarly, the distribution of the sample children age groups did not also vary from the normal accepted percentage, which also shows that the sample was unbiased.

Table 5-4: Distribution of age & sex of children 6-59 months, Qala-e-Naw city IDP camp (segment A) Boys Girls Total Ratio AGE (mo) no. % no. % no. % Boy: girl 6-17 47 50.0 47 50.0 94 22.5 1.0 18-29 43 42.2 59 57.8 102 24.4 0.7 30-41 52 52.0 48 48.0 100 23.9 1.1 42-53 41 53.9 35 46.1 76 18.2 1.2 54-59 32 69.6 14 30.4 46 11.0 2.3 Total 215 51.4 203 48.6 418 100.0 1.1

Table 5-5: Distribution of age & sex of children 6-59 months, Qala-e-Naw city IDP camp (segment B) Boys Girls Total Ratio AGE (mo) no. % no. % no. % Boy: girl 6-17 52 51.5 49 48.5 101 22.5 1.1 18-29 75 54.7 62 45.3 137 30.6 1.2

30-41 48 52.2 44 47.8 92 20.5 1.1 42-53 40 51.9 37 48.1 77 17.2 1.1 54-59 23 56.1 18 43.9 41 9.2 1.3 Total 238 53.1 210 46.9 448 100.0 1.1

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

GAM WHZ is defined as <-2 z scores weight-for-height and/or oedema while severe acute malnutrition is defined as <-3z scores weight-forheight and/or oedema.

The prevalence of GAM and SAM in the IDP camps are presented in Table 5-6 & 5-7. Prevalence of GAM in segment A was 7.5% (5.6 - 10.0 95% C.I.), whereas SAM was 1.9% (1.0 - 3.9 95% C.I.). GAM among households in segment B was 8.3% (5.8 - 11.8 95% C.I.), and SAM was found to be 1.6 % (0.6 - 4.1 95% C.I.). No oedema case was observed during the assessment in both segments.

In the final analysis, 11 children (7 in segment A & 4 in segment B) were excluded due to out of range values using SMART flags (-3 to 3 Z-score).

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

n = 411 n = 211 n = 200 Prevalence of global malnutrition (31) 7.5 % (16) 7.6 % (15) 7.5 % (<-2 z-score and/or oedema) (5.6 - 10.0 95% C.I.) (5.1 - 11.1 95% C.I.) (4.6 - 11.9 95% C.I.) Prevalence of moderate malnutrition (23) 5.6 % (10) 4.7 % (13) 6.5 % (<-2 z-score and >=-3 z-score, no (4.0 - 7.8 95% C.I.) (2.5 - 8.7 95% C.I.) (4.1 - 10.1 95% C.I.) oedema) Prevalence of severe malnutrition (8) 1.9 % (6) 2.8 % (2) 1.0 % (<-3 z-score and/or oedema) (1.0 - 3.9 95% C.I.) (1.3 - 5.9 95% C.I.) (0.3 - 3.8 95% C.I.) The prevalence of oedema is 0.0 %

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

n = 444 n = 236 n = 208 Prevalence of global malnutrition (37) 8.3 % (21) 8.9 % (16) 7.7 % (<-2 z-score and/or oedema) (5.8 - 11.8 95% C.I.) (5.8 - 13.5 95% C.I.) (4.8 - 12.1 95% C.I.) Prevalence of moderate malnutrition (30) 6.8 % (17) 7.2 % (13) 6.3 % (<-2 z-score and >=-3 z-score, no (4.4 - 10.2 95% C.I.) (4.2 - 12.0 95% C.I.) (3.7 - 10.3 95% C.I.) oedema) Prevalence of severe malnutrition (7) 1.6 % (4) 1.7 % (3) 1.4 % (<-3 z-score and/or oedema) (0.6 - 4.1 95% C.I.) (0.6 - 4.5 95% C.I.) (0.3 - 6.2 95% C.I.)

The prevalence of oedema is 0.0 %

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

As shown in table 5-8 & 5-9, younger children 6-29 months were the most malnourished by WHZ than any other age group .Table 5-10 shows the distribution of acute malnutrition based on WHZ and oedema. No cases of kwashiorkor were observed in the sample. Malnutrition was presented as marasmas only.

Table 5-8: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, segment A Severe wasting Moderate wasting Normal Oedema (>= -3 and <-2 z- (> = -2 z score) (<-3 z-score) score ) Age (mo) Total no. No. % No. % No. % No. % 6-17 91 4 4.4 12 13.2 75 82.4 0 0.0 18-29 101 4 4.0 4 4.0 93 92.1 0 0.0 30-41 98 0 0.0 0 0.0 98 100.0 0 0.0 42-53 75 0 0.0 4 5.3 71 94.7 0 0.0 54-59 46 0 0.0 3 6.5 43 93.5 0 0.0 Total 411 8 1.9 23 5.6 380 92.5 0 0.0

Table 5-9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema, segment B Severe wasting Moderate Normal Oedema wasting (> = -2 z score) (<-3 z-score) (>= -3 and <-2 z- score ) Age (mo) Total no. No. % No. % No. % No. % 6-17 97 4 4.1 12 12.4 81 83.5 0 0.0 18-29 137 3 2.2 8 5.8 126 92.0 0 0.0 30-41 92 0 0.0 7 7.6 85 92.4 0 0.0 42-53 77 0 0.0 1 1.3 76 98.7 0 0.0 54-59 41 0 0.0 2 4.9 39 95.1 0 0.0 Total 444 7 1.6 30 6.8 407 91.7 0 0.0

Table 5-10: Distribution of acute malnutrition and oedema based on weight-for-height z-scores Qala-e-Naw city IDP camp Qala-e-Naw city IDP camp (Segment B)

(Segment A) <-3 z-score >=-3 z-score <-3 z-score >=-3 z-score Oedema present Marasmic Kwashiorkor Marasmic kwashiorkor Kwashiorkor kwashiorkor No. 0 No. 0 No. 0 No. 0 (0.0 %) (0.0 %) (0.0 %) (0.0 %) Oedema absent Marasmic Not severely Marasmic Not severely No. 12 malnourished No. 11 malnourished

(2.9 %) No. 406 (2.5 %) No. 437 (97.1 %) (97.5 %)

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

The prevalence of global acute malnutrition based on MUAC (<125mm) and/or oedema in segment A was 8.1% (5.6 - 11.7 95% C.I.) and of severe acute malnutrition (MUAC <115mm and/or oedema) was 2.4% (1.3 - 4.4 95% C.I.). In segement B, the prevalence of global acute malnutrition based on MUAC was 8.7% (6.4 - 11.8 95% C.I.), and SAM was found to be 1.6% (0.7 - 3.5 95% C.I.). Detailed results are presented in tables 5-11 & 5-12.

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

n = 418 n = 215 n = 203 (34) 8.1% (21) 10.3% Prevalence of global malnutrition (13) 6.0% (5.6 - 11.7 95% (6.2 - 16.7 95% (< 125 mm and/or oedema) (3.4 - 10.6 95% C.I.) C.I.) C.I.) (16) 7.9% Prevalence of moderate malnutrition (24) 5.7% (8) 3.7% (4.5 - 13.4 95% (< 125 mm and >= 115 mm, no oedema) (3.8 - 8.6 95% C.I.) (1.9 - 7.3 95% C.I.) C.I.) Prevalence of severe malnutrition (10) 2.4% (5) 2.3% (5) 2.5% (< 115 mm and/or oedema) (1.3 - 4.4 95% C.I.) (0.8 - 6.7 95% C.I.) (1.1 - 5.5 95% C.I.)

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

n = 448 n = 238 n = 210 (20) 8.4% (19) 9.0% Prevalence of global malnutrition (39) 8.7% (5.5 - 12.7 95% (6.4 - 12.6 95% (< 125 mm and/or oedema) (6.4 - 11.8 95% C.I.) C.I.) C.I.) (16) 6.7% (16) 7.6% Prevalence of moderate malnutrition (32) 7.1% (4.3 - 10.4 95% (4.9 - 11.6 95% (< 125 mm and >= 115 mm, no oedema) (5.1 - 10.0 95% C.I.) C.I.) C.I.) Prevalence of severe malnutrition (7) 1.6% (4) 1.7% (3) 1.4% (< 115 mm and/or oedema) (0.7 - 3.5 95% C.I.) (0.6 - 4.4 95% C.I.) (0.5 - 4.4 95% C.I.)

According to table 5-13 & 5-14, younger children 6-29 months were more malnourished by MUAC than older children above 2 years of age. This is consistent with the known fact that MUAC tends to identify younger children.

Table 5-13: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, segment A Severe wasting Moderate Normal Oedema wasting (> = 125 mm ) (< 115 mm)

(>= 115 mm and < 125 mm) Age (mo) Total no. No. % No. % No. % No. % 6-17 94 7 7.4 13 13.8 74 78.7 0 0.0 18-29 102 3 2.9 10 9.8 89 87.3 0 0.0 30-41 100 0 0.0 1 1.0 99 99.0 0 0.0 42-53 76 0 0.0 0 0.0 76 100.0 0 0.0 54-59 46 0 0.0 0 0.0 46 100.0 0 0.0 Total 418 10 2.4 24 5.7 384 91.9 0 0.0

Table 5-14: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema, segement B Severe wasting Moderate Normal Oedema wasting (> = 125 mm ) (< 115 mm) (>= 115 mm and < 125 mm) Age (mo) Total no. No. % No. % No. % No. % 6-17 101 6 5.9 21 20.8 74 73.3 0 0.0 18-29 137 1 0.7 11 8.0 125 91.2 0 0.0 30-41 92 0 0.0 0 0.0 92 100.0 0 0.0 42-53 77 0 0.0 0 0.0 77 100.0 0 0.0 54-59 41 0 0.0 0 0.0 41 100.0 0 0.0 Total 448 7 1.6 32 7.1 409 91.3 0 0.0

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

Weight for Age is a composite index that measures both stunting and wasting. The prevalence of underweight in segment A and segment B of Qala-e-Naw city IDP camp was 21.6% (17.7 - 26.1 95% C.I.) and 26.6% (22.3 - 31.4 95% C.I.), respectively as indicated in table 5-15 & 5-16.

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

n = 412 n = 212 n = 200 Prevalence of underweight (89) 21.6% (44) 20.8% (45) 22.5% (<-2 z-score) (17.7 - 26.1 95% C.I.) (15.0 - 27.9 95% C.I.) (16.4 - 30.0 95% C.I.) Prevalence of moderate underweight (65) 15.8% (31) 14.6% (34) 17.0% (<-2 z-score and >=-3 z-score) (12.8 - 19.3 95% C.I.) (9.9 - 21.1 95% C.I.) (12.9 - 22.1 95% C.I.) Prevalence of severe underweight (24) 5.8% (13) 6.1% (11) 5.5% (<-3 z-score) (3.7 - 9.1 95% C.I.) (3.4 - 10.9 95% C.I.) (2.6 - 11.2 95% C.I.) Table 5-16: Prevalence of underweight based on weight-for-age z-scores by sex., segment B All Boys Girls

n = 447 n = 237 n = 210 Prevalence of underweight (68) 28.7% (51) 24.3% (119) 26.6% (<-2 z-score) (23.0 - 35.1 95% (17.9 - 32.1 95% (22.3 - 31.4 95% C.I.) C.I.) C.I.) Prevalence of moderate underweight (50) 21.1% (42) 20.0% (92) 20.6% (<-2 z-score and >=-3 z-score) (17.1 - 25.8 95% (14.9 - 26.3 95% (17.3 - 24.3 95% C.I.) C.I.) C.I.)

Prevalence of severe underweight (27) 6.0% (18) 7.6% (9) 4.3% (<-3 z-score) (3.9 - 9.3 95% C.I.) (4.5 - 12.5 95% C.I.) (2.1 - 8.7 95% C.I.)

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

Stunting is indicated by low height/length for age compared to WHO standard 2006. From the survey findings, the stunting rate for children aged 6-59 months in Qala-e-Naw city IDP camp was 40.0% (35.3 - 44.9 95% C.I.) in segment A and 47.5% (40.2 - 55.0 95% C.I.) in segment B as indicated in table 5-17 & 5- 18.

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

n = 410 n = 208 n = 202 Prevalence of stunting (164) 40.0% (83) 39.9% (81) 40.1% (<-2 z-score) (35.3 - 44.9 95% (33.6 - 46.6 95% (32.3 - 48.4 95% C.I.) C.I.) C.I.) Prevalence of moderate stunting (102) 24.9% (51) 24.5% (51) 25.2% (<-2 z-score and >=-3 z-score) (21.2 - 29.0 95% (19.3 - 30.6 95% (20.0 - 31.4 95% C.I.) C.I.) C.I.) Prevalence of severe stunting (62) 15.1% (32) 15.4% (30) 14.9% (<-3 z-score) (11.8 - 19.1 95% (11.7 - 20.0 95% (10.3 - 20.9 95% C.I.) C.I.) C.I.)

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

n = 444 n = 235 n = 209 Prevalence of stunting (211) 47.5% (123) 52.3% (88) 42.1% (<-2 z-score) (40.2 - 55.0 95% (44.4 - 60.1 95% (31.4 - 53.6 95% C.I.) C.I.) C.I.) Prevalence of moderate stunting (150) 33.8% (81) 34.5% (69) 33.0% (<-2 z-score and >=-3 z-score) (28.3 - 39.8 95% (27.9 - 41.7 95% (24.7 - 42.6 95% C.I.) C.I.) C.I.) Prevalence of severe stunting (61) 13.7% (42) 17.9% (19) 9.1% (<-3 z-score) (10.4 - 18.0 95% (13.5 - 23.2 95% (5.6 - 14.5 95% C.I.) C.I.) C.I.)

5.4. Child morbidity

High prevalence of diarrhoea was recorded in both segment A and B of Qala-e-Naw city IDP camp (Table 5-19). Nearly one-third of surveyed children reportedly suffered from diarrhoea in the two weeks prior to the assessment (31.6% in segment A and 33.9% in B)

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

(Segment A) (Segment B) n % n % Diarrhea 6-59 months, 139 31.6 % 160 33.9 % two weeks recall

5.5. Maternal nutritional status

From the survey findings, 28.4% and 39.3% of women were found to be acutely malnourished in segment A and B, respectively as indicated in table 5-20.

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

(Segment A) (Segment B) n % n % Global Acute Malnutrition 58 28.4% 88 39.3% (GAM) MUAC < 230 mm Moderate Acute Malnutrition 56 27.5% 87 38.9% (MAM) MUAC < 230 -≥185 mm Severe Acute Malnutrition 2 0.9% 1 0.4% (SAM) MUAC < 185 mm

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

The Combined GAM (cGAM) and Combined SAM (cSAM) among children 6-59 months based on WHZ and or MUAC (mm) is shown in table 5-21.

Table 5-21 : Prevalence of Combined Acute Malnutrtion based on WHZ and/or MUAC for children 6-59 months old Qala-e-Naw city IDP Qala-e-Naw city IDP Combined Indicator camp (Segment camp (Segment A) B) Global Acute Malnutrition (45) 10.9% (58) 13.1% (<-2 z-score and/or oedema and/or < 125 mm) (8.4-14.0 95% CI) (10.7-15.8 95%CI) Severe Acute Malnutrition (14) 3.4% (13) 2.9% (<-3 z-score and/or oedema and/or < 115 mm) (2.0- 5.8 95% CI) (1.6- 5.3 95% CI) 5.7. Proportion of acutely malnourished children enrolled in & referred to a nutrition program

The number of children enrolled in the nearby therapeutic feeding program was only 11.8 % and 7.7% in segment A and segment B, respectively. Overall, of children identified as acutely malnourished by the survey teams only 20.6% in segment A and 12.8% in segment B were enrolled in a program at the time of survey (Table 5-22). The low coverage of nutrition services is seen as a gap in response needs in the camps.

All acutely malnourished children found during assessment were referred using referral forms to the nearby health centre with OPD-SAM and OPD-MAM programme.

Table 5- 22: Proportion of Acutely Malnourished Children 6-59 Months Enrolled in a Treatment Programme Enrolled in Enrolled in an Enrolled in Sample Not Enrolled an OPD-SAM OPD-MAM an IPD-SAM Acutely malnourished children 6-59 months by WHZ, MUAC, or oedema (4) 8.9 % (3) 6.7 % (0) 0.0 % (38) 84.4 % (N=45) in segment A Acutely malnourished children 6-59 months by WHZ, MUAC, or oedema (3) 5.2 % (2) 3.4 % (0) 0.0 % (53) 91.4 % (N=58) in segment B

6. DISCUSSION

6.1. Nutritional status

The survey results in segment A and segment B revealed GAM rates of 7.5 % (5.6 - 10.0 95% C.I.) and 8.3% (5.8-11.8 95% CI), respectively. The GAM prevalence based on weight-for-height <-2 z-scores was classified as medium for both camps according to WHO-UNICEF thresholds for the level of severity of malnutrition6. There was no significant difference in the level of acute malnutrition between the two segments of Qala-e-Naw city IDP camp.

The prevalence of cGAM in segment A and segment B was 10.9% (8.4-14.0 95% C.I.) and 13.1% (10.7-15.8 95 % CI), respectively. This indicates a higher proportion of children under-five affected by acute malnutrition in the camps when considering both WHZ and MUAC criteria instead of considering separately those 2 indicators. Combined prevalence captures a greater proportion of acute malnourished children 6-59 months, and may inform better the estimation of SAM and MAM caseloads in the camp, ultimately, strengthening planning and programming7.

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

Figure 1: GAM children captured by WHZ, MUAC and Combined MUAC and/or WHZ 14.0% 13.1%

12.0% 10.9%

10.0% 8.1% 8.3% 8.1% 7.5% 8.0%

6.0%

4.0%

2.0%

0.0% Combined GAM WHZ GAM MUAC GAM Combined GAM WHZ GAM MUAC GAM Segment A Segment B (Kharistan, Jar Khoshk, Jar Haji Sakhi, Chakaran) (Zaimati, Sanjidak, Baghlar, Shamal Darya)

Stunting, identify as low height for age z-score, is caused by long-term insufficient nutrient intake and/or frequent infections. The stunting rates in both segments are categorized as very high according to WHO- UNICEF new thresholds of a prevalence8: 40.0% (35.3 - 44.9 95% CI) in segment A, and 47.5 % (40.2 - 55.0 95% CI) in segment B. Very high stunting levels are usually seen in contexts with very low access to health services, low sanitation levels and low maternal nutritional status. The proportion of malnourished pregnant and lactating women recorded in the two assessments was high with 28.4% of PLW in segment A and 39.3% of PLW in segment B being found to have a MUAC of <23cm. Maternal undernutrition affects a woman’s chances of surviving pregnancy as well as her child’s health. Nutritional status of pregnant and lactating women are crucial for ensuring healthy fetal growth and development. There is need to design programs to reverse the high prevalence of chronic malnutrition and maternal malnutrition with all sectors involved.

The underweight prevalence is higher in segment B, 26.6% (22.3-31.4 95 % C.I) than segment A, 21.6% (17.7 – 26.1 95% C.I) though not statistically significant. The prevalence of underweight is classified as high in both camps, using the WHO classification9 for assessing severity of malnutrition by prevalence ranges among children under 5 years of age

Although not significant, there was a slight decline in the rates of acute malnutrition (figure 2), where a GAM rate of 10.0 (6.6 - 15.0; 95% CI) and SAM rate of 2.7% (1.2 - 6.0; 95% CI) was recorded in June 2018 in the selected hotspot locations of Badghis province. The reduction in acute malnutrition can be

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

25 attributed to several factors including: i) WVI nutrition & health services implemented through MHT in the IDP camp; ii) AAH nutrition & health programme in 3 districts (Bala Murghab, Jawand and Ab Kamary); iii) food distribution by WFP and NRC in the IDP camp.

Sustained multi-sectoral efforts will be necessary to continue this trend in the Qala-e-Naw city IDP camp. However, the critical nutrition situation of the surveyed population may be aggravated by poor maternal and child care (high proportion of malnourished women) and high child morbidity. Moreover the food security is still a major concern considering the vulnerable situation of the surveyed population which is reliant on food aid both as a source of food and as a major source of income. The nutrition situation in the Qala-e-Naw city IDP camp is precarious and can further slide into an emergency situation in the event of any shock. The situation is compounded by the fact that the livelihoods of IDP have been destroyed, making them more vulnerable to acute food insecurity and disease outbreaks.

Figure 2: Comparison of GAM and SAM prevalence in June 2018 and April 2019 12.0

10 (6.6-15) 10.0 8.3 (5.8-11.8) 8.0 7.5 (5.6-10,)

6.0 Prevalence 4.0 2.7 (1.2-6.0) 1.9 (1.0-3.9) 2.0 1.6 (0.6-4.1)

0.0 GAM SAM

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

6.2. Child health indicators

The prevalence of diarrhea in the survey sample was high. The diarrhea morbidity prevalence found in the two assessments (31.6% in segment A and 33.9% in segment B) are higher than the national average of 29% [AfDHS, 2015]. The high proportion of children reported to have had diarrhoea in the two weeks prior to the assessment may partly be attributed to the lack of safe drinking water, and poor hygiene and sanitation conditions and practices. Much can be done to turn this situation around by improving access to safe water source, promotion of water treatment options, improving sanitation access and hygiene promotion as well as focusing on the home management of childhood illness.

7. RECOMMENDATIONS

 Although there is slight improvement of the nutrition situation, there is a need to strengthen and continue to provide all the components of the integrated management of acute malnutrition and scaling up the services where possible, in order to have better access to the treatment in the entire IDP camp.  Improve the coverage of Targetted Supplementary Feeding Program (TSFP) for MAM children 6- 23 months and Pregnant and Lactating Women.  Conduct full SMART assessment in Badghis province.

ANNEXES

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

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of out of range subjects) 0 5 10 20 0 (1.7 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.557)

Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.699)

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

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

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

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . and and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 0 (1.09)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 1 (-0.33)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.07)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.794)

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

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

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

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of out of range subjects) 0 5 10 20 0 (0.9 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.186)

Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 4 (p=0.002)

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

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

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (9)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . and and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 0 (1.04)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 1 (-0.35)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 1 (-0.30)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.238)

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

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

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

Geographical unit Population size Cluster # Kharistan Chief /Malik 02 2100 1 Kharistan Chief /Malik 03 1316 2

Kharistan Chief /Malik 05 2170 3 Kharistan Chief /Malik 07 1050 4 Kharistan Chief /Malik 08 2380 5 Kharistan Chief /Malik 10 854 6 Kharistan Chief /Malik 12 1120 7 Kharistan Chief /Malik 14 2191 8 Kharistan Chief /Malik 15 2107 9 Kharistan Chief /Malik 17 1092 10 Kharistan Chief /Malik 19 2226 RC Kharistan Chief /Malik 20 2485 11 Kharistan Chief /Malik 22 1344 12 Kharistan Chief /Malik 23 1386 13 Kharistan Chief /Malik 25 1295 14 Kharistan Chief /Malik 26 2730 15 Jari Khushk Chief /Malik 29 679 16 Jari Khushk Chief /Malik 34 462 17 Jari Khushk Chief /Malik 38 511 18 Jari Khushk Chief /Malik 42 651 19 Jari Haji Sakhi Chief /Malik 46 910 RC Jari Haji Sakhi Chief /Malik 48 1407 20 Jari Haji Sakhi Chief /Malik 50 1540 21 Jari Haji Sakhi Chief /Malik 52 1274 RC Jari Haji Sakhi Chief /Malik 54 735 22 Jari Haji Sakhi Chief /Malik 56 1925 23 Chakaran Chief /Malik 59 539 24 Chakaran Chief /Malik 62 735 25

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

Geographical unit Population size Cluster #

Zaimati Chief /Malik0 2 1470 1 Zaimati Chief /Malik0 3 1421 2 Zaimati Chief /Malik0 5 1246 3 Zaimati Chief /Malik0 7 1155 4 Zaimati Chief /Malik0 8 1890 5 Zaimati Chief /Malik0 10 2240 6 Zaimati Chief /Malik0 12 1155 RC Zaimati Chief /Malik0 13 1393 7 Zaimati Chief /Malik0 15 1456 8 Sanjitak Chief /Malik0 18 910 9 Sanjitak Chief /Malik0 21 623 10 Sanjitak Chief /Malik0 23 826 11 Sanjitak Chief /Malik0 25 1330 12 Sanjitak Chief /Malik0 28 931 13 Sanjitak Chief /Malik0 31 784 14 Baghlar Chief /Malik0 34 2905 15,16 Baghlar Chief /Malik0 35 2940 17 Baghlar Chief /Malik0 36 2730 18 Baghlar Chief /Malik0 37 2716 19 Baghlar Chief /Malik0 38 1500 20 Baghlar Chief /Malik0 39 3514 21,RC Baghlar Chief /Malik0 40 3248 22 Baghlar Chief /Malik0 41 2000 23 Camp Shamal e darya Chief /Malik0 43 539 24 Camp Shamal e darya Chief /Malik0 47 700 25 Camp Shamal e darya Chief /Malik0 52 504 RC

Annex 5: Rapid SMART Assessment questionnaires for children and pregnant and lactating women Date Cluster Name (dd/mm/year) Cluster Number Team Number HH Number Child Questionnaire 0-59 months

1 2 3 4 5 6 7 8 9 10 Child Sex Birthday Age Weight Height or Measure Bilatera MUAC With ID (f/m) (dd/mm/yyyy) (months) (00.0 length (l/h)* l (000 clothes kg) (00.0 cm) edema mm) (y/n) Y/N Left arm

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

Child Questionnaire Child (6-59 months) ID Number For any child that is identified as acutely malnourished (WHZ, MUAC, or edema)

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

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

1=OPD SAM 2=OPD MAM 3=IPD SAM 4=No treatment 98=Don’t know If the child is not enrolled in a treatment program, refer to nearest appropriate treatment center

Q2. Did you refer the child?

1=yes

0=no

Child (0-59 months) ID Number Q3. In the past two weeks, has the child had diarrhea?

Diarrhea defined as the passage of three or more loose or liquid stools in a day

1=yes 0=no 98=don’t know

Woman (15-49 years) age in years Physiologic Status of woman

1=Pregnant 2=Lactating 3=Pregnant and lactating 4=None MUAC measurement (mm)

General comments (optional)

Annex 6: Event calendar

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

نوروز نوروز نوروز نوروز نوروز سمنک سمنک سمنک سمنک سمنک

ح روز دهقان روز دهقان روز دهقان روز دهقان روز دهقان م 1 13 25 37 49 ل سیزده بدل سیزده بدل سیزده بدل سیزده بدل سیزده بدل شعبان شعبان شعبان شعبان شعبان روز معارف روز معارف روز معارف روز معارف روز معارف

پیروزی مجاهدین پیروزی مجاهدین پیروزی مجاهدین پیروزی مجاهدین ث و وقت توت 12 وقت توت 24 وقت توت 36 وقت توت 48 ر باروکوج کوچی باروکوج کوچی باروکوج کوچی باروکوج کوچی ماه مبارک رمضان جودرو جودرو جودرو جودرو جودرو

روزمادر روزمادر روزمادر روزمادر روزمادر ج و 11 23 35 47 59 ز عیدرمضان عیدرمضان عیدرمضان عیدرمضان عیدرمضان ا عرفه عرفه عرفه عرفه عرفه

س شول پسته چندن شول پسته چندن شول پسته چندن شول پسته چندن شول پسته چندن ر 10 22 34 46 58 طا رسیدن میوه رسیدن میوه رسیدن میوه رسیدن میوه رسیدن میوه ن

عیدقربان عیدقربان عیدقربان عیدقربان عیدقربان

روزاستقالل افغانستان روزاستقالل افغانستان روزاستقالل افغانستان روزاستقالل افغانستان روزاستقالل افغانستان ا س 9 21 33 45 57 د روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب روخصتی ګرمی مکاتب ګندم درو ګندم درو ګندم درو ګندم درو ګندم درو آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق آمدن ګوچی ازبندبه پسته لیق سن روزعاشوری روزعاشوری روزعاشوری روزعاشوری روزعاشوری بل 8 20 32 44 56 ه

روزمعلم روزمعلم روزمعلم روزمعلم روزمعلم می 7 19 31 43 55 زا زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری زمان جمع کردن جوزوچواری ن

روزمیالدالنبی روزمیالدالنبی روزمیالدالنبی روزمیالدالنبی روزمیالدالنبی عق برګ درخت هامیریزد 6 برګ درخت هامیریزد 18 برګ درخت هامیریزد 30 برګ درخت هامیریزد 42 برګ درخت هامیریزد 54 ر ب

شروع امتحانات مکاتب شروع امتحانات مکاتب شروع امتحانات مکاتب شروع امتحانات مکاتب شروع امتحانات مکاتب ق و شروع برف باری 5 شروع برف باری 17 شروع برف باری 29 شروع برف باری 41 شروع برف باری 53 س

شاندن بخاری شاندن بخاری شاندن بخاری شاندن بخاری شاندن بخاری

اولین برف اولین برف اولین برف اولین برف اولین برف چله خورد چله خورد چله خورد چله خورد چله خورد ج 4 16 28 40 52 د چله کالن چله کالن چله کالن چله کالن چله کالن ی

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