Anthropometric nutrition survey

Children from 6 to 59 months

Pregnant - Lactating women

And

Infant and Young Child Feeding Practices study

Children from 0 to 23 months

Final Report

Mihtarlam and Qarghayi districts

Laghman province, Afghanistan

From the 22 nd to the 28 th of May 2011

Funded by UNICEF

Islamic Republic of Afghanistan

1 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan ACKNOWLEDGEMENT

With funding from UNICEF, this anthropometric nutrition survey and Infant and Young Child Feeding study could be undertaken in Mihtarlam and Qarghayi districts, Laghman province. The coordinator of this project was Ms Brigitte Tonon, ACF Health - Nutrition Coordinator highly supported by M. Tariq Khan, ACF Nutrition Program Manager. This work would not have been possible without the dedicated efforts of the nutrition community and the local population in Afghanistan. These partners included:

• The Ministry of Public Health and particularly the Public Nutrition Department, for their collaboration in this project;

• The Nutrition Cluster body for their support;

• The community representatives of the surveyed villages who have supported the nutrition survey teams during the data field collection;

• The community members in the surveyed villages for welcoming and supporting the nutrition survey teams during the field work ;

• The numerous Non Governmental Organizations and United Nations agencies for sharing information on the general situation in Laghman province and particularly in the selected districts;

• The entire ACF and SCA Teams for their great support in this project;

2 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan LIST OF ABBREVIATIONS

ACF Action Contre la Faim AIMS Afghanistan Information Management System BPHS Basic Package of Health Services CMAM Community Management of Acute Malnutrition CI Confidence Interval CSO Censes Statistics Office EPI Expanded Program for Immunization ENA Emergency Nutrition Assessment EPHS Expended Package of Hospital Services FAO Food and Agriculture Organization FEWS NET Famine Early Warning Systems Network GAM Global Acute Malnutrition HH House-hold HMIS Health Management Information System IYCF Infant and Young Child Feeding MAM Moderate Acute Malnutrition MoPH Ministry of Public Health MUAC Mid Upper Arm Circumference NCHS National Centre for Health Statistics NGO Non Governmental Organization NRVA National Risk and Vulnerability Assessment OCHA Office of Coordination of Humanitarian Affairs OTP Out patient Therapeutic Program PND Public Nutrition Department RC Reserve Cluster SAM Severe Acute Malnutrition SC Stabilization Centre (CMAM Context) SCA Swedish Committee for Afghanistan SMART Standardized Monitoring and Assessment of Relief and Transitions SFP Supplementary Feeding Program TFU Therapeutic Feeding Unit UN United Nations U-5 Under Five Children UNICEF United Nation Children’s Fund WFP World Food Program W/H Weight for Height index WHO World Health Organization

3 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan TABLE OF CONTENTS

EXECUTIVE SUMMARY ...... 5 1. INTRODUCTION ...... 9 1.1. Agencies ...... 9 1.2. Surveyed area...... 9 1.3. Data population – Demography ...... 10 1.4. Geography and climate...... 10 1.5. Administrative organisation...... 11 1.6. Economic – Food security situation ...... 11 1.7. Water and sanitation situation...... 12 1.8. Health situation and intervention...... 12 1.9. Nutrition intervention...... 13 1.10. Humanitarian interventions ...... 13 2. SURVEY OBJECTIVES...... 14 3. METHODOLOGY...... 15 3.1. Sampling strategy: sampling design and sample size calculation...... 15 3.2 Final stage sampling: Selection of households and children ...... 20 3.3 Data collected and measurement techniques...... 24 3.4 Definition of nutritional status of children 6-59 months: ...... 28 3.5 IYCF indicators ...... 29 3.6 Training and supervision...... 31 3.7 Data analysis ...... 32 4. RESULTS ...... 33 4.1. Nutritional status of children 6-59 months (according to WHO standards 2006)...... 33 4.2. Anthropometric results: Pregnant/Lactating women (based on MUAC criterion) ...... 39 4.3. Measles vaccination coverage – Children 9-59 months...... 40 4.4. Vitamin A supplementation coverage – Children 6-59 months ...... 41 4.5. IYCF study ...... 41 5. DISCUSSION...... 46 5.1 Constraints and bias...... 46 5.2 Acute malnutrition problematic – Children 6-59 months old...... 47 5.3 Chronic malnutrition problematic – Children 6-59 months old ...... 47 5.4 Acute malnutrition problematic - Pregnant/Lactating women...... 48 5.5 Causal analysis...... 48 6. CONCLUSION...... 51 7. RECOMMENDATIONS...... 52 8. REFERENCES ...... 54

9. ANNEXES...... 55 9.1 Annex 1: Map Laghman province, Afghanistan May 2011 – Source: MoPH –HMIS ...... 55 9.2 Annex 2: Map Detailed districts - Laghman province, Afghanistan –...... 56 9.3 Annex 3: List of 114 villages excluded due to security constraints, Mihtarlam (71) and Qarghayi (44) districts, Laghman province, Afghanistan May 2011 – Source: CSO – 2010/2011...... 57 9.4 Annex 4: Cluster selection, Mitharlam and Qarghayi districts, Laghman province, May 2011...... 59 9.5 Annex 5: Selection of cluster with Probability Proportional to Population Size (PPS)...... 60 9.6 Annex 6: Household selection sheet – SMART Training Package – Version 2011 ...... 62 9.7 Annex 7: Anthropometric survey – children 6-59 months old, Mitharlam and Qarghayi districts, Laghman province, May 2011...... 63 9.8 Annex 8: Local event calendar, Nangarhar/Laghman provinces, Afghanistan, May 2011...... 64 9.9 Annex 9: IYCF survey – children 0-23 months old, Mitharlam and Qarghayi districts, Laghman province, May 2011...... 65 9.10 Annex 10: IYCF questionnaire skip patterns– children 0-23 months old, Mitharlam and Qarghayi districts, Laghman province, May 2011...... 66 9.11 Annex 11: Standardization test results, ENA Delta software version April 2011...... 67 9.12 Annex 12: Plausibility check for AFG_201105_LGH_VF.as ...... 69 9.13 Annex 13: Districts affected by floods – Eastern provinces – August 2010 – Source: OCHA...... 80

4 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan EXECUTIVE SUMMARY Laghman is one of the 34 provinces of Afghanistan in the east of the country and is composed of 5 districts. It is bordered with the following provinces: Kunar, Nuristan, Panjsheer, Kapisa Kabul and Nangarhar provinces. Out of the 5 districts, only 2 were included in the survey: Mihtarlam and Qarghayi districts. Indeed, the 3 other districts in Laghman were categorized as unsecure. Moreover, 115 villages were excluded from the survey in the 2 selected districts due to instable situation at the time of the survey. These nutrition survey and IYCF study were conducted jointly by the NGOs ACF and SCA.

Methodology A multi-stage cluster sampling method was applied using ENA software version April 2011 for the anthropometric nutrition survey conducted in Mihtarlam and Qarghayi districts, Laghman province.

Anthropometric survey – Children 6-59months (or 65-110cm) Children from 6 to 59 months old or, if the age was not available, children with a height equal or more than 65 cm and less than 110 cm, represent the anthropometric survey’s targeted population. 28 clusters were expected to be completed but 2 clusters could not be finalized due to insecurity in the area during the data field collection. Hence, a total of 520 households 1 were surveyed, corresponding to 26 clusters of 20 households, while 557 were expected at minimum for estimating the acute malnutrition prevalence. Nevertheless, the minimum of 602 children expected to be surveyed is reached, 610 children been included in the survey. The minimums required for estimating the chronic malnutrition prevalence were achieved as 520 households were visited while only 139 were expected at minimum and 625 children were surveyed while only 150 were required.

Anthropometric measurements – Pregnant-Lactating women Following the selection of households for the anthropometric nutrition survey, all pregnant and lactating women with children 0-59 months included in the anthropometric survey and found at household level were expected to have their MUAC measured. Hence, the sample size depended on the number of pregnant/lactating women with children included in the survey found at household level while conducting the survey. At the end of the data field collection, 71 pregnant women and 77 lactating breastfeeding women were found at household level, for a total of 148 women screened by MUAC.

IYCF study Following the selection of households for the anthropometric nutrition survey, all children from 6 to 23 months old, included in the anthropometric nutrition survey were included in the IYCF questionnaire. The infants less than 6 months excluded from the anthropometric nutrition survey were included as well in the IYCF questionnaire. The sample size depended on the number of children 0-23 months old found at household level while conducting the anthropometric nutrition survey. 78 infants less than 6 months and 247 children 6-23 months were found in the visited households for a total sample of 325 children 0-23 months.

1 A household is defined as all people eating from the same pot - WFP Household definition

5 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Main results

Anthropometric data are presented referring to WHO standards 2006.

Acute malnutrition prevalence – Children from 6 to 59 months old According to Weight for Height indice– Children from 6 to 59 months old Prevalence of Acute malnutrition All Z-score 95% CI According to WHO standards N = 600 Prevalence of global acute malnutrition N = 51 8.5 % (5.6 – 12.7 95% C.I.) (<-2 z-score and/or oedema) Prevalence of moderate acute malnutrition N = 43 7.2 % (5.0 – 10.2 95% C.I.) (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe acute malnutrition N = 8 1.3 % (0.5 – 3.8 95% C.I.) (<-3 z-score and/or oedema)

According to MUAC criterion – Children from 6 to 59 months old Prevalence of Acute malnutrition All Z-score 95% CI According to MUAC criterion and WHO standards N = 603 Prevalence of global malnutrition N = 28 4.6 % (3.0 – 7.1 95% C.I.) MUAC < 125mm Prevalence of moderate malnutrition N = 25 4.1 % (2.6 – 6.6 95% C.I.) MUAC >=115 <125mm Prevalence of severe malnutrition N = 3 0.5 % (0.2 – 1.5 95% C.I.) MUAC < 115mm

Chronic malnutrition prevalence – Children from 6 to 59 months old Prevalence of Chronic malnutrition All Z-score 95% CI According to WHO standards N = 583 Prevalence of stunting n = 229 39.3% [34.9 – 43.9 95% C.I.] (<-2 z-score) Prevalence of moderate stunting N = 145 24.9% [20.3 – 30.1 95% C.I.] (<-2 z-score and >=-3 z-score) Prevalence of severe stunting n = 84 14.4% [11.8 – 17.5 95% C.I.] (<-3 z-score)

Acute malnutrition among pregnant/lactating women screened

Definition MUAC Acute malnutrition Pregnant women Lactating women TOTAL in mm WHO Standards N % N % N % <210 Severe malnutrition 0 0.0% 0 0.0% 0 0.0% ≥210 - <230 Moderate malnutrition 9 12.7% 2 2.7% 11 7.5% ≥230 No malnutrition 62 87.3% 73 97.3% 135 92.5% Total 71 100% 75 100% 146 100%

Measles vaccination coverage – Children from 9 to 59 months old All Measles vaccination coverage N (567) N % Confirmed with immunization card 272 48.0% Confirmed verbally by the caregiver but no immunization card to prove it 216 38.1% No immunization according to the caregiver 55 9.7% Unknown 24 4.2% Total 567 100%

6 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Vitamin A supplementation coverage – Children from 6 to 59 months old All Vitamin A supplementation coverage N (610) within the last 6 months N % Vitamin A dose received 557 91.3% Vitamin A dose not received 16 2.6% Unknown 37 6.1% Total 610 100%

IYCF study – Children from 0 to 23 months old

CORE INDICATORS DEFINITION N Yes % No % Early initiation of Proportion of children born in the last breastfeeding 23 months who were put to the breast 311 175 56.3% 136 43.7% within one hour of birth Continued breastfeeding at Proportion of children 12 – 15 months 55 50 90.9% 5 9.1% 1 year of age who are fed with breast milk OPTIONAL INDICATORS DEFINITION N Yes % No % Children ever breastfed Proportion of children born in the last 325 311 95.7% 14 4.3% 24 months who were ever breastfed Continued breastfeeding at Proportion of children 20–23 months of 40 21 52.5% 19 47.5% 2 years age who are fed with breast milk

Recommendations The recommendations submitted by SCA after the conduction of a rapid nutritional assessment in this province in November/December 2010, are still relevant and are reformulated below. Additional recommendations are submitted in regard to the results highlighted by these anthropometric nutrition survey and IYCF study.

In regard to SCA field of intervention:


To set up intensive health education and outreach work to educate communities on early signs of malnutrition and referral to health facilities;


To implement intensive growth monitoring program;


To identify and refer all identified cases of severe acute and moderate malnutrition to therapeutic and supplementary feeding programs when existing in the area;


To monitor and verify HMIS data for malnutrition and referral statistics in all health facilities;


To identify clusters and pockets of malnutrition cases and analyze the root causes of malnutrition in those settings;


To consider Supplementary Feeding Programs jointly with other partners such as WFP in areas not currently covered by the agency Health Net TPO.

7 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan

In regard to fields of intervention of SCA and other actors:


To advocate to the Ministry of Public Health and the NGO SCA, BPHS implementer in the studied area, to maintain the Vitamin A supplementation coverage satisfactory and to improve the measles vaccination coverage;
To scale up CMAM project within the BPHS framework in the whole province in accordance to the national nutrition policy and in collaboration between the several health actors present in the area; o In patient units should be implemented at district level. Only one TFU is running in Mihtarlam district. Stabilization Centre instead of TFU should be envisaged when medical capacities are limited at district level; o SFP component should be extended to all districts. Pregnant and lactating women should be offered treatment within SFP; o Community mobilization program should be extended to remote areas as much as possible according to security clearance;
To conduct an IYCF study separately from an anthropometric nutrition survey. This study could provide more reliable and precise results and deeper understanding of the malnutrition causes;
To monitor the nutrition situation on regular basis. o To improve the regular collect of data through the HMIS to enable following nutrition trends on regular basis; o To conduct further nutrition surveys. According to the nutrition national policy, surveys should be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in nutritional situation; o Further nutrition survey could be conducted during winter time to allow comparison of the nutritional situation during the spring time versus winter period. The survey could be conducted at the end of the winter season to evaluate the resilience of the population during this period;


To survey districts excluded by this survey: 3 districts of Laghman province were excluded from this survey and may be assessed later on depending on the security clearance;

8 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 1. INTRODUCTION

1.1. Agencies The anthropometric nutrition survey and IYCF study were conducted in partnership between 2 agencies: ACF and SCA.

Action Contre La Faim (ACF) is a non-political, non-religious and non-profit Non Governmental Organization established in Paris-France in 1979 and is also registered with the Ministry of Economy in Afghanistan on file #167. Its main objective is to bring assistance to people affected by either natural or man made disaster with interventions in the main areas of Food Security, Water Sanitation and Hygiene Promotion (WASH) and Nutrition. From 1995 to 2008 ACF has been operational in Afghanistan in nutrition, supporting the treatment of moderate and severe acute malnutrition especially in Kabul. The interventions included supplementary and therapeutic feeding and psychosocial programs which moved from being operational to capacity building of the Ministry of Public Health and the Public Nutrition Department. Today, ACF is operational in Food security and Water, Sanitation and Hygiene (WASH) in Ghor, Samangan and Day Kundi provinces as well as in Kabul district. Nutrition intervention has been relaunched by mid 2010 focusing on nutrition surveillance system. A nutrition surveillance project is implemented at national level in collaboration with 5 nutrition clusters partners since December 2010. As part of this project, ACF provided support to the local NGO HN TPO for conducting an anthropometric nutrition survey and IYCF study in Nangarhar province by May 2011.

Swedish Committee for Afghanistan (SCA) is one of the largest non-profit organizations in Afghanistan. Established in Sweden in 1980 shortly after the Soviet invasion of Afghanistan, it supported the Afghan people in emergency and humanitarian assistance across the border. Even in these early and difficult years SCA had a developmental approach to this humanitarian catastrophe. With the arrival of democracy in Afghanistan and the restoration of the state, SCA has transitioned to a participatory development approach, supporting governance at all levels. Currently, SCA implements substantial development programs in Health, Education, Disability and Rural Development across 17 provinces. SCA’s programs target rural population with a focus on vulnerable sections of population, including women, children and the disabled. The organization has an annual budget of approximately USD28 million (2010) and is mainly funded by Sida, Forum Syd, the World Bank and the European Commission. SCA employs about 4,400 staff, 99.7% are Afghan Nationals.

1.2. Surveyed area is one of the 34 provinces of Afghanistan. Located in the ( ن :Laghman (Persian/Pashto eastern portion of Afghanistan its capital is Mihtarlam city. It is bordered with the following provinces: Kunar on the east, Nuristan on the north, Panjsheer on the north-west, Kapisa and Kabul on the west, and Nangarhar on the whole southern part. The area represents 3,843 km 2 (1,483.8 sq mi) 2. Maps are presented in annexes 1 and 2. The province is composed of 5 districts including: Alingar, Alishing, Dawlat Shah, MihtarLam, and Qarghayi. Out of the 5 districts, only 2 were included in the survey: Mihtarlam and Qarghayi districts. Indeed, Alingar, Alishing and Dawlat Shah districts were categorized as unsecure. Moreover, 115 villages were excluded from the survey in the 2 selected districts due to instable situation at the time of the survey.

2 http://laghman.com

9 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Mihtarlam district is located in the center of Laghman province and consists of the urban centre and 24 major villages (159 villages according to CSO population data -2010/2011). The Alishing and Alingar rivers run though the district. Due to its close location to Pakistan, many young men are working as laborers in the neighbor country. Qarghayi District has 140 villages according to CSO population data -2010/2011. It is the largest district in Laghman Province, and is located 30 Km from the provincial centre. The north side borders Nuristan Province and the south borders Nangarhar. Most of the arable land in this district has not been drought-affected, however in a small number of villages the land is sometimes affected by drought (Ambir, Kashmund and Sar Khil villages) and in other villages (Sawadi and Locar Lam) some areas of land are threatened by the river.

1.3. Data population – Demography Laghman is an ethnically diverse population, with substantial Pashtun, Pashai, Nuristani, and Tajik populations. Pashto is spoken by around 58% of the population 3. Pashais and Nuristanis are also native tribes, and represent 33% of the population according to some estimates. There is also a Tajik minority of 9% . The people of Laghman are overwhelmingly Sunni Muslim. The populous southern districts of Mihtarlam and Qarghayi have substantial populations of Suliaman Khel Pashtuns. The other large Pashtun tribe in the Province, the Safi, populate portions of Mihtarlam as well. The most significant minority are the Pashais. In certain areas there have been tensions between the Pashais and neighboring communities. Laghman province also has a population of Kuchis or nomads whose numbers vary in different seasons. In winter, 94.020 individuals, or around 4% of the overall Kuchi population, stay in Laghman living in 40 communities 4. Of these communities 2% are short-range migratory, 1% is settled, and 97% are long-range migratory. Amongst migratory Kuchi, all households are fully migratory which means no families remain behind in Laghman during the summer. The most important summer area for the short range migratory Kuchi is in Dawlat Shah District of Laghman province. The Kuchi population in the summer is estimated around 3.670 individuals. The overwhelming majority of Laghman's relatively small population (around 99% 5) lives in rural areas, largely concentrated in the river valleys in the northern, mountainous areas and flatter lowlands to the south. The most populous district is Mihtarlam which has a population of nearly 112,860 inhabitants 5

1.4. Geography and climate The province covers an area of 3408 km 4. More than half of the province is mountainous or semi mountainous terrain (55.4%) while around forty percent of the area is made up of flat land (40.9%). Intensively cultivated lands are located along the river valleys. Forested areas are mainly located in Alingar, Alishing, and Dawlat Shah districts. There is a lake in Qarghayi district 6. Laghman is a tropical area having hot weather in summer and moderate cold in winter. During summer season or precisely monsoon, heavy rains occurs, which may ruin the property, fields and garden of local people. These heavy rains patterns are often preceded by hot dry periods or even droughts.

3 http://complexoperations.org/cowiki/Laghman_Province 4 http://www.foodsecurityatlas.org/afg/country/provincial-Profile/Laghman 5 CSO – 2010/2011 6 AIMS, Afghanistan Laghman Province Land Cover Map , April 2002 and Nelles Verlag, Afghanistan , 2006.

10 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 1.5. Administrative organisation Afghanistan is divided in 34 provinces which are then divided into 401 districts, themselves divided into cities or villages. These cities or villages constitute the smallest administrative organisation. Lagman province is composed of 5 districts, themselves composed with 621 cities/villages. Out of these 5 districts, only 2 were included in the survey: Mihtarlam and Qarghayi districts, which represent 299 villages in total. Out of these 299, 115 villages categorized as insecure and hence were excluded from the survey (cf. tables 1 and 2, Population figures, p15). Indeed, Laghman remains unsecure province in most of its parts.

1.6. Economic – Food security situation The Alingar and Alinshang rivers pass through Laghman and the province is known for its lushness. Laghman has sizable amounts of irrigated land as one can find scores of fruits and vegetables from Laghman in Kabul. Other main crops in Laghman include rice, wheat and cotton and many people living in the area are involved in agricultural trade business and government employment. Pastoralist people usually trade cows, goats, sheep, hens and donkeys. Unlike other provinces, Laghman houses a relatively large number of villages that grow industrial crops. Cotton, sugar, sesame, tobacco, olives and sharsham are grown in a total of 443 villages. Around half of these (47%) of these grow cotton – 204 out of 433, and Cotton growers and sugar cane growers account for 88 percent of all the villages producing industrial crops 7. These villages are mostly concentrated in the Mihtarlam and Qarghayi districts, corresponding to the 2 districts targeted by this survey. Laghman also has an array of precious stones and minerals; it is well known for being a relatively untapped source of the Tourmaline and Spodumene gemstones which are reported to be in abundance at the northern portions of the province. Consecutive to its strongly agricultural orientation, Laghman is also very dependent of weather conditions. Devastating droughts or on the contrary, floods, may occur and seriously damage productions, generating food insecurity. This situation occurred in 2010: after crop failures due to the June severe drought 8, the population faced highly damaging floods in August, to the point that populations had to be given food assistance for several months after the floods 9. The floods affected several provinces in the eastern part of the country such as Nangarhar and Kunar provinces. In regard to military intervention, the United States and the multi-national coalition forces, International Security Assistance Force (ISAF), are active in the area. Security in Laghman Province is fairly poor, and there is a significant insurgent presence, including the Taliban, the Haqqani Network, and Hezb-e Islami 10 . The province also has multiple other non-state armed groups, including militias controlled by local strongmen and community leaders, as well as criminal groups.

7 http://www.foodsecurityatlas.org/afg/country/provincial-Profile/Laghman 8 IRC food security assessment, June 2010, available at http://ochaonline.un.org/afghanistan/Clusters/FoodSecurityAgriculture/tabid/5582/language/en- US/Default.aspx (last visit: July 21 2011) 9 FEWS food security outlook October 2010 to March 2011, available at: http://ochaonline.un.org/afghanistan/Clusters/FoodSecurityAgriculture/tabid/5582/language/en- US/Default.aspx (last visit: July 21 2011). 10 http://complexoperations.org/cowiki/Laghman

11 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 1.7. Water and sanitation situation In Laghman province and according to NRVA 2005, on average 39% of households use safe drinking water. More than four households in five (84%) have direct access to their main source of drinking water within their community, however one in six households (16%) has to travel for up to an hour to access drinking water as the table below shows:

Time required accessing main source of drinking water In community Less than 1 hour 1-3 hours 3-6 hours % 84 16 0 0

On average only 4% of households have access to safe toilet facilities. The following table shows the kinds of toilet facilities used by households in the province 11 : Toilet facilities used by households None/ bush Dearan / Sahrah (area in Open Traditional Improved Flush

open field/ compound but not pit) pit covered latrine latrine latrine % 6 9 9 72 4 0

1.8. Health situation and intervention In overall, the on-going health reforms in Afghanistan have resulted in an extensive number of policy documents and guidelines. The most prominent are the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS). The Ministry of Public Health (MoPH) and a number of major donors (European Union, World Bank and USAID) have gradually introduced a framework that seeks to promote a more prominent ‘stewardship’ rather than implementing role of the MoPH at central and provincial level. Actual implementation, that is the provision of health services, is “contracted-out” to NGOs 12 :

A basic infrastructure of health services exists in Laghman province. According to statistics provided in 2005 13 , there were 23 health centers and 5 hospitals with a total of 236 beds. There were also 37 doctors and 92 nurses employed by the Ministry of Health working in the province, which represented around half the number of doctors (down from 66) and three quarters of the number of nurses (down from 119) in 2003. Accessibility to healthcare is rather difficult for a large proportion of the population, and just under two thirds of residents have to travel over 5kms to get medical attention (63.5%). Today, the agency SCA is the BPHS implementer in Laghman province. SCA activities are implemented in the 5 districts of the province, following the BPHS framework and the National Health policy. In addition, the local NGO Health Net TPO is bolstering some BPHS and EPHS components of the health system in Laghman province. Health Net TPO is managing some projects such as the TB control programme or the scalling up of malaria control interventions.

11 NRVA 2005 12 http://www.etc-crystal.org 13 http://www.foodsecurityatlas.org/afg/country/provincial-Profile/Laghman

12 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 1.9. Nutrition intervention In regard to nutrition activities, SCA does run any nutrition project in Laghman province. Nevertheless, at the time of this report writing, SCA was conducting a household survey for assessing the feeding practices in children under 24 months old and the access to health facilities for women from 15 to 49 years old. Health facilities were evaluated as well as part of this survey. Meanwhile, the local NGO Health Net TPO implements programs related to nutrition in Laghman province. Nutrition project corresponds to the 4 Community based Management of Acute Malnutrition (CMAM) components which are as follows:


Treatment of Moderate Acute Malnutrition in Supplementary Feeding Program (SFP);


Treatment of Severe Acute Malnutrition in Outpatient Therapeutic Program (OTP);


Treatment of Severe Acute Malnutrition in Inpatient Unit - Therapeutic Feeding Unit (TFU);


Community mobilization; Related to this framework, Health Net TPO is currently running:
1 TFU located in Mitharlam Provincial Hospital;
6 OTP sites covering the whole province: 1 OTP site located in Mihtarlam Provincial Hospital, 2 OTP sites located in Dawlat Shah district and 1 OTP site located in Alishing, Qarghayi and Alingar districts; o These OTP centres were open recently. Indeed the activities started by the end of May 2011;
1 SFP site located in Mihtarlam Provincial Hospital; o This SFP centre is only running since beginning of July 2011;
Community mobilization in the targeted areas.

1.10. Humanitarian interventions Many humanitarian actors are operating in Laghman province and hence cannot be listed exhaustively in this report. Nevertheless, UN agencies such as UNICEF, OCHA or WFP are present in the area. Many local and international NGOs are providing humanitarian assistance to the population in various different sectors like water and sanitation, food security or livelihoods. According to the ‘Who – What – Where’ report published by OCHA in January 2010 14 , the following agencies were in charge to run projects in Laghman province: - Food security and agriculture: WFP – MADERA - Education: BRAC – SCA – WADAN; - Water, Sanitation and Hygiene (WASH): CRAA – DACAAR; - Capacity building: MADERA – ACTED; - Health: HN TPO – SCA;

14 http://3w.unocha.org

13 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 2. SURVEY OBJECTIVES

The current survey aims to collect representative nutrition and IYCF data at the level of SCA’s work areas. This will allow monitoring the population’s nutritional status and IYCF practices as part of SCA’s program requirements. These data will also be part of the nutrition surveillance initiave as mentioned previously.

• To estimate the prevalence of acute malnutrition in children aged from 6 to 59 months in Mihtarlam and Qarghayi districts, Laghman province;

• To estimate the prevalence of chronic malnutrition in children aged from 6 to 59 months in Mihtarlam and Qarghayi districts, Laghman province;

• To estimate the prevalence of acute malnutrition among pregnant and lactating women of the households included in the children anthropometric survey and the Infant and Young Child Feeding study, in Mihtarlam and Qarghayi districts, Laghman province;

• To estimate the measles vaccination coverage in children aged from 9 to 59 months in Mihtarlam and Qarghayi districts, Laghman province;

• To estimate the coverage of Vitamin A supplementation for children aged from 6 to 59 months old in Mihtarlam and Qarghayi districts, Laghman province;

• To obtain quantitative data on Infant and Young Child Feeding (IYCF) practices using the WHO IYCF indicators 15 in Mihtarlam and Qarghayi districts, Laghman province;

15 WHO. Indicators for Assessing Infant and Young Child Feeding Practices - 2008

14 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 3. METHODOLOGY

3.1. Sampling strategy: sampling design and sample size calculation A SMART ©16 multi-stage cluster sampling method was used for the anthropometric nutrition survey and IYCF practices study conducted in Mihtarlam and Qarghayi districts, Laghman province. The sampling frame consisted of the total villages from Mihtarlam and Qarghayi districts, without 115 villages excluded from these districts (Annex 3). The primary sampling unit is the cluster. The smallest administrative unit being the village, clusters always corresponded to villages. However, big villages could have several clusters. The basic sampling unit was the household. Here, a household is defined as all people eating from the same pot according to WFP definition. According to population figures provided in 2010-2011 by CSO, the population data per district are as follows.

Table 1: Population figures, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 – Source: CSO 2010-2011 Nber Total Pop Pop Pop Pop Total District Villages Pop Male Female U5 P/L HH Mihtarlam 159 112,860 57,927 54,933 22,572 9,029 16,844 Qarghayi 140 70,658 36,118 34,540 14,132 5,653 11,142 TOTAL 299 183,518 94,045 89,473 36,704 14,682 27,986

Due to security constraints and according to SCA national staff, 44 villages in Qarghayi district and 71 villages in Mitharlam district were excluded from the survey for a total of 115 villages. The total population including in the survey is presented in the table below.

Table 2: Population figures, Mihtarlam and Qarghayi districts (115 unsecure villages excluded), Laghman province, Afghanistan, May 2011 – Source: CSO 2010-201

Nber Pop Pop Pop Total District Total pop Pop Male Villages Female U5 P/L HH Mihtarlam 88 79,447 40,753 38,694 15,889 6,356 11,775 Qarghayi 96 54,161 27,702 26,459 10,832 4,333 8,563 TOTAL 184 133,608 68,455 65,153 26,722 10,689 20,338

In total, 184 villages were included in the survey. According to the statistics provided by CSO, the average household size is rounded up to 6.6 members. In overall, the population is fixed to their location, except the migration of Kuchi nomads as mentioned above (Part 1.3 Data population – Demography, p.10). The national nutrition policy indicates a proportion of children under five of about 20% out of the total population, so representing around 26,722 children under five in the target area. According to the same source, pregnant and lactating women represent 8% of the total population, so corresponding to 10,689 women in the 2 districts.

16 Standardized Monitoring and Assessment in Relief and Transition, see web sites www.nutrisurvey.de/ena/ena.html and www.smartmethodology.org

15 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 3.1.1 First stage sampling: cluster selection Clusters selection and data analysis were done using ENA Delta software 2011 April version. Clusters were selected using the Probability Proportional to Size (PPS) method. The procedure was done automatically in ENA software. 28 villages, corresponding to 28 clusters were included in the survey and are listed in annex 4. Due to insecurity in the area during the data field collection, 2 clusters could not be completed: cluster number 3 corresponding to Bar Kashmon village and cluster number 21 corresponding to Qala Rahim village. Hence, only 26 clusters out of the 28 expected could be surveyed and are included in the data analysis. No reserve cluster was surveyed as less than 10% of the total sample was cancelled by excluding the 2 mentioned clusters. Indeed, 3 Reserve Clusters (RCs) were selected by ENA software. Reserve clusters should be used only if 10% or more clusters were impossible to reach during the survey. In that case, all RCs should be surveyed. According to transportation constraints to reach the clusters and other factors such as the time to conduct interview estimated at 20 minutes or the time required for meeting the community leaders, it was estimated that one team could cover 20 households per day. By targeting 20 households per cluster and by conducting 28 clusters, 560 households were expected to be surveyed. This was planed in order to reach the maximum sample required which was of 557 households for the anthropometric sample – Children 6-59 months. If several clusters were to be surveyed in one village, then the village was divided into surveyable segments of 150 households or less using the Probability Proportional to Population Size (PPS) methodology. Selected segments became the clusters to be surveyed and other segments were ignored (Annex 5). In villages having only one selected cluster, if the size of the area to survey was equal or over 150 households or scattered, a second selection could be launched according to the segmentation methodology presented in the chapter ‘3.2 Selection of households and children’ part 3.2.1.2 “Segmentation”.

3.1.2 Sampling procedure and sample size for anthropometric data The sample size of households to survey was determined by using the ENA Delta software April 2011 version according to a 40% global acute malnutrition prevalence estimation with a desired precision estimated of 5% and a design effect equal to 1.5. The table below summarizes all parameters used for sample size calculation.

Table 3: Population expected to be surveyed for anthropometric nutrition survey according to parameters, Mihtarlam, and Qarghayi districts, Laghman province, Afghanistan, May 2011 Parameters Value Justification Estimated 40 A Rapid Assessment of Nutritional Status by MUAC of Under Five Prevalence of Children and Pregnant Women was conducted by SCA in Alingar GAM (%) and Qarghayi districts of Laghman Province in November - December 2010. The main results of this rapid nutritional assessment were as follows: 38.6% of the screened children in Alingar district were acutely malnourished while 43% of the screened children in Qarghayi district were acutely malnourished. Even if these results have to be taken with caution as the estimated proportion of acutely malnourished children or pregnant/lactating women seem considerably high compared to the national estimation, they were used to estimate the GAM prevalence of this survey to 40% (assuming that the rate of

16 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan malnutrition could increase while using W/H indicator). ± Desired precision 5 Since the expected GAM prevalence was high enough, a precision (%) of ± 5% was chosen in order to allow further comparison. Design Effect 1.5 The design effect was estimated at 1.5 as the target population is composed of 2 main ethnic groups having the same cultural habits, as well as comparable livelihoods: Pasthus and Tadjiks. Average HH Size 6.6 According to CSO population data 2010-2011, the average household size is 6.6. % Children under-5 20 The proportion of children under five was estimated at 20% according to the national nutrition policy. By using ENA Delta software, the assumption made by SMART is that the population of children 6-59 months represents approximately 90% of the population U5. The software then calculated 90% of 20% less than 5 among 6.6 average people in HH: 20% x 6.6 = 1.32 under 5 per HH, that is 90% x 1.32 = 1.18 6- 59 months per HH, that is 1.18/6.6= 17.8% of the total population, or 23,782 6-59months % Non-response 9 The percentage of non respondent households was estimated at Households 9%. Indeed, due to cultural factors, households were suspected to refuse taking part to the study. Indeed, most of the women are not allowed to welcome strangers at household’s level when men are away. Children 6-59 months to be included (according to ENA) : 602 children 6-59 months old Households to be included (according to ENA): 557 households

At the end of the data field collection, only 520 households were visited while 557 were expected at minimum. The sample size decreased of 40 households due to the cancelation of 2 clusters (20 households expected per cluster). No children were found in 54 households, leading to a total of 466 households having children under five. The minimum of 602 children expected to be surveyed is reached as 625 children have been included in the survey. 15 children were absent at the time of the survey, corresponding to 2.4% of the total sample while the Non-Response Households rate was estimated at 9%. No household refused to take part to the study. Hence, data analysis was done with a sample of 610 children. According to these statistics, the average of children 6-59 months per household is estimated at 1.2 while it was estimated at 1.18 according to ENA software and CSO statistics (Table 3 - % Children Under 5). Although sample sizes were calculated for the majority of indicators in order to make sure that results’ confidence intervals would be reasonable (cf. following pages), priority was given to the sample size required for GAM determination. Moreover, since it was the highest one compared to other sample sizes needed, the expected precision of other final results increased. This choice was also made in order to avoid complicating field procedures and indirectly generate bias due to confusion. From an ethical viewpoint, although more respondents were interviewed, no invasive data collection technique was used and then no harm was generated by this choice.

The sample size for the determination of the chronic malnutrition prevalence was estimated at minimum of 150 children and 139 households as presented in the table 4 below. According to the National Nutrition survey conducted by the MoPH in 2004, the stunting was estimated at 60.5%. No more recent data concerning stunting are available. The rapid nutrition assessment conducted by SCA in 2 districts of Laghman province in 2010 did not release stunting rate as only MUAC criterion was used. For the calculation of the sample size, the desired precision was estimated at 10%.

17 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 4: Population expected to be surveyed for anthropometric nutrition survey and the estimation of chronic malnutrition in children 6-59 months, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Estimated Children Average % of non % Households prevalence Desired Design 6-59 to Survey Household Response Children to be of chronic precision effect be size Households under five included malnutrition included Mihtarlam and 60.5% 10% 1.5 6.6 9% 20% 150 139 Qarghayi districts

At the end of the data field collection, 520 households were visited while only 139 were expected at minimum. 625 children were surveyed while only 150 were required. For both estimations, the rates of non responders correspond to 2.4% (including absent children) while 9% was expected. Indeed, only 15 children out of 625 were absent during the data field collection. No family refused to take part to the survey.

3.1.3 Sampling procedure and sample size for measles immunization coverage study: Following the selection of households for the anthropometric nutrition survey, all children from 9 to 59 months old, included in the anthropometric nutrition survey were expected to be included in the measles immunization coverage. At national level and for children from 12 to 23 months old, the measles vaccine coverage is estimated at 62.6% 17 . The design effect of this outcome was fixed at 4. Indeed, it often happens that some villages are covered by immunization campaign while some others may have not been targeted. With a desired precision of 10% and an expected coverage of 62.6%, the sample size was estimated at 372 children aged 9 to 59 months and 385 households. Design effect, average of household size, and percentage of non response households were similar than the ones used for the calculation of the anthropometric sample size. ENA Delta software provides the household sample size only for children 6-59 months old; the target group for measles vaccination coverage being different, the conversion was then done manually according to the following steps:


Find out the ratio of 9-59 months among the general population; The ratio of 9-59 months among the population could not be found. However, according to the ACF Anthropometric nutrition survey done in Day Kundi province by ACF in October 2010 with a similar methodology 18 , children from 9 to 59 months old represented 95% of the total sample (725 out of 766) of children 6-59 months . The ratio of 1.18 6-59 months found previously (cf. section 3.1.2 table 3) was used to deduce the ratio of children 9 to 59 months among the general population as follows: 0.95 x 1.18 = 1.12 children aged 9 to 59 months per household (that is: 1.12/6.6 = 0.169, or 16.9% of the total population).

17 Afghanistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan 18 ACF Anthropometric nutrition and retrospective mortality survey – Ashtarlay district – Day Kundi province – Afghanistan – October 2010

18 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan


Convert the sample size needed from children to households: This was done by using the following formula: Number of units needed from the target group/ ratio of target group per HH That is: n(HH) = 392/1.12 = 350 households.


Apply the non-response rate (9%, or 0.09): The final sample size was inflated as follows to compensate for non response rate: n final = 350/(1-0.09) =385 households

At the end of the data field collection and as for the anthropometric survey, 520 households were visited while a minimum of 385 was expected. A sample of 567 children out of the 610 children surveyed for the anthropometric nutrition survey is used for data analysis while a minimum of 372 was required. 43 children were less than 9 months old and were automatically excluded for the final analysis. The proportion of children 9-59 months out of the total sample of children 6-59 months represents 92.9%, which corresponds approximately to the estimation provided by the anthropometric survey done in Day Kundi in October 2010 of 95%.

3.1.4 Sampling procedure and sample size for Vitamin A supplementation coverage study: All children from 6 to 59 months old, included in the anthropometric nutrition survey were expected to be included in the Vitamin A supplementation coverage study. At national level and according to the MoPH Health survey done in 2006, more than three quarters (76.5%) of children 6-59 months of age received Vitamin A in the last six months. Indeed, vitamin A is often given during polio campaigns with the polio vaccine. As for the measles immunization coverage, the design effect of this outcome was fixed at 4. It often happens that some villages are covered by supplementation campaign while some others may have not been targeted. With a desired precision of 10% and an expected coverage of 76.5%, the sample size was estimated at 301 children and 278 households. Indicators such as the average of household size, the percentage of non response households and the proportion of children under five, were similar than the ones used for the calculation of the anthropometric sample size. At the end of the data field collection, 520 households were visited while only 278 households were expected at minimum. 610 children are included in the data analysis; the minimum was fixed at 301 children.

3.1.5 Sampling procedure and sample size for anthropometric data – Pregnant – Lactating women Following the selection of households for the anthropometric nutrition survey, all pregnant and lactating women with children 0-59 months included in the survey and found at household level should be targeted by the survey: • All pregnant women with children 0-5 months included in the IYCF study or with children 6-59 months included in the anthropometric survey should be included. Almost no women with children 0-5 months old should be found at household level, as pregnancy occurs generally several months after a first delivery. Nevertheless, this category was kept for exceptional case. No threshold was fixed for the duration of pregnancy, only a pregnancy certificate was required;

19 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan • All lactating women for the first six months after delivery with children 0-5 months included in the IYCF study should be included in the survey; The sample size depended on the number of pregnant/lactating women with children included in the survey found at household level while conducting the anthropometric nutrition survey. The sample used as reference for this survey was the anthropometric sample for children 6-59 months old. The goal to collect data about the nutrition status of pregnant-lactating women was more dedicated for project design than for nutrition surveillance. Taking into consideration the limit of this survey, the lack of precision for this indicator should be acknowledged. At the end of the data field collection, 71 pregnant women with children 6-59 months old and 77 lactating women breastfeeding an infant less than 6 months old (2 mothers were absent at the time of the survey), were found at household level, for a total of 148 women screened by MUAC. No pregnant women with children 0-5 months were found during the data field collection. The sample size used for estimating the prevalence of acute malnutrition among pregnant/lactating women is low. Hence results presented further in this report have to be considered with caution.

3.1.6 Sampling procedure and sample size for IYCF study Following the selection of households for the anthropometric nutrition survey, all children from 6 to 23 months old, included in the anthropometric nutrition survey were expected to be included in the IYCF questionnaire. The infants less than 6 months excluded from the anthropometric nutrition survey should be included in the IYCF questionnaire. The sample size depended on the number of children 0-23 months old found at household level while conducting the anthropometric nutrition survey. At the end of the data field collection, 78 infants less than 6 months and 247 children 6-23 months were found in the visited households for a total sample of 325 children 0-23 months. The sample size used for evaluating the IYCF practices is not really consequent. Hence results presented further in this report have to be considered with caution.

3.2 Final stage sampling: Selection of households and children

3.2.1 Household selection A non exhaustive screening was chosen as the population size was too big or not well concentrated in one area. It was not possible to put together a sample that is representative of the area, but subjects must nevertheless have been selected at random. All the children living in the selected house in the correct age range have to be included in the sample and measured. If two eligible children were found in a household, both were included, even if they were twins. This is extremely important, as it ensures that every child has the same chance of being selected, which is a basic principle of the survey design. In each selected village, one or more community member(s) helped the survey teams to conduct their work by providing information about the village as the geographical organization or the number of households. A map of the selected village was drawn when arriving in the cluster. From this map, the systematic random sampling method was used for the selection of households to survey.

20 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 3.2.1.1 Final stage selection by using the systematic random sampling method Systematic random sampling method was used to select households within each cluster. If the population size in the selected village was equal or over 150 households or scattered, an intermediate step was to subdivide the population into segments of roughly the same number of households or into unequal parts when equal segmentation was not feasible (see below segmentation section). In Laghman province, 12 clusters corresponding to 12 villages were segmented following the methodology described below. Then one segment was randomly selected giving an equal chance to all households. The households included in the segment (corresponding to a survey cluster) were selected by using the systematic random selection as described below. The following steps were respected and a household selection sheet was completed in order to ensure the respect of this methodology (Annex 6) :

1. The “sampling interval” was determined by dividing the total number of households in the cluster by the number that must be visited (20 households). The first household was the one selected randomly.  For example, if the total population in the cluster is 150 HH and 20HH have to be visited, the sample interval is 7.5.  For selecting the houses to survey, the sampling interval should be rounded down to the nearest whole number. In this example, it is rounded down to 7. 2. The first household was randomly selected within the sampling interval (1–7) by drawing a random start number between 1 and the sampling interval and using a random table.  For example, if the random number drawn is 5, the team starts with the fifth house. 3. The next household to be visited was found by adding the sampling interval to the first household selected (or counting the number of households along the prescribed route).  In the example, 5 + 7.5 = 12.5. 4. The houses number 5, 12… and so on were surveyed, until all selected households have been visited. 5. All children in each selected house were measured and their measurements were recorded on the datasheet. 6. All required questionnaires were completed for each household. 7. This process was followed up until to reach the required number of households to survey.

Note: The population data referred to were the ones provided by the community leaders instead of using the CSO data 2010-2011. Indeed, population data provided by community leaders are considered more accurate than official statistics.

3.2.1.2 Segmentation When the population size in the selected village was equal or over 150 households or scattered, the first step was to subdivide the population into segments of roughly the same number of people or into unequal segments with a minimum of 20 households per segment.

21 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan The villages were divided according to: • Existing administrative subdivisions. • Natural barriers: river, road, mountain, etc. • Public places: market, schools, mosques,etc.

The segmentation was done into: • Equal parts: when the area could be divided into parts of roughly equal size. The first step was to subdivide the population into segments of approximately the same number of households, as presented in the graph 1.

Graph 1 : Example of equal segmentation for conducting anthropometric nutrition survey

Then one segment was randomly selected giving an equal chance to all households. The selection of households included in the segment was done following the systematic random sampling methodology. If at the limit of the segment, the cluster was not completed, the team went to the closest preselected segment and followed up the same methodology.

• Unequal parts: when the area could not be divided into parts of roughly equal size. Indeed, in some cases, it might be impossible to divide the village into equal parts. Some natural barriers should be found that can help divide the village into separate segments, as presented in the graph 2.

Graph 2: Example of unequal segmentation for conducting anthropometric nutrition survey

Then the segments are selected using the Probability Proportional to Population Size (PPS) method to give every household the same chance of being selected. This PPS methodology is used for household selection and is different to the one used for the cluster selection as presented in annex 5.

22 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Example: according to the graph 2 above Segment Population Cumulative Intervals (HH) population  A = 70 HH A 70 70 1 – 70  B = 100 HH  C = 30 HH B 100 170 71 - 170  D = 190 HH C 30 200 171 - 200  TOTAL = 390 HH D 190 390 201 - 390  Cluster size = 15 HH After filling out the cumulative population for each segment, a 3-digit number is picked from the random number table between 1 and the total cumulative of the all the segments. The segment containing the selected number will be the one to survey. Example: the number 123 is picked; hence the segment B will be surveyed.

3.2.2 Children selection for anthropometric nutrition survey All children from 6 to 59 months old or if the age was not available height >= 65 cm and < 110 cm in the selected household were included in the anthropometric nutrition survey. Infants from 0 to 23 months old found at household level were included in the IYCF study.

Special cases:
If a child lives in a house but is not present at the time of the survey, he/she is recorded on the data sheet. The team returns at the end of the day to take the child’s measurement. If the child is still absent, he/she is not replaced, meaning that in the cluster one data will be missing.
If a house is empty, the team returns at the end of the day. If it is not possible to return for any reason, the house is evaluated, and it appears on the questionnaire. A house is never substituted by another one. In all cases, neighbours are asked about the household, on who lived in this house and if the residents are absent for a short period or indefinitely.
In case of refusal from the parents to include their child in the survey, he/she is not replaced, meaning that in the cluster one data will be missing.
Orphan children taken in charge by a family are considered as part of the family and are included in the survey. It is similar for children who are under care (living permanently) of their grandparents or relatives.
Disable children are eligible and are included whenever possible. If it is not possible to measure their height, weight or MUAC due to deformity or other abnormality, they are given an ID number and data recorded is missing (and not taken unless they have oedema). For people with left arm handicapped, the MUAC is done on the right arm.
If a polygamous family contains different HH, each HH should be included separately in the list for household’s selection.
If several families are part of the same HH 19 , all children included in these families are targeted by the survey.
In a compound with several households, each households should be included separately in the list for household’s selection.

19 WFP definition

23 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Note:
Following the household selection conducted for the children anthropometric nutrition survey, all children from 0 to 5 months as well as children from 6 to 23 months old were included in the IYCF study.
Following the household selection conducted for the children anthropometric nutrition survey, MUAC was measured for all pregnant with children 0-59 months old and for all lactating women with children 0-5 months old.

3.3 Data collected and measurement techniques

3.3.1 Anthropometric questionnaire for children 6-59 months (Annex 7) Different parameters are used to assess the nutritional status of an individual. Weight, height, Mid Upper Arm Circumference and bilateral oedema are the most commonly used. These are often linked to sex and age. For each selected child, the following information was collected: 1. Age (in months): Only children between 6 and 59 months old or if the age was not available height >= 65 cm and < 110 cm were included in the sample. Age was confirmed by showing a vaccination card or a birth certificate. If these documents were not available, the use of a local event calendar built for Laghman, as well as Nangarhar provinces helped to determine the age (Annex 8). The age was recorded into the questionnaire in months. This measure was taken in order to determine the prevalence of acute malnutrition but also to have maximum reliable results regarding chronic malnutrition prevalence (height-for-age in z- score <-2). 2. Sex: M=male and F=female 3. Weight (in kg): Children were weighed by using an Electronic Uniscale sensitive to the nearest 0.1kg. The children who could easily stand were asked to stand on the weighing scale and their weight was recorded. In a situation where the children could not stand up, the double weighing method was applied. 4. Height (in cm): Measuring board was used to measure bare headed and barefoot children. The precision of the measurement is 1 mm. Children of less than 87 cm were measured lying down and those equal to or above 87 cm were measured standing up. 5. Mid Upper Arm Circumference (in mm) : MUAC is an indicator of mortality risk by malnutrition and was measured to the nearest 1mm for all children with a height = or > 65cm. 6. Oedema: The presence of oedema was verified by pressing both feet at the same time with the thumbs during three seconds. Only children with bilateral pitting nutrition oedema were recorded as having nutritional oedema: Y= Yes; N= No

Note: Beside anthropometric data, additional information were collected as follows:

24 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 7. Measles immunization status For children from 9 to 59 months old, the mother/caretaker was asked if the child has been immunized against measles or not, and if there is a vaccination card to prove it. The analysis excludes children less than 9 months of age according to international immunization protocol. When the child had a vaccination card with a registered date then it was recorded as ‘Y’. When the card was not available, but the mother/caretaker said that the child has been immunized against measles, ‘VWC’ (Vaccination Without Card) was recorded. If there was no card and the mother or caretaker said that the child has not been immunized ‘N’ was recorded. If the mother/caretaker did not know "DK" was recorded. 8. Vitamin A supplementation within the last 6 months For children from 6 to 59 months old, the mother/caretaker was asked if the child has received a Vitamin A dose within the last 6 months, following the international health policy to extend Vitamin A supplementation to all children from 6 to 59 months old. One Vitamin A capsule was shown to the mother or caretaker to facilitate the understanding. The record was done as follows: Y = Yes; N= No; DK=Does not know

3.3.2 IYCF practices questionnaire for children 0-23months old (Annex 9) All children from 6 to 23 months old included in the anthropometric nutrition survey were expected to be included in the IYCF questionnaire. The infants less than 6 months excluded from the anthropometric nutrition survey were included in the IYCF questionnaire. The IYCF questionnaire is based on the WHO recommendations 20 . Additional indicators were incorporated to the questionnaire to enable deeper analysis.

1. Introduction of breastfeeding The mother/caretaker was asked if she ever breastfed her child. It does not matter how long the mother/caretaker breastfed the child, only whether or not she ever gave the child her breast: Y = Yes - N = No - DK = Does not know

If no at this question: the question 2 was asked. If yes at this question (If the mother/caretaker breastfed her child ): the question 2 was skipped and the question 3 was asked.

2. No introduction of breastfeeding If no at question 1 and so if the child has never been breastfed, the reason of non breastfeeding was investigated as follows (only one answers possible): A: Breast-milk not good for the child F: Mother/caretaker sick B: Pain G: Advice of family members C: No breast milk coming out of the breast DK: Does not know D: Refusal of the child to be breastfed Other (Specify) E: Child sick

20 WHO. Indicators for Assessing Infant and Young Child Feeding Practices - 2008

25 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan

No more question was asked to the mother/caretaker, as she never breastfed her child. If yes at the question 1: the following questions were asked:

3. Timing for the introduction of breastfeeding If the mother/caretaker has given her breasts to the infant, she was asked how long after birth she put her child to her breast. Record was done of how many hours after birth the baby was first put to the breast. If the baby was put to breast:
Within the first hour of life
Within the first 24 hours
Within more than 24 hours
If not known, record DK

4. Colostrum (first milk) and prelacteal feeding The mother/caretaker who breastfed her infant was asked if she gave the colostrum during the first 3 days after delivery: Y = Yes - N = No - DK = Does not know

5. Introduction of prelacteal feeding The mother/caretaker is then asked whether the infant was given any prelacteal feeding (anything to drink other than breast milk): Y = Yes - N = No - DK = Does not know

6. Currently breastfeeding The mother/caretaker was asked if she is still breastfeeding her child: Y = Yes - N = No - DK = Does not know It does not matter if the mother was giving to her child other liquids or foods as well as breast milk; what was of interest is if the infant or child was still breastfed during the time of the survey. If yes at the question 6:
No more questions were asked to the mother/caretaker, as she was still breastfeeding.
Nevertheless, if the mother had an infant 0-5months old, her MUAC was measured as explained in the question 10. If no at question 6: the following questions were asked:

7. Duration of breastfeeding The mother/caretaker was asked how long she breastfed her child. This question was only for mothers/caretakers who are no longer breastfeeding the infant or child in question. It was important to try to get as accurate information as possible. The use of a calendar of local events and celebrations was used to help the mother/caretaker to remember. Record of the number of months when the mother/caretaker completely stopped breastfeeding the infant or child was done. It does not matter if she was giving the infant or child other liquids or foods in addition to breast milk; record was made on how many months she breastfed the infant or child.

26 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 8. Reason of weaning The mother/caretaker was then asked why she stopped breastfeeding and reasons were reported as follows: (only one answer possible) A: Child too old F: Child sick B: Pain G: Mother/caretaker sick C: No enough milk H: Advice of family members D: New pregnancy DK: Does not know E: Refusal of the child to be breastfed Other (Specify)

9. End of breastfeeding : The mother/caretaker was then asked how she stopped breastfeeding: (only one answer possible) A: Progressively B: Abruptly DK: Does not know

10. MUAC for Lactating women and Pregnant women with children 0-5 months old: The MUAC for all lactating women for the first 6 months after delivery (hence having a child 0-5 months old and responding ‘yes’ to the question 6) was measured. MUAC was recorded in millimetres on the IYCF questionnaire sheet. In addition, the MUAC for all pregnant women having a child between 0-5 months old surveyed in the IYCF study was measured. The pregnancy was checked by asking a pregnancy certificate to women. MUAC was recorded in millimetres on the IYCF questionnaire sheet. Note: • The MUAC of all pregnant women having children between 6-23 months old included in the IYCF questionnaire and not breastfeeding children 0-5 months old was measured and recorded on the anthropometric questionnaire sheet. • In case a women having a child 6-59 months is pregnant and is as well breastfeeding an infant 0-5 months, her MUAC is recorded in the IYCF questionnaire sheet under ‘lactating category’. • MUAC was measured for women obviously pregnant despite the absence of medical certificate.

Skip patterns for IYCF module (Annex 10) It is very important that the mother/caretaker is asked only those questions that are relevant to her situation. For example, if a mother/caretaker never breastfed her infant or child she should not be asked how long after birth she put the infant to the breast.

27 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 3.4 Definition of nutritional status of children 6-59 months:

3.4.1 Acute malnutrition in children 6-59 months:

3.4.1.1 Wasting in children 6-59 months:

Wasting in children 6-59 months can be expressed by using 2 index; Weight for Height (W/H) or Mid Upper Arm Circumference (MUAC) as described below.

Weight-for-height index (W/H) A child’s nutritional status is estimated by comparing it to the weight-for-height curves of a reference population (NCHS references and WHO standards data 21 ). These curves have a normal shape and are characterized by the median weight (value separating the population into two groups of the same size) and its standard deviation (SD).

The weight-for-height index of a child from the studied population can be expressed either as a percentage of the median or as a Z-score according to NCHS reference and only as a Z-score according to WHO standards. WHO recommends the use of Z-scores as it is considered to be more reliable in terms of statistical theory. The expression of the weight-for-height index as a Z-score (WHZ) compares the observed weight (OW) of the surveyed child to the mean weight (MW) of the reference population, for a child of the same height. The Z-score represents the number of standard deviations (SD) separating the observed weight from the mean weight of the reference population: WHZ = (OW - MW) / SD. During the field data collection, the weight-for-height index in Z-score was calculated on the field for each child in order to refer malnourished cases to appropriate centre if needed. Moreover, the results are presented in Z-score using WHO reference in this report.

Mid Upper Arm Circumference (MUAC) The mid upper arm circumference is a reliable indicator of the muscular status of the child and is mainly used to identify children with a risk of mortality. The MUAC is an indicator of malnutrition only for children equal or taller than 65 cm.

Table 5: Cut offs points of MUAC, children 6-59 months, WHO standards Target group MUAC (mm) Nutritional status < or = 135 No malnutrition > or = 125 and < 135 At risk of malnutrition Children 6-59 months < 125 and > or = 115 Moderate acute malnutrition < 115 Severe acute malnutrition

3.4.1.2 Nutritional bilateral pitting oedema in children 6-59 months: Nutritional bilateral pitting oedema is a sign of Kwashiorkor, one of the major clinical forms of severe acute malnutrition. When associated with Marasmus (severe wasting), it is called Marasmic-Kwashiorkor. Children with bilateral oedema are automatically categorized as being severely malnourished, regardless of their weight-for-height index.

21 NCHS: National Centre for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. WHO: World Health Organization, WHO growth curves for children, 2006

28 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 3.4.1.3 Classification of acute malnutrition in children 6-59 months: The table below defines the acute malnutrition according to W/H index, MUAC criterion and oedema.

Table 6: Definition of acute malnutrition 22 according to weight-for-height index (W/H), expressed as a Z- score according to WHO standards Severe Acute Malnutrition ( SAM) z-score W/H <-3 z-score and /or bilateral oedema and/or MUAC < 115 mm Moderate Acute Malnutrition z-score W/H <-2 z-score and >= -3 z-score and absence of bilateral oedema and/or MUAC >= 115mm and <125mm Global Acute Malnutrition (GAM) z-score W/H <-2 z-score and /or bilateral oedema and MUAC < 125 mm

3.4.2 Chronic malnutrition in children 6-59 months: The height-for-age index (H/A) indicates if a child of a given age is stunted and so if he is chronically malnourished. This index reflects the nutritional history of a child rather than his/her current nutritional status. This is mainly used to identify chronic malnutrition. The same principle is used as for weight-for-height, except that a child’s chronic nutritional status is estimated by comparing its height with NCHS reference or WHO standards height-for-age curves, as opposed to weight-for-height curves. The height-for-age index of a child from the studied population is expressed in Z-score (HAZ). The following HAZ cut-off points are used:

Table 7: Cut offs points of the Height for Age index (HAZ) expressed in Z-score, WHO standards Not stunted: ≥ -2 z-score Moderate stunting: -3 z-score ≤ H/A < -2 z-score Severe stunting: < -3 z-score

3.4.3 Acute malnutrition in pregnant/lactating women: In pregnant and lactating women, Mid Upper Arm Circumference has been shown in several studies to be a reliable tool to rapidly assess nutritional status.

Table 8: Cut offs points of the MUAC – Pregnant /Lactating women , WHO standards Target group MUAC (mm) Nutritional status > or = 230 No malnutrition Pregnant/lactating women > or = 210 and < 230 Moderate acute malnutrition < 210 Severe acute malnutrition

3.5 IYCF indicators The IYCF criteria for selected infant feeding practices used for the indicators and the IYCF core/optional indicators are described as follows.

22 WHO, use and interpretation of anthropometric indicators of nutritional status, Bulletin of the WHO,64 (6) : 929-941 (1986)

29 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 9: Criteria for selected infant feeding practices used for the indicators, WHO Feeding Requires that the Allows the infant Does not allow Practice Infant receive to receive the infant to receive Exclusive Breast milk (including ORS, drops, syrups Anything else breastfeeding milk expressed or from a (vitamins, minerals, wet nurse) medicines) Predominant Breast milk (including Certain liquids (water and Anything else (in breastfeeding milk expressed or from a water-based drinks, fruit particular, wet nurse) as the juice), ritual fluids and ORS, nonhuman milk, predominant source of drops or syrups (vitamins, food-based fluids) nourishment minerals, medicines) Complementary Breast milk (including Anything else: any food or NA feeding 23 milk expressed or from a liquid including nonhuman wetnurse) and solid or milk and formula semi-solid foods

Breastfeeding Breast milk (including Anything else: any food or NA milk expressed or from a liquid including nonhuman wet nurse) milk and formula Bottle-feeding Any liquid (including Anything else: any food or NA breast milk) or semi-solid liquid including nonhuman

food from a bottle with milk and formula nipple/teat

Table 10: Core and additional indicators for IYCF study, WHO CORE INDICATORS OPTIONAL INDICATORS Early initiation of breastfeeding Children ever breastfed Exclusive breastfeeding under 6 months Continued breastfeeding at 2 years Continued breastfeeding at 1 year Age-appropriate breastfeeding Introduction of solid, semi-solid foods or soft foods Predominant breastfeeding under 6 months Minimum dietary diversity Duration of breastfeeding Minimum meal frequency Bottle-feeding Minimum acceptable diet Milk feeding frequency for non-breastfed children Consumption of iron-rich or iron-fortified foods

In order to ensure the reliability of the data collected, only several indicators were selected to be assessed by this survey. Indeed, data quality is dependent to data quantity while conducting such kind of study.

Hence, the following core indicators for IYCF study were assessed: 2. Early initiation of breastfeeding: Proportion of children born in the last 23 months who were put to the breast within one hour of birth. 3. Continued breastfeeding at 1 year: Proportion of children 12 – 15 months of age who are fed breast milk.

23 The term complementary feeding is no longer used in the indicators to assess infant and young child feeding practices. This indicator has therefore been replaced by the indicator 'Introduction of solid, semi- solid or soft foods' which is a measure of a single feeding practice.

30 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan The following additional indicators for IYCF study were assessed: 4. Child ever breastfed: Proportion of children born in the last 24 months who were ever breastfed 5. Continued breastfeeding at 2 years: Proportion of children 20–23 months of age who are fed breast milk Other relevant data were collected to enable deeper analysis.

3.6 Training and supervision Three teams of three members and one team of four members conducted the data field collection as additional staff was allocated from SCA to join the project. Each team was composed of at least two monitors and one team leader. Each team has one or two female members to ensure acceptance of the team amongst the surveyed households. 4 marhams joined the teams to facilitate the work of the female data collectors at community level. Due to cultural habits, women are not allowed to go outside without being accompanied by one male relative called locally a ‘marham’. The teams were supervised by ACF Nutrition program manager and punctually by SCA Nutrition focal point. Due to security constraints, ACF Health - Nutrition coordinator could not supervise the field work. Nevertheless, a short visit was organized at the midterm of the data field collection for checking the clusters already completed and organizing refresh training sessions accordingly. ACF team participating to the survey was composed of: 1 nutrition program manager, 1 nutrition team leader and 5 nutrition surveyors. SCA provided 8 surveyors (4 females and 4 males) to take part to the survey and punctually 1 nutrition focal points. In total, 16 staff members took part to this survey. The entire team received a 5-days training on the survey methodology and all its practical aspects. The session was managed by ACF Health-Nutrition coordinator and ACF Nutrition program manager. A standardization test was conducted on the third day in order to evaluate the accuracy and the precision of the surveyors in taking the anthropometrics measurements (Annex 11). A field test was conducted by the team in Kabul town on the fourth day, in order to evaluate their work in real field conditions. A refresher training on the anthropometric measurement was organized on the last day due to poor quality of the standardization test. MUAC and weight measurements were emphasized. An overall review of the training components was done on the fifth day. One field guidelines document with instructions and a materiel kit was provided to each team member. All documents, such as local event calendar, questionnaires or consent forms were translated either in Pashtu or in Dari, local languages, for better understanding and for avoiding direct translation during the data field collection. The questionnaires were tested during the field test and were reviewed accordingly. Several team members could speak English as well as Dari and Pashtu, so they were able to check the translation of the questionnaires from English to Dari and Pashtu. The random selection of 28 clusters was done using ENA smart software April 2011 version. Planning of the survey was realized after this selection in order to complete the data field collection over 7 days based on one cluster per team per day. Refresher training sessions were organized during the data field collection. Indeed, analysis of the data collected was done on daily basis using ENA plausibility check and other evaluation tools. Refresh trainings were organized accordingly when required.

31 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 3.7 Data analysis The anthropometric data are analyzed using ENA Delta software April 2011 version. Other data collected are analyzed using Excel version 2005. EPI 5 Stat Calc Software is used to validate comparisons. Anthropometric survey results are presented in reference to WHO standards for overall final analysis. Other indicators like the Vitamin A supplementation, measles immunization coverage or IYCF results were analysed using Excel version 2005 and are expressed in percentage out of the sample surveyed. Recommendations in order to improve the situation in the surveyed area but as well to advocate for the reinforcement or the implementation of humanitarian intervention are submitted at the end of this report.

32 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 4. RESULTS

The anthropometric results are presented according to WHO standards 2006. The plausibility check issued by ENA software version April 2011 is presented in annex 12.

4.1. Nutritional status of children 6-59 months (according to WHO standards 2006) The analysis of the acute malnutrition prevalence based on weight for height according to WHO standards is done with a sample of 600 children out of the 610 children surveyed, 10 children being excluded as their data were more likely to be aberrant than actual values according to the SMART flagging system 24 . The analysis of chronic malnutrition (stunting) prevalence is based on a sample of 583 children, 27 children being excluded for the same reason.

4.1.1 Age and sex distribution of the targeted population

Table 11: Distribution of age and sex of sample, n=610, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Age groups Boys Girls Total Ratio No. % No. % No. % Boy:girl 6-11 months 37 43.0 49 57.0 86 14.1 0.8 12-23 months 69 41.3 98 58.7 167 27.4 0.7 24-35 months 81 52.6 73 47.4 154 25.2 1.1 36-47 months 60 53.1 53 46.9 113 18.5 1.1 48-59 months 51 56.7 39 43.3 90 14.8 1.3 Total 298 48.9 312 51.1 610 100.0 1.0

The sex ratio is acceptable being of 1.0 which validates the representativeness of the sample in terms of sex representation. Moreover, the sex distribution is well balanced according to age groups without predominance of one group compared to another. This reflects also the acceptable representativeness of the sample in terms of age group representation.

Figure 1 : Distribution per age of children surveyed, n=610, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Distribution per age of children surveyed, n=610, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

30 27.4 25.2 25 18.5 20 14.1 14.8 15 10 Percentage 5 0 6-11 months 12-23 months 24-35 months 36-47 months 48-59 months

Age group

24 SMART flags being considered (+/- 3SD from the observed mean)

33 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan The age distribution is well balanced, except for the age group 6-11 months which looks under represented (only 14.1% out of the total population surveyed). This should be moderated as this classification considers a period of 6 months instead of one year as the other ones. The age group 12-23 months is the most represented corresponding to 27.4% of the total surveyed population.

4.1.2 Anthropometric results: children (based on WHO standards 2006)

4.1.2.1 Acute malnutrition prevalence expressed in Z-score The analysis of the malnutrition prevalence based on weight for height according to WHO standards is done with a sample of 600 children out of the 610 children surveyed, 10 children being excluded as their data have been flagged by ENA Software. The results are presented in the table 11. To take into account that children were weighted with clothes. As correction, 100 gr were subtracted for each weight measurement in ENA software.

Table 12: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) according to WHO standards, n=600, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Prevalence of Acute malnutrition All Z-score 95% CI According to WHO standards N = 600 Prevalence of global acute malnutrition N = 51 (<-2 z-score and/or oedema) 8.5 % (5.6 – 12.7 95% C.I.)

Prevalence of moderate acute malnutrition N = 43 (<-2 z-score and >=-3 z-score, no oedema) 7.2 % (5.0 – 10.2 95% C.I.)

Prevalence of severe acute malnutrition N = 8 (<-3 z-score and/or oedema) 1.3 % (0.5 – 3.8 95% C.I.)

The Global Acute Malnutrition (GAM) rate expressed according to WHO standards can be considered as low, being of 8.5 % [5.6 – 12.7 95% CI] in Mihtarlam and Qarghayi districts, Laghman province. This rate is inferior to the threshold of 15% determined by the WHO Expert Committee classification for wasting 25 . To remind that the GAM was estimated at 40% at planning stage according to SCA data. The methodology used by SCA for conducting the rapid nutrition assessment in November/December 2010, as well as the target areas and the indicators referred to for determining the acute malnutrition prevalence differ considerably between the rapid assessment and this current survey. These differences can explain partially the discrepancies highlighted by this report.

In regard to gender balance, the prevalence of acute malnutrition could reflect a small difference between the nutritional status of boys and girls, but this difference is not statistically significant as the confidence intervals are largely overlapping and p>0.05. No case of bilateral oedema was reported by the teams on the field.

25 WHO 1995: percentage of children with weight-for-height <-2 z-score >= 15% is critical

34 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 13: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex, WHO standards, n=600, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Prevalence of acute malnutrition All Boys Girls WHO standards N = 600 n = 293 n = 307 Prevalence of global malnutrition (51) 8.5 % (29) 9.9 % (22) 7.2 % (<-2 z-score and/or oedema) (5.6 - 12.7 95% (6.0 - 16.0 95% (4.4 - 11.4 95% C.I.) C.I.) C.I.) Prevalence of moderate malnutrition (43) 7.2 % (25) 8.5 % (18) 5.9 % (<-2 z-score and >=-3 z-score, no oedema) (5.0 - 10.2 95% (5.2 - 13.7 95% (3.7 - 9.2 95% C.I.) C.I.) C.I.) Prevalence of severe malnutrition (8) 1.3 % (4) 1.4 % (4) 1.3 % (<-3 z-score and/or oedema) (0.5 - 3.8 95% (0.4 - 4.3 95% (0.4 - 4.3 95% C.I.) C.I.) C.I.) The prevalence of oedema is 0.0 %

Table 14: Prevalence of acute malnutrition by age based on weight-for-height z-scores and/or oedema, WHO standards, n=610, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Age Total Severe wasting Moderate wasting Normal Oedema groups (<-3 z-score) (>= -3 and <-2 z- (> = -2 z score) score ) Mths No. No. % No. % No. % No. % 6-11 84 3 3.6 18 21.4 63 75.0 0 0.0 12-23 164 2 1.2 9 5.5 153 93.3 0 0.0 24-35 151 3 2.0 9 6.0 139 92.1 0 0.0 36-47 113 0 0.0 4 3.5 109 96.5 0 0.0 48-59 88 0 0.0 3 3.4 85 96.6 0 0.0 Total 600 8 1.3 43 7.2 549 91.5 0 0.0

Children 6-11 are clearly more subject to acute malnutrition than older children (Relative risk =4.30 (2.59

Curve 1: Distribution of weight-for-height z-scores vs. reference, WHO standards (WHZ), n=610, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

35 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan The distribution of the weight for height index expressed in Z-score in comparison to the reference curve is shifted to the left, meaning that the surveyed children do have a relative weight for height deficit compared to the reference population. The observed mean ± SD for WHZ (n=600) equals -0.56 ±1.03 The design effect WHZ is 2.24, showing an important heterogeneity among the population. A design effect was estimated at 1.5 at the planning stage of the survey and hence was under estimated.

4.1.2.2 Acute malnutrition prevalence expressed by MUAC The analysis of the acute malnutrition prevalence according to MUAC classification and referring to WHO standards is done with a sample of 603 children out of the 610 children surveyed as 7 children measured were less than 65cm of length, so their MUAC was not considered.

Table 15: Prevalence of acute malnutrition based on MUAC criterion according to WHO standards, n=603, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Prevalence of Acute malnutrition All Z-score 95% CI According to MUAC criterion and WHO standards N = 603 Prevalence of global malnutrition N = 28 4.6 % (3.0 – 7.1 95% C.I.) MUAC < 125mm Prevalence of moderate malnutrition N = 25 4.1 % (2.6 – 6.6 95% C.I.) MUAC >=115 <125mm Prevalence of severe malnutrition N = 3 0.5 % (0.2 – 1.5 95% C.I.) MUAC < 115mm

The prevalence of acute malnutrition according to MUAC criterion is low, with a GAM rate of 4.6% (3.0-7.1 95%CI).

Table 16: Prevalence of acute malnutrition based on MUAC criterion and by sex, WHO standards, n=603, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Prevalence of acute malnutrition All Boys Girls MUAC criterion - WHO standards N = 603 N = 297 n = 306 Prevalence of global malnutrition (28) 4.6 % (13) 4.4 % (15) 4.9 % MUAC < 125mm (3.0 – 7.1 95% (2.6 – 7.2 95% (2.6 – 9.0 95% C.I.) C.I.) C.I.) Prevalence of moderate malnutrition (25) 4.1 % (12) 4.0 % (13) 4.2 % MUAC >=115 <125mm (2.6 – 6.6 95% (2.3 – 7.0 95% (2.2 – 7.9 95% C.I.) C.I.) C.I.) Prevalence of severe malnutrition (3) 0.5 % (1) 0.3 % (2) 0.7 % MUAC < 115mm (0.2 – 1.5 95% (0.0 – 2.5 95% (0.2 – 2.7 95% C.I.) C.I.) C.I.)

There is no significant difference between the nutritional status of boys and girls according to MUAC criterion.

According to the table below, children 6-11 months seem more subject to acute malnutrition according to MUAC criterion compared to other age groups. Nevertheless, this comparison is not statistically significant as the P value > 0.05 (Relative risk =2.21 (0.97

36 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 17: Prevalence of acute malnutrition according to Mid Upper Arm Circumference (MUAC) classification and age groups, WHO standards, n=603, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Age Total MUAC < 115 mm MUAC >= 115 < 125 mm MUAC >= 125 mm groups n n % N % N % 6-11 1.3% 7.6% 91.1% months 79 1 ( 0.2- 9.2 95% CI) 6 ( 3.3-16.3 95% CI) 72 (82.7-95.7 95% CI) 12-23 0.6% 7.8% 91.6% months 167 1 ( 0.1- 4.8 95% CI) 13 ( 3.7-15.7 95% CI) 153 (83.7-95.9 95% CI) 24-35 0% 2.6% 97.4% months 154 0 ( 0.0- 0.0 95% CI) 4 ( 0.5-11.7 95% CI) 150 (88.3-99.5 95% CI) 36-47 0.9% 1.8% 97.3% months 113 1 ( 0.1- 6.6 95% CI) 2 ( 0.4- 7.5 95% CI) 110 (91.7-99.2 95% CI) 48-59 0% 0% 100.0% months 90 0 ( 0.0- 0.0 95% CI) 0 ( 0.0- 0.0 95% CI) 90 ( 0.0- 0.0 95% CI) Total 0.5% 4.1% 603 3 (0.2 - 1.5 95% CI) 25 ( 2.6- 6.6 95% CI) 575 -

These results have to be interpreted with caution as the confidence intervals are wide and the sample sizes are not consequent.

Table 18: Prevalence of acute malnutrition according to Mid Upper Arm Circumference (MUAC) classification using height cut off, WHO standards, n=603, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Height in cm Definition MUAC TOTAL Acute malnutrition ≥65 - <75 ≥75 - <90 ≥90 - ≤ 110 in mm WHO standards N % N % N % N % <115 Severe malnutrition 2 1.2% 1 0.3% 0 0.0% 3 0.5% ≥115- <125 Moderate malnutrition 18 11.1% 7 2.4% 0 0.0% 25 4.1% ≥125 No malnutrition 142 87.7% 281 97.2% 152 100.0% 575 95.4% Total 162 100% 289 100% 152 100% 603 100%

Children more or equal 65cm and less than 75cm are more subject to acute malnutrition according to MUAC criterion compared to other age groups (Relative risk =6.81 (3.06

The results according to age groups as well as to height groups have to be taken with caution as MUAC for children below one year, and so below 75cm, are physiologically lower than for bigger children.

4.1.2.3 Chronic malnutrition prevalence expressed in Z-score The analysis of the chronic malnutrition prevalence based on height for age according to WHO standards is done with a sample of 583 children out of the 610 children surveyed, 27 children being excluded due to plausibility check. The results are presented in the table 18. To remind that all ages of the surveyed children should have been certified by the presentation of official documents as birth certificates or crosschecked by the use of a local event calendar.

37 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 19: Prevalence of chronic malnutrition based on height-for-age z-scores according to WHO standards, n=583, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Prevalence of Chronic malnutrition All Z-score 95% CI According to WHO standards N = 583 Prevalence of stunting N = 229 39.3% [34.9 – 43.9 95% C.I.]

Prevalence of moderate stunting N = 145 24.9% [20.3 – 30.1 95% C.I.]

Prevalence of severe stunting N = 84 14.4% [11.8 – 17.5 95% C.I.]

The chronic malnutrition rate is high with a prevalence of 39.3% [24.9 – 43.9 95% CI]. At planning stage and according to the National Nutrition survey conducted by the MoPH in 2004, the stunting was estimated at 60.5%. The prevalence raised by this survey is lower than the expected one.

Table 20: Prevalence of chronic malnutrition based on height-for-age z-scores and by sex, WHO standards, n=583, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Prevalence of Chronic malnutrition All Boys Girls According to WHO standards N = 583 N = 286 N = 297 Prevalence of stunting (229) 39.3 % (114) 39.9 % (115) 38.7 % (<-2 z-score) (34.9 - 43.9 (33.8 - 46.3 (32.1 - 45.8 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate stunting (145) 24.9 % (71) 24.8 % (74) 24.9 % (<-2 z-score and >=-3 z-score) (20.3 - 30.1 (18.3 - 32.8 (19.1 - 31.9 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe stunting (84) 14.4 % (43) 15.0 % (41) 13.8 % (<-3 z-score) (11.8 - 17.5 (11.0 - 20.2 (10.1 - 18.6 95% C.I.) 95% C.I.) 95% C.I.)

There is no difference between the nutritional status of boys and girls in regard to stunting prevalence (p>0.05).

Table 21: Prevalence of chronic malnutrition based on height-for-age z-scores according to age groups, WHO standards, n=583, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Age Total Severe stunting Moderate stunting Normal groups in (<-3 z-score) (>= -3 and <-2 z-score ) (> = -2 z score) mths No. % No. % No. %

6-11 81 1 1.2 12 14.8 68 84.0 12-23 160 20 12.5 35 21.9 105 65.6 24-35 146 30 20.5 39 26.7 77 52.7 36-47 109 20 18.3 34 31.2 55 50.5 48-59 87 13 14.9 25 28.7 49 56.3 Total 583 84 14.4 145 24.9 354 60.7

No disparities can be highlighted in the nutritional status according to age classification. Nevertheless, stunting prevalence seems lower in children 6-11. In general, acute malnutrition is higher in younger children (less stock), but chronic malnutrition is higher in older children.

38 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Curve 2: Distribution of height-for-age z-scores vs. reference (HAZ), WHO standards, n=583, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

The distribution of the weight for age index expressed in Z-score in comparison to the reference curve is shifted to the left, with a flatter curve indicating a high proportion of children with a worse height for age than the reference population. The mean ± SD of HAZ (n=583) equals -1.68±1.19. The design effect is 1.18. To mention that all ages of the surveyed children should have been certified by the presentation of official documents as birth certificates or crosschecked by the use of a local event calendar. Ages were recorded in months and not in date of birth as dates are mostly not well known and are determined roughly by health workers. The Muslim lunar calendar is used in Afghanistan while ages are analysed in ENA software referring to the Gregorian solar calendar. The birth dates should have been converted from the lunar system to the solar one which could have led to error. Despite these precautions and according to plausibility check, the age determination was not very precise, leading to biases in the analysis of these results. Nevertheless, the height measurements are evaluated as acceptable (Digit preference score = 4). Although, there is an age determination bias, stunting rate is so high that the problematic of very high level of chronic malnutrition has to be acknowledged.

4.2. Anthropometric results: Pregnant/Lactating women (based on MUAC criterion) 71 pregnant women and 77 lactating women breastfeeding an infant less than 6 months old, excluding 2 mothers absent at the time of the survey, were found at household level, for a total of 148 women screened by MUAC. Due to sampling issues (not randomly chosen), results are presented in percentage of the women screened. Out of 148, only 11 (7.5%) women were moderately malnourished and none were severely malnourished. Pregnant women are more affected by malnutrition then lactating women with 12.7% of pregnant women malnourished (9 out of 71 pregnant women) while only 2.7% of lactating women malnourished (2 out of 75) (Relative risk =4.75 (1.06

39 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 22: Prevalence of acute malnutrition amongst pregnant/lactating women based on MUAC criterion according to WHO standards, n=146, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Definition MUAC Acute malnutrition Pregnant women Lactating women TOTAL in mm WHO Standards N % N % N % <210 Severe malnutrition 0 0.0% 0 0.0% 0 0.0% ≥210 - <230 Moderate malnutrition 9 12.7% 2 2.7% 11 7.5% ≥230 No malnutrition 62 87.3% 73 97.3% 135 92.5% Total 71 100% 75 100% 146 100%

4.3. Measles vaccination coverage – Children 9-59 months Only children from 9 to 59 months old are included in the analysis according to the international vaccination protocol. The analysis of the measles vaccination coverage is done with a sample of 567 children out of the 610 children surveyed as 43 children were less than 9 months old and were automatically excluded for the final analysis. The results reported according to caretaker recall without immunization card shown as proof; have to be interpreted with caution due to the difficulties for caretakers to distinguish different vaccinations/treatment administrated to the children. Indeed, 38.1% (216 out of 567) were said as vaccinated but no immunization card was shown to prove it.

Table 23: Measles vaccination coverage for children equal or more than 9 months old, n=567, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 All Measles vaccination coverage n (567) N % Confirmed with immunization card 272 48.0% Confirmed verbally by the caregiver but no immunization card to prove it 216 38.1% No immunization according to the caregiver 55 9.7% Unknown 24 4.2% Total 567 100%

In any case, 48% of the children surveyed (272 out of 567 children surveyed) were vaccinated against measles, with the immunization card shown as proof, while only 9.7% (55 out of 567) were said as no vaccinated. Only 4.2% of the caretakers interviewed (24 out of 567) could not mention if their children were immunized against measles or not.

At national level and for children from 12 to 23 months old, the measles vaccine coverage was estimated at 62.6% 26 in 2006. Even if the target population, here, is children 9 – 59 months, the measles immunization coverage raised by this survey is well below the one published by the MoPH in 2006. Moreover, the coverage of confirmed measles vaccination is low compared to the SPHERE standards of 90%.

26 Afganistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan

40 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 4.4. Vitamin A supplementation coverage – Children 6-59 months The sample used for the analysis of the Vitamin A supplementation coverage within the last 6 months is similar to the total number of children included in the anthropometric survey, so 610 children. The results are presented in the table below.

Table 24: Vitamin A supplementation coverage within the last 6 months, n=610, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 All Vitamin A supplementation coverage N (610) within the last 6 months N % Vitamin A dose received 557 91.3% Vitamin A dose not received 16 2.6% Unknown 37 6.1% Total 610 100%

The Vitamin A supplementation coverage within the last 6 months is satisfactory being of 91.3% (557 children out of 610). Routine Vitamin A distribution campaigns are regularly ensured by the MoPH at provincial level. Only 6.1% of the caretakers interviewed (37 out of 610) could not mention if their children received a Vitamin A dose within the last 6 months.

At national level and according to the MoPH Health survey done in 2006, 76.5% of children 6-59 months of age received Vitamin A in the last six months. The coverage expressed by this study is even higher than the one published by the MoPH about 5 years ago and is higher to the threshold of 90% of the SPHERE standard.

4.5. IYCF study Following the selection of households for the anthropometric nutrition survey, all children from 6 to 23 months old as well as infants less than 6 months were expected to be included in the IYCF questionnaire. At the end of the data field collection, 78 infants less than 6 months and 247 children 6-23 months were found in the visited households for a total sample of 325 children 0-23 months.

Table 25: Children ever breastfed, n=325, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Children ever breastfed Yes 311 95.7% No 14 4.3% TOTAL 325 100%

Out of 325 children surveyed, 311 were breastfed at least once in their life, representing 95.7%. Only 4.3% (14 children out of 325) have never been breastfed. Women who never breastfed their children were asked the reason for no-breastfeeding. Some responders gave several answers, the reasons being sometimes linked together. The table below shows reasons for no-breastfeeding for 14 responders but includes 18 explanations.

41 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Table 26: Reasons for no-breastfeeding, n=14 but multiple answers, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Reason for no-breastfeeding (n=14 with multiple answers per responders) Breast milk not good for the child 2 11.1% Pain 1 5.6% No breast milk coming out of the breast 5 27.8% Refusal of the child to be breastfed 1 5.6% Child sick 3 16.7% Mother/caretaker sick 4 22.2% Advice of family members 2 11.1% TOTAL 18 100%

Most of the mothers/caretakers did not breastfeed their children because lack of milk coming out of the breast (5 out of 18) or because they were sick. Some responders explained that they were sick and hence were advised by family members to stop breastfeeding. The sickness of the child leads to the child’s refusal to be breastfed and correspond to possible 2 answers from one mother/caretaker.

The following analysis is based on the sample of children ever breastfed as presented in the table 25 above and so includes 311 children.

Table 27: Early initiation of breastfeeding after birth, n=311, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Early initiation of breastfeeding after birth First hour of life 175 56.3% Less than 24 hours after delivery 77 24.8% More than 24 hours after delivery 56 18.0% Does not know 3 1.0% TOTAL 311 100%

56.3% of the surveyed children were put on the breast within the first hour of life (175 out of 311 children). 18% of the children were put on breast after more than 24 hours of life (56 out of 311 children). These rates highlight the late introduction of breastmilk after birth.

Table 28: Administration of colostrum, n=311, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Colostrum given during the 3 first days after delivery Yes 303 97.4% No 4 1.3% Does not know 4 1.3% TOTAL 311 100%

97.4% of the interviewed mothers gave the colostrum to their new born during the 3 first days of life (303 mothers out of 311). Only 1.3% (4 out of 311) of the mother did not give the colostrum, which reflects a satisfactory administration of colostrum after birth to infants.

42 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Mothers were asked if they gave other liquids/foods to their children during the 3 first days of life. The results are presented in the table below.

Table 29: Introduction of other liquids/foods during the 3 first days of life, n=311, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Introduction of other liquids/foods during the 3 first days of life Yes 209 67.2% No 99 31.8% Does not know 3 1.0% TOTAL 311 100%

31.8% of the infants were not exclusively breastfed as they received other liquids/foods during the 3 first days of life (209 out of 311 children). Only 67.2% of the responders did not give other liquids/foods to their new born babies.

Table 30: Continued breastfeeding, n=311, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Currently breastfeeding Yes 260 83.6% No 51 16.4% DK 0 0.0% TOTAL 311 100%

Out of 311, 260 mothers, representing 83.6%, were still breastfeeding their children at the time of the survey. The continued breastfeeding according to age categories is presented in the table below.

Table 31: Currently breastfeeding according to age categories, n=311, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Currently breastfeeding Yes % No % TOTAL Infants less than 6 mths 77 98.7% 1 1.3% 78 Children 6-11 mths 78 92.9% 6 7.1% 84 Children 12-17 mths 73 83.9% 14 16.1% 87 Children 18-23 mths 32 51.6% 30 48.4% 62 TOTAL 260 83.6% 51 16.4% 311

98.7% of infants less than 6 months were breastfed, corresponding to 77 infants out of 78 for this age category. Children 6-17 were mostly all breastfed but only 51.6% of the children 18-23 months old were still breastfed at the time of the survey. This shows relative good practices of breastfeeding among the target population but does not provide information about exclusive breastfeeding. As shown above, 67.2% of the interviewed mothers gave other foods/liquids to their infants during the 3 first days of life. It can be assumed that other foods/liquids were as well given later on to children below 6 months old. The assumption that mothers stop breastfeeding when children get older is confirmed as shown in the table 33 below presenting the reasons for cessation of breastfeeding).

43 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Additional questions were asked to the 51 mothers who stopped breastfeeding their children. Indeed, the duration of the breastfeeding, the reasons and way of cessation were asked and reported as below.

Table 32: Duration of breastfeeding, n=51, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Duration of breastfeeding Less than 3 months 2 3.9% Between 3 and 5 months 3 5.9% Between 6 and 11 months 14 27.5% Between 12 and 23 months 29 56.9% Does not know 3 5.9% TOTAL 51 100%

Most of the mothers breastfed their children between 12 and 23 months or between 6 and 11 months, which corresponds to 84.4% of children breastfed at least 6 months. The reasons for cessation of breastfeeding and the way of cessation were asked to the 51 mothers/caretakers who stopped breastfeeding. In some cases, responders provided several answers which are detailed in the table 33 below.

Table 33: Reasons for cessation of breastfeeding, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011 Reasons for cessation of breastfeeding (n=51 with multiple answers per responders) Child too old 13 17.6% Pain 4 5.4% No enough milk 20 27.0% New pregnancy 11 14.9% Refusal of the child to be breastfed 4 5.4% Child sick 3 4.1% Mother/caretaker sick 13 17.6% Advice of family members 3 4.0% Does not know 3 4.0% TOTAL 74 100.0%

Most of the interviewees stopped breastfeeding because they did not have enough milk (27% out of total answers). 31.4% of the interviewees stopped breastfeeding their children abruptly (16 out of 51), meaning that they did not introduce progressively other foods in the daily feeding of their children.

Table 34: Way of cessation of breastfeeding, n=51, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

Way of cessation of breastfeeding Abruptly 16 31.4% Progressively 25 49.0% Does not know 10 19.6% TOTAL 51 100%

44 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan As summary, results are presented according to two IYCF core and two additional indicators, WHO reference in the table below.

Table 35: IYCF core and additional indicators, WHO reference, Mihtarlam and Qarghayi districts, Laghman province, Afghanistan, May 2011

CORE INDICATORS DEFINITION N Yes % No % Early initiation of Proportion of children born in the last breastfeeding 23 months who were put to the breast 311 175 56.3% 136 43.7% within one hour of birth Continued breastfeeding at Proportion of children 12 – 15 months 55 50 90.9% 5 9.1% 1 year of age who are fed with breast milk OPTIONAL INDICATORS DEFINITION N Yes % No % Children ever breastfed Proportion of children born in the last 325 311 95.7% 14 4.3% 24 months who were ever breastfed Continued breastfeeding at Proportion of children 20–23 months of 40 21 52.5% 19 47.5% 2 years age who are fed with breast milk

45 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 5. DISCUSSION

5.1 Constraints and bias
28 villages, corresponding to 28 clusters were included in the survey at the planning stage. Due to insecurity in the area, 2 clusters were canceled: cluster number 3 corresponding to Bar Kashmon village and cluster number 21 corresponding to Qala Rahim village. o At planning stage, 184 villages considered as ‘unsecure’ were excluded from the first selection step. Despite prior security assessment, these 2 villages were kept in the selection. o One survey team could start the data collection in Qala Rahim village but had to leave the place after visiting only 13 households. The cluster had to be canceled as the data collected was of very poor quality due to the level of tension within the village at the time of the data collection. The team was indeed working under high pressure because of serious insecurity and could not perform its work in optimal conditions. It has been recognized that the systematic random selection was not well respected due to the reluctance of the community members to perform the survey. o In addition, the access to Bar Kashmon village was not feasible at the time of the data field collection due to unpredicted security event happening there.
Due to security constraints, ACF Health - Nutrition coordinator could not supervise the data field collection. Nevertheless, ACF Nutrition program manager and ACF Nutrition team leader have ensured the supervision from the beginning up to the completion of the data field collection. However, they could not fully supervise the work done by the four teams at the same time. Due to workload beside the survey, SCA nutrition focal point could not supervise the field work on daily basis and only participated to the survey punctually;
The weight of children was measured with clothes. Indeed, caretakers of children were reluctant to present their children naked in front of strangers. The analysis of malnutrition prevalence has been done accordingly by subtracting 100gr for each weight measurement. Clothes of several children were weighted to estimate the average clothes weight to subtract.
According to plausibility check: o The age determination was not precise, with digit preferences for 36 and 48 months (Score Overall Age distribution = 10, which is problematic). This lead to biases in the estimation of the chronic malnutrition as well as in the interpretation of other results such as the age and sex distribution of the targeted group or the malnutrition prevalence according to age groups. o The index of dispersion has a p<0.05, meaning that GAM cases are aggregated in some clusters. Pockets of malnutrition can exist within the target area.
Multiple answers were recorded for some IYCF questions despite the advice to record limited number of replies. Indeed, the number of answers was limited for some questions, but due to misunderstanding by the teams, multiple replies were recorded. Moreover, some replies were linked to each other and the team did not know which answer to record. For example, a mother was sick and so was asked by her family members to stop breastfeeding. In that case, 2 answers were possible: sickness of the mother and advice from the family members. However, the analysis is done taking into consideration all recorded answers.

46 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 5.2 Acute malnutrition problematic – Children 6-59 months old The Global Acute Malnutrition (GAM) rate expressed according to WHO standards can be considered as relatively low, being of 8.5 % [5.6 – 12.7 95% CI] in Mihtarlam and Qarghayi districts, Laghman province. This rate is inferior to the threshold of 15% determined by the WHO Expert Committee classification for wasting 27 . To remind that the GAM was estimated at 40% at planning stage. However, the percentage of acutely malnourished children corresponds to approximately 2022 children among the population, which is quite substantial and should compel our attention. A Rapid Assessment of Nutritional Status by MUAC of Under Five Children and Pregnant Women was conducted by SCA in Alingar and Qarghayi districts of Laghman Province in November - December 2010. The main results of this rapid nutritional assessment were as follows: 38.6% of the screened children in Alingar district were acutely malnourished while 43% of the screened children in Qarghai district were acutely malnourished. The malnutrition prevalence raised by this survey is well below the one found by SCA while conducting the rapid nutritional assessment. The methodology used by SCA in 2010 differs to the one used for this current survey, especially for the collection of field data. This can explain the different results raised by the 2 studies. The target areas were not the same as SCA covered Alingar and Qarghayi districts of Laghman province, while the anthropometric nutrition survey did not include Alingar district. Only Mihtarlam and Qarghayi districts were surveyed in May 2011 and by respect to the methodology, the results cannot be extrapolated to the whole province. The nutrition situation in the 3 excluded districts can be assumed of concern, as these districts are estimated as unsafe and so under covered by humanitarian assistance. The area is not accessible safely due to ongoing conflicts happening there sporadically. Presence of military forces (national, international and anti-governmental), as well as tribal conflicts leads to unstable situation. The index of dispersion shows that pockets of malnutrition may exist in the target area (Each team’s work quality has been assessed with the plausibility check and there is no evidence of one team over-reporting cases compared to other teams). It can be assumed that the malnutrition prevalence is not homogeneous among the surveyed area and that some areas are more subject of being affected by acute malnutrition than others. Comparisons and follow up of trends cannot be made as no surveys were conducted in the past years. Only data collected on regular basis such as HMIS data can provide information about the nutritional trends but are limited as they only include data collected at health facility level and do not contain data collected at community level.

5.3 Chronic malnutrition problematic – Children 6-59 months old The chronic malnutrition rate is high with a prevalence of 39.3% [24.9 – 43.9 95% CI]. At planning stage and according to the National Nutrition survey conducted by the MoPH in 2004, the stunting was estimated at 60.5%. The prevalence raised by this survey is lower than the expected one. It is well acknowledged that stunting is of high concern in Afghanistan. Compared to national statistics, this rate is lower but remains problematic being high according to international thresholds 28 . The stunting rate among children 6-59 months old and the rate of acute malnutrition among pregnant women may be related. Malnourished women are having babies of low birth weight who become malnourished children. This corresponds to the cycle of hunger.

27 WHO 1995: percentage of children with weight-for-height <-2 z-score >= 15% is critical 28 WHO 1995: percentage of children with height-for-age <-2 z-score >= 15% is critical

47 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan

5.4 Acute malnutrition problematic - Pregnant/Lactating women The malnutrition prevalence among pregnant/lactating women should not be underestimated. Indeed, 7.5% of the women screened were moderately malnourished and none were severely malnourished. Pregnant women seem more affected by malnutrition then lactating women with 12.7% of pregnant women malnourished (9 out of 71 pregnant women) while only 2.7% of lactating women were detected as malnourished (2 out of 75). According to SCA rapid nutritional assessment conducted in Alingar and Qarghayi districts, nutritional disorders were observed in 21.9% of pregnant women in Alingar district and in 16.8% in Qarghayi district. No lactating women were included in this assessment. The thresholds used by SCA to determine acute malnutrition among women do not correspond to the ones used for this current survey. Indeed, acute malnutrition was determined by SCA when MUAC was below 220mm without distinction between moderate and severe malnutrition. ACF refers to WHO classification as mentioned in the methodology part. To note that the sample size used for SCA assessment was of 1,231 pregnant women while the current one refers to only 148 pregnant/lactating women. This can lead to biases in comparison and related analysis. The malnutrition rates for pregnant women raised by SCA are higher than the ones shown by this survey. Nevertheless, the vulnerability of pregnant women to be affected by acute malnutrition should be acknowledged. Several factors well recognized in Afghanistan can explain this situation: early pregnancy, multiple pregnancies with short delay in between or traditional practices to decrease the amount of foods while being pregnant to avoid having a ‘fat’ baby.

5.5 Causal analysis Despite its restrictive aspects, this study provides relatively sufficient information to understand better the malnutrition problematic in Laghman province. The anthropometric survey shows that younger children are more affected by acute malnutrition than older children. This can be assumed as a consequence of inappropriate care practices , although other causes could explain this fact. In relation to the cycle of hunger, the nutritional status of women can impact the nutritional status of children. Indeed, most of the malnutrition causes commonly acknowledged in Afghanistan are related to IYCF practices and women conditions. The rate of acute malnutrition among pregnant women according to MUAC criteria raised by this survey is of concern. As mentioned above, several factors well acknowledged in Afghanistan can explain this situation: One of the cause mentioned are the multiple pregnancies with short delay in between . The fertility rate 29 is estimated at 7.2 children per women 30 in Afghanistan. Women have consecutive pregnancies without a minimum of 2 years delay between each one. This can lead to the weakening of women after several pregnancies. This fact could be related to the high Maternal Mortality Ratio. Indeed, the ‘Reproductive Age Mortality Survey’ conducted by UNICEF & Centers for Disease Control and Prevention (CDC) in 2002 estimated a Maternal Mortality Ratio (per 100,000 live births) of 1,600, one of the highest rate in the world.

29 Fertility rate: Number of children who would be born per woman if she lived to the end of her childbearing years and bore children at each age in accordance with prevailing age-specific fertility rates. 30 State of the World’s Children (SOWC), UNICEF, 2008

48 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan In addition, traditional practices like decreasing the amount of foods while being pregnant to avoid having a ‘fat’ baby is recurrent in Afghanistan and is associated to cultural believes. Most of pregnancies happen at home with no possibility of seeking medical assistance. By controlling weight gain of the infant during pregnancy, the delivery would be expected less problematic and so healthcare won’t be needed. In addition, prior to the delivery, the Afghanistan Health Survey conducted by the MoPH in 2006 indicated that only 32.3% of pregnant women benefited of at least one antenatal care visit. Pregnant women have low access to health care before the delivery mainly due to the low coverage of services but as well due to traditional habits and cultural aspects. The access to health facilities is rather difficult for a large proportion of the population and just under two thirds of residents have to travel over 5kms to get medical attention (63.5%) 31 . According to HNSS statistics 32 , 20% of respondents living less than 2 hours from a facility had an institutional delivery compared to less than 1% of respondents living more than 6 hours from a facility.

Moreover, this accessible health structure can provide only basic cares but does not have the capacity to handle complicated medical cases. Access to such kind of services is relatively available in Laghman province, the province being better developed than others in Afghanistan, especially in terms of road conditions and open access to main cities. Nevertheless, many villages are located in remote areas and so the population does not benefit from these services. Insecurity may impact the access to health facilities as well, since most inhabitants avoid travelling for long distances.

In regard to care practices, this survey highlights that breastfeeding is lately introduced to infants after birth. Nevertheless, colostrum was said as mostly given to infants during the 3 first days of life. According to the ‘Afghanistan Health Indicators, Fact Sheet - August 2008’ published by the MoPH, additional food is regularly given to children. While the number of children between 0-5 months of age was small (636 children), 83% were reported to have received only breast milk in the last 24 hours 33 . This is anecdotal evidence that infants in Afghanistan are frequently given tea or maska (butter) or other foods soon after birth. Breastfeeding seems to be continued for most infants up to 1 year old, which can be interpreted as a relative good practice. Nevertheless, according to the present IYCF study, women stop breastfeeding when they face sickness. Moreover, it shows that a high proportion of women do not ever breastfeed their infants because of sickness. This corresponds to traditional assumption that breastmilk won’t be good for infants if the lactating women is sick. This can lead to early cessation and particularly to abrupt cessation of breastfeeding, and so can cause episodes of acute malnutrition. Moreover, one of the highlighted reasons for stopping breastfeeding was the age of the children. It does not seem well recognized that breastmilk can be given to older children. Surprisingly, the rate of acute malnutrition among lactating women raised by this survey is low. Nevertheless, it has to be interpreted carefully as the sample referred to was of small size. Another reason highlighted for stopping breastfeeding but also for not breastfeeding infants at all was that the lack of milk. Breastmilk is said regularly insufficient while most of the time, breastmilk could be produced if all optimal conditions were met. These conditions are commonly known, as for example to have sufficient food intake, to be healthy and to have a favourable social environment.

31 ‘Provincial Development Plan, Laghman Provincial Profile, prepared by the Ministry of Rural Rehabilitation and Development (MRRD), 2007 32 Health and Nutrition Sector Strategy – MoPH Annual report -2010 33 Afghanistan Health Indicators, Fact Sheet - August 2008

49 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan In regard to food security situation , Laghman province, and especially the 2 surveyed districts, can be recognized as mostly favourable. Indeed, the province is relatively well developed but remains dependent of its agricultural activities. Regular natural disasters, such as floods or droughts, affect the area and so impair the food security at household level. The last episode of heavy floods occurred in August 2010 and affected most of Laghman districts (Map in Annex 13). In normal settings, the local production is spread all over the year, without drastic decrease during winter time. In Afghanistan, the seasonal calendar and critical events timeline is defined as follows 34 for 2011:

The survey was conducted in May 2011, corresponding to the end of the lean season and the beginning of the harvest.

34 FEWS – NET; March 2011

50 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 6. CONCLUSION

The anthropometric nutrition survey and the IYCF study conducted in Laghman province have limitations. Causes of malnutrition could not be assessed and only assumptions can be made in regard to highlighted results. Acute malnutrition levels can be considered as relatively low as being below the alert threshold but still indicates a nutritional deficiency among the target population. The significant differences between the rates released by conducting a rapid nutritional assessment by SCA and the ones raised by this survey should be recognized. To acknowledge that the districts targeted by SCA in November-December 2010 were Alingar and Qarghayi (winter time) while Mitharlam and Qarghayi districts were assessed by this current survey in May 2011 (spring time). The methodologies used were not similar and there were some limitations of comparisons to some extent. It is important to acknowledge that, given the exclusion of 3 districts out of 5 in the province as well as the exclusion of multiple villages within the 2 selected districts, the results of this survey are not representative of the whole province. The malnutrition situation in the excluded places should be assessed when feasible to provide better view on fighting affected areas. Despite difficulties in determining the exact age of the surveyed children and the lack of precision in taking measurements, the stunting rate remains of concern. Chronic deficit is well acknowledged in Afghanistan and corresponds to one of the major health public problematic. In overall, IYCF study results show satisfactory practices. However, some of them needs to be improved as the introduction of other foods/liquids during the 3 first days of life or for maintaining breastfeeding when children get older. The malnutrition prevalence expressed by MUAC criterion amongst pregnant women screened is of concern and should be one issue to tackle. For any intended intervention, the access to the area remains one of the major restriction. The security situation is mostly considered as unstable in the whole province. The threat level is significant due to the activities of the Talibans and other armed groups. Community outreach work is hard to implement and so should be envisaged only when feasible. The access to insecure area corresponds to one of the main issue in this complex afghan context.

As conclusion, the World Bank defined in 2010 5 pillars to tackle the malnutrition problematic in Afghanistan. This can reflect the willingness to intervene and hence to put efforts in improving the situation.


Pillar 1: Nutrition as foundational to national development


Pillar 2: Adequate local capacity built and supported to design and execute effective nutrition policies and programs


Pillar 3: Direct nutrition interventions


Pillar 4: Determinants of under-nutrition addressed through multi-sectoral approaches


Pillar 5: Coordinated support for nutrition from development partners General humanitarian intervention should take into consideration these recommendations. Specific recommendations should be submitted according to the context of intervention.

51 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 7. RECOMMENDATIONS

According to National Public Nutrition Policy and Strategy, 2010-2013, emergency feeding programs shall only be implemented when and where there is a demonstrated increase in Global Acute Malnutrition, using the following criteria:

For a GAM rate greater than 10%: SAM treatment services should be expanded if required and targeted Supplementary Feeding Programmes (SFP) should be established for the management of moderate acute malnutrition in children 6 to 24 months of age.

For a GAM rate greater than 15%: SAM treatment services should be expanded if required and blanket SFPs should be established for children six to 24 months of age. According to the GAM rates raised by this survey and in respect to the national public nutrition policy, no direct nutrition intervention should be required. However, recommendations to decrease the threshold to 5% and to take into considerations aggravating factors for designing nutrition projects were raised by many humanitarian agencies at beginning of 2011 35 . Moreover, the national nutrition policy advocates for scaling up CMAM component within health intervention. Nutrition programs are part of the BPHS framework and correspond to one of the 7 pillars of this strategy.

As recall and consecutively to the conduction of the rapid nutrition assessment by SCA in Alingar and Qarghayi districts, Laghman province, in November/December 2010, several recommendations were submitted. The preliminary conclusions and recommendations for directing future efforts at different levels of the health system in Laghman province were as follows:

1) Community level • Intensive health education and outreach work to educate communities on early signs of malnutrition and referral to HF 2) HF level • Intensive growth monitoring program • Identification and referral of all identified cases of severe acute and moderate malnutrition to therapeutic and supplementary feeding programs 3) Project level • Verification of HMIS data for malnutrition and referral statistics in all HF which participated in the assessment • Identification of clusters and pockets of malnutrition cases and analysis of root causes of malnutrition in those settings 4) SCA central level • Conduct another survey with a more robust methodology and covering larger parts of Laghman province • Consideration of supplementary feeding programs jointly with other partners such as WFP etc

35 The Integration of CMAM into BPHS – Merlin – March 2011

52 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan At this time, SCA was advocating for conducting another survey, which has been done presently. Other submitted recommendations are still relevant and are formulated below. Additional recommendations are submitted in regard to the results highlighted by the anthropometric nutrition survey and IYCF study.

In regard to SCA field of intervention:


To set up intensive health education and outreach work to educate communities on early signs of malnutrition and referral to health facilities;


To implement intensive growth monitoring program;


To identify and refer all identified cases of severe acute and moderate malnutrition to therapeutic and supplementary feeding programs when existing in the area;


To monitor and verify HMIS data for malnutrition and referral statistics in all health facilities;


To identify clusters and pockets of malnutrition cases and analyze the root causes of malnutrition in those settings;


To consider Supplementary Feeding Programs jointly with other partners such as WFP in areas not currently covered by the agency Health Net TPO.

In regard to fields of intervention of SCA and other actors:


To advocate to the Ministry of Public Health and the NGO SCA, BPHS implementer in the studied area, to maintain the Vitamin A supplementation coverage satisfactory and to improve the measles vaccination coverage;
To scale up CMAM project within the BPHS framework in the whole province in accordance to the national nutrition policy and in collaboration between the several health actors present in the area; o In patient units should be implemented at district level. Only one TFU is running in Mihtarlam district. Stabilization Centre instead of TFU should be envisaged when medical capacities are limited at district level; o SFP component should be extended to all districts. Pregnant and lactating women should be offered treatment within SFP; o Community mobilization program should be extended to remote areas as much as possible according to security clearance;
To conduct an IYCF study separately from an anthropometric nutrition survey. This study could provide more reliable and precise results and deeper understanding of the malnutrition causes;
To monitor the nutrition situation on regular basis. o To improve the regular collect of data through the HMIS to enable following nutrition trends on regular basis; o To conduct further nutrition surveys. According to the nutrition national policy, surveys should be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in nutritional situation; o Further nutrition survey could be conducted during winter time to allow comparison of the nutritional situation during the spring time versus winter period. The survey could be conducted at the end of the winter season to evaluate the resilience of the population during this period;


To survey districts excluded by this survey: 3 districts of Laghman province were excluded from this survey and may be assessed later on depending on the security clearance;

53 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 8. REFERENCES

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WHO: Indicators for Assessing Infant and Young Child Feeding Practices - 2008
WHO: Use and interpretation of anthropometric indicators of nutritional status, Bulletin of the WHO,64 (6) : 929-941 (1986)

54 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9. ANNEXES 9.1 Annex 1: Map Laghman province, Afghanistan May 2011 – Source: MoPH – Department of HMIS

55 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.2 Annex 2: Map Detailed districts - Laghman province, Afghanistan – Source: www.laghman.org

56 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.3 Annex 3: List of 114 villages excluded due to security constraints, Mihtarlam (71) and Qarghayi (44) districts, Laghman province, Afghanistan May 2011 – Source: CSO – 2010/2011

MITHARLAM DISTRICT Total Total Village Name Village Name Population Population

AKHOND PATE 113 PANJ PAI MIR ALI KHAIL 235 ALKOZAI 463 PURTA HAND ROAD 682 BAD PEASH BAR KALA 580 QABELA 623 BAD PEASH KOZA KALA 165 QALA AKHUND 911 BADDULDIN KHAIL 623 QALA BAGHAL 165 BAGHALY 274 QALA FATAHULLAH 940 BAILA 86 QALA MALIK 425 BARAN GUL 78 QALA NOT 95 DOSEYA SAY SARA 227 QALA SAHEB 86 DURGI PANJ PAI 104 QALA SALLA 172 GAMEN 2,911 QALA SANGI DAR KUNDA 511 GHORIZHONA 136 QALA SHAH FAQIR 21 GOM GULUCH 59 QAZEYAN 143 HAKIM ABAD 1,156 QEROZI 346 HAND ROAD 207 SAHIB JAMAL 274 HUSSAIN KHAIL 142 SAKORA 814 KACHOR 841 SANG KASH 302 KARALY KAS 43 SAPERI 836 KARNEACH 610 SAYID ABAD 364 KHAK ZAR 176 SAYID ABAD 875 KHUSHA DAND 85 SAYID MULLAH 944 KOHESTANI 359 SHA KHAIL 707 KUMAKI 32 SHAH GULYAN 759 LAKRI 186 SHAHDA 1,554 LATEF ABAD 12 SHAHI KHAIL 445 LOKHI 62 SHOW KALA 64 MABAIN DAHI 95 SOMOCHAN 402 MANO 393 TANZELI 617 MANO KALA 82 TAPA KUNJ 893 MARKAZ GULUCH 624 TARA KHAIL 938 MUSKIN ABAD 452 TEAR GAR 1,168 MUSSA KHAIL 520 TURKI 460 NANGAZI 1,176 ZARA KALAY 297 NOW ABAD 819 ZARGAR MALA 437 PAD PEASH MAHMOD 19 ZARMANY 33 PANJ PADAR 965 14,875 18,538 TOTAL 33,413

57 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan QARGHAYI DISTRICT Total Total Village Names Village Names Population Population

CHAR BAGH 1,493 MEYA KHAN KAS HULYA 251 GUNDAK 53 MEYA KHAN KAS SUFLA 186 HAIDAR ABAD 180 MIR ALAM QALA 333 HAJI GULDAD 431 MOHABAT BANDA 42 HALYAS KHAIL 58 MOHAMMAD AMIN BANDA 111 HARWA 235 MUFTE QALA 201 HAZARA BANDA 33 MULLAH KHAIL 398 HUSSAIN ABAD 678 NAHR KARIM 407 IBRAHIM KHAIL 526 NAJOLAK 45 KACHOR KALAY 218 NOOR 278 KACHRA 89 NOW ABAD 291 KALA LAN 494 NOW ABAD 290 KAMI DARGI 170 NOW ABAD SAFAT KHAN 825 KARIM ABAD 544 NOWI KACHRA KALAY 105 KUNDA MUBARAK BAD 66 OMAR KHAIL 840 LAL KHAN ABAD 155 OMARA KHAN KALAY 598 LARA MORA 663 PATOR GAMBA 709 LONTORAK 63 PAYRA KHAIL 357 MANSOOR KALAY 905 PEROZ ABAD 498 MARWANDI 310 QABELA 291 MASHENA 409 QALA MAHEGERAN 519 MEYA KHAIL 890 QALA MALIK 259 8,663 7,834 TOTAL 16,497

58 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.4 Annex 4: Cluster selection, Mitharlam and Qarghayi districts, Laghman province, May 2011

District Total Total Cluster Village Name Name Population Households selection Mihtarlam ALISHANG 3,738 595 1 Mihtarlam BADI ABAD 1,450 218 2 Mihtarlam CHALMATE 6,295 961 4,5 Mihtarlam DAHI MALAKH 779 113 6 Mihtarlam DANDAR 106 14 7 Mihtarlam HAIDAR KHANI PAYEN 1,639 223 11 Mihtarlam KATAL 2,089 313 RC Mihtarlam MARYAM KORA 1,023 128 16 Mihtarlam MOHAMMAD KHAIL 894 137 17 Mihtarlam PACHA KHAIL 201 30 18 Mihtarlam QALA DAMAN 3,352 485 19 Mihtarlam QALA SHAIKHAN 4,520 615 RC Mihtarlam SANG TOUDA 731 120 22 Mihtarlam SAR SAYEDA 2,875 454 23 Mihtarlam SHAH MANGAL 796 124 24 Mihtarlam SUFI QALA 147 27 25 Mihtarlam TAJGARI 866 133 26 Mihtarlam TUNDI 541 87 27 Qarghayi AHMAD ZAI HULYA 858 135 RC Qarghayi BAR KASHMON 381 53 3 Qarghayi FARMAN KHAIL 1,692 272 8 Qarghayi GHONDI 1,494 220 9 Qarghayi GULA KHAIL 354 63 10 Qarghayi KA KAS 1,537 279 12 Qarghayi KHAROTI 2,315 359 13 Qarghayi KUTOB KHAIL 836 147 14 Qarghayi MANDOR 2,114 330 15 Qarghayi QALA NAJARAN 626 107 20 Qarghayi QALA RAHIM 1,152 149 21 Qarghayi ZERANI SUFLA 375 62 28

59 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.5 Annex 5: Selection of cluster with Probability Proportional to Population Size (PPS)

• Collect population figures for each village, division or section of the map using the smallest geographical unit with existing data and a name.

• Calculate the cumulative total population and allocate numbers. Example: cumulated population corresponding to the 2 nd village will be equal to population of village 1 + population of village 2 (see table below).

Estimated Total Cumulative Total N° VILLAGES Population Population Allocated N° 1 500 500 1 – 500 N° 2 400 900 501 – 900 N° 3 160 1060 901 - 1060 N° 4 650 1710 1061 - 1710 N°5 520 2230 1711 - 2230 N°6 640 2870 2231 - 2870 N°7 700 3570 2871 - 3570 N°8 104 3674 3571 - 3674 N°9 470 4144 3675 - 4144 N°10 52 4196 4145 - 4196 N°11 904 5100 4197 - 5100 N°12 270 5370 5101 - 5370 N°13 46 5416 5371 - 5416 N°14 118 5534 5417 - 5534 N°15 240 5774 5535 - 5774 N°16 72 5846 5775 - 5846 N°17 190 6036 5847 - 6036 N°18 426 6462 6037 - 6462 N°19 304 6766 6463 - 6766 N°20 212 6978 6767 - 6978 N°21 108 7086 6979 - 7086 N°22 490 7576 7087 - 7576 N°23 42 7618 7577 - 7618 N°24 24 7642 7619 - 7642 N°25 104 7746 7643 – 7746 N°26 136 7882 7747 - 7882 N°27 98 7980 7883 - 7980 N°28 192 8172 7981 - 8172 N°29 202 8374 8173 - 8374 N°30 112 8486 8375 - 8486 N°31 500 8986 8487 - 8986 N°32 32 9018 8987 - 9018 N°33 170 9188 9019 - 9188 N°34 300 9488 9189 - 9488 N°35 126 9614 9489 - 9614 N°36 108 9722 9615 - 9722 N°37 175 9897 9723 - 9897 N°38 103 10000 9898 - 10000 TOTAL 10 000 10 000 10 000

• Identify villages where you will conduct 30 clusters: Determine the sampling interval. We know that we have 10 000 people in our total population and we want to draw 30 clusters, for example. The sampling interval is equal to 10 000/30 = 333.

60 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan First cluster to survey : we draw a number between 1 and the sampling interval = 333. Let's say we have drawn the No. 200. The No. 200 is located between 1 and 500, which is in the village No 1. The first village to survey will therefore be the village is No. 1. Next cluster to survey: we add the number drawn (200) to the sampling interval (333): 200 + 333 = 533. The No. 533 is located between 501 and 900, in the village No. 2. The second village to survey is therefore the village No. 2. Following clusters to survey : we add the sampling interval to the preceding number: 533+333 = 866. The No. 866 is also in the village No. 2. The third cluster to survey is in the village No. 2. And so on to obtain 30 clusters (Table below). To check that we got it right, if we add the sampling interval (333) to the number corresponding to the thirtieth cluster selected at random, we will fall outside of the target population ( above 10 000). Note: ENA Software performs all those calculations automatically.

Estimated Total Cumulative Total N° Clusters VILLAGES Population Population Allocated N° 1 500 500 1 – 500 1 N° 2 400 900 501 - 900 2-3 N° 3 160 1060 901 - 1060 N° 4 650 1710 1061 - 1710 4 - 5 N° 5 520 2230 1711 - 2230 6-7 N°6 640 2870 2231 - 2870 8-9 N°7 700 3570 2871 - 3570 10-11 N°8 104 3674 3571 - 3674 N°9 470 4144 3675 - 4144 12 N°10 52 4196 4145 - 4196 13 N°11 904 5100 4197 - 5100 14 -15 N°12 270 5370 5101 - 5370 16 N°13 46 5416 5371 - 5416 N°14 118 5534 5417 - 5534 17 N°15 240 5774 5535 - 5774 N°16 72 5846 5775 - 5846 N°17 190 6036 5847 - 6036 18 N°18 426 6462 6037 - 6462 19 N°19 304 6766 6463 - 6766 20 N°20 212 6978 6767 - 6978 21 N°21 108 7086 6979 - 7086 N°22 490 7576 7087 - 7576 22 - 23 N°23 42 7618 7577 - 7618 N°24 24 7642 7619 - 7642 N°25 104 7746 7643 – 7746 N°26 136 7882 7747 - 7882 24 N°27 98 7980 7883 - 7980 N°28 192 8172 7981 - 8172 N°29 202 8374 8173 - 8374 25 N°30 112 8486 8375 - 8486 N°31 500 8986 8487 - 8986 26 - 27 N°32 32 9018 8987 - 9018 N°33 170 9188 9019 - 9188 N°34 300 9488 9189 - 9488 28 N°35 126 9614 9489 - 9614 29 N°36 108 9722 9615 - 9722 N°37 175 9897 9723 - 9897 30 N°38 103 10000 9898 - 10000 TOTAL 10 000 10 000 10 000

61 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.6 Annex 6: Household selection sheet – SMART Training Package – Version 2011

Household Selection Sheet

Date: ______Team number: ______Union: ______Village: ______

Cluster number: ______

Number of HH in the village (N) = Number of HH to survey = x

Sampling interval (S) = N/ x = Random number (r) (corresponds to the 1 st HH to visit) =

• To choose the 1 st HH to visit, you select a number randomly between 1 and the sampling interval that is rounded to the lowest level (e.g. S= 7.7; so, it should be rounded to 7; and the 1 st HH will be randomly chosen between 1 and 7).

• HH to survey should be rounded (e.g. if calculation led to 92.6; so, we round to 93; if calculation led to 174.2, so, if we round, it will be 174; if the calculation led to 335.5, so we round to 336).

HH to survey No HH Calculation Total (rounded) 1 (r) 2 (r) + S 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Etc.

62 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.7 Annex 7: Anthropometric survey – children 6-59 months old, Mitharlam and Qarghayi districts, Laghman province, May 2011

ANTHROPOMETRIC SURVEY - CHILDREN 6-59 MONTHS AND 65-110 CM - PREGNANT WOMEN LAGHMAN PROVINCE, MAY 2011 DATE: N° CLUSTER: N° TEAM: VILLAGE: MUAC Measles Vitamin MUAC Weight in Height in N° N° Sex Age in W/H Oedema for Vaccination A last 6 for kg +/- cm Remarks child HH (F/M) months SD (Y/N) children (Y/VWC/ months Pregnant 100gr +/-0.1cm in mm N/DK) (Y/N/DK) in mm 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Y = yes VWC = Vaccination Without Card W/H = Weight for Height F = Female N = No DK = Does Know M = Male MUAC for pregnant women should be measured to mother with children 6-23 (included in IYCF questionnaire) AND with children 24-59mths

63 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.8 Annex 8: Local event calendar, Nangarhar/Laghman provinces, Afghanistan, May 2011

200 6 20 07 2 008 2009 201 0 20 11 Yearly M on ths Event Mths 1385 so lar M th s 138 6 sola r M th s 1387 so la r M th s 1 388 solar M th s 1389 sola r M th s 138 9 solar

10 - 30 1 0 - 30 10 - 3 0 10 - 30 1 0 - 30 10 - 30 DALW D a lw a D alw a D alw a D alw a D a lw a D alw a 6 4 5 2 4 0 2 8 1 6 4 J an La m d a or L am da o r Lam da or La m da or Lam d a or Lam da o r S pee na S eila S peena Seila Sp eena Se ila S peen a S eila S pee na S eila Spe ena Se ila

HO O T 10 - 30 H oot 1 0 - 30 H oot 10 - 3 0 H oo t 10 - 30 H o ot 1 0 - 30 H oot 10 - 30 H oo t 6 3 5 1 3 9 2 7 1 5 3 F e b B ado ona B ad oona Ba doon a B adoo na B ado ona Bad oona N o wroz N ow ro z N ow roz N ow roz N o w ro z m inista ry o f N a ra nj Gu l N aranj G ul N aranj G ul N aran j G ul N a ra nj Gu l edcuation M a ila 1 5 M aila 15 M aila 15 M a ila 15 M aila 1 5 C ele bration HAM AL Ham al H amal Ham al Ham al Hamal day ,, 6 2 5 0 3 8 2 6 1 4 2 M a rc h N ow roz N aranj G ul M aila 15 Ham al

C rop of C ro p of C rop o f C rop of C rop of C ro p of S AU R "to ut", 8 th "tout", 8th "tou t", 8th "to ut", 8 th "tout", 8th "tout", 8th S aur 6 1 S au r 4 9 Sa ur 3 7 S aur 2 5 S aur 1 3 S au r 1 A p r M u ja hid een M ujahideen M ujahidee n M u jah ide en M uja hid een M ujahideen E ntranc e E ntran ce En tranc e E ntrance E ntran ce Entra nc e

1 - 10 Jaw za 1 - 10 Ja w za 1 - 10 Jaw za 1 - 1 0 Jaw za 1 - 10 Jaw za 1 - 10 Ja w za W h eat W heat W hea t W heat W h eat W heat JAW ZA H a rvest, 15 H arvest, 15 H arve st, 15 H arvest, 15 H a rvest, 15 H arvest, 15 6 0 4 8 3 6 2 4 1 2 0 M a y Jaw za Jaw za Ja w za Jaw za Jaw za Ja w za S chools S choo ls Scho ols S ch ools S chools Schoo ls V acations V acation s Va ca tio ns V acations V acations Vacation s

S AR A T A R ic e R ic e R ic e R ice R ic e R ic e S ow ing(N ih a 5 9 S ow ing(N iha 4 7 So w ing (N iha 3 5 S ow in g(N iha 2 3 S ow ing(N iha 1 1 Sow ing(N iha N Ju n e ale S ha li) a le Sh ali) ale S hali) ale S hali) a le Sha li) ale Sh ali)

20 A ssad 20 A ssa d 28 A ssad 2 8 A ssa d 28 A ssad 28 Assad E id ulfita r,, Ram adan , AS SAD E stiq lal E s tiqla l E s tiqlal E stiqlal 28 A ssad 28 A ssa d 5 8 4 6 3 4 2 2 1 0 J u ly da y(Ind epen d ay(In depe n day(Inde pen da y(Ind epen E stiq lal E s tiqla l de nce D a y) d ence D ay) den ce D ay) de nce D ay) d ay(In depe n day(Indep en dence D a y) dence D ay)

15 S unb ula SU N BO L 15 S unbu la 1 5 S unb ula 15 S un bula 15 Su nbula 1 5 S unbu la Schoo ls S chools 5 7 S choo ls 4 5 Scho ols 3 3 S ch ools 2 1 S chools 9 Sta rts, 10 A A u g S ta rts S ta rts S t a rts S ta rts S ta rts Sun bula E idulfitar M IZAN 2 7 M e zan 17 M ezan 10 Eid u l S e pt E id ul F itar E id F itar F it a r 1 - 10 Aq ra b 25 Aq ra b 1 - 10 A qrab R ic e AQ RAB 1 - 10 A qrab 1 - 10 Aqrab 1 - 10 Aq ra b E id Qu rb an, R ic e 5 5 4 3 3 1 1 9 7 H arvest, 5 R ice H arvest R ice H a rvest R ice H arve st 1 - 1 0 A qrab H a rvest, 15 O c t Aqrab Eid R ice H arvest E id Q urban Q u rb an 1 5 Q aus E id 5 Q aus E id W heat W h eat W heat Q u rba n, Q urban, S ow in g S ow ing Sow ing Q AU S W h eat S ow ing 5 4 W heat 4 2 W hea t 3 0 M o nth 1 8 M onth 6 M onth N o v M o nth S ow ing So w ing M onth M on th

JAD I 1 - 30 U cha 1 - 30 U ch a 1 - 30 U cha 1 - 3 0 U cha 1 - 30 U ch a 1 - 30 U cha 5 3 4 1 2 9 1 7 5 D e c or T o ra Se ila o r Tora S eila or T ora S eila or T ora Seila o r T o ra Se ila or T ora S eila

64 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.9 Annex 9: IYCF survey – children 0-23 months old, Mitharlam and Qarghayi districts, Laghman province, May 2011

IYCF SURVEY - FOR ALL CHILDREN 0-23 MONTHS LAGHMAN PROVINCE, MAY 2011 Date: N* Team: N* Cluster: Village: N* Child: N*HH: Sex (F/M): Age (mths): 1 Has (NAME) ever been breastfed? (if No, go to question N*2) YN DK 2 If yes at question 1, go to question 3 If no at question N*1: why did you never breastfeed (NAME)? (One answer possible) Breastmilk not good for the child A Pain B No breastmilk coming out of the breast C Refusal of the child to be breastfed D Child sick E Mother/caretaker sick F Advice of family members G Does not know DK Other (Specify) No more question is asked to the mother/caretaker who never breastfed 3 How long after birth did you first put (NAME) to the breast? Within first Less than More than If does not know, record DK hr of life 24 hrs 24 hrs 4 During the first three days after delivery, did you give (NAME) the liquid that came from your breasts? Y N DK 5 In the first three days after delivery, was (NAME) given anything to drink other than breast milk? Y N DK 6 Are you still breastfeeding (NAME)? Y N DK If yes at question N*6, no more question asked to the mother/caretaker BUT if yes at question N*6 and child less than 6 mths, MUAC is measured at question N*10 7 If no at question N*7 For how many months did you breastfeed (NAME)? MONTH |___|___| DK 8 Why did you stop breastfeeding? (One anwser possible) Child too old A Pain B No enough milk C New pregnancy D Refusal of the child to be breastfed E Child sick F Mother/caretaker sick G Advice of family members H Does not know DK Other (Specify) 9 Progressive How did you stop breastfeeding ly Abruptly DK 10 MUAC measurement for lactating women (Yes at question N*6 and child 0-5mths) or pregnant women with child 0-5mths and no lactating Lactating women with child 0-5mths and still breastfeeding Pregnant women with child 0-5mths and no lactating Note: MUAC for pregnant women having a child from 6-23mths is recorded on the anthropometric sheet

65 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.10 Annex 10: IYCF questionnaire skip patterns– children 0-23 months old, Mitharlam and Qarghayi districts, Laghman province, May 2011

Question 1 Has (NAME) ever been breastfed?

If Yes If No

Question 3 Question 2 How long after birth did you first put Why did you never breastfeed (NAME) to the breast? (NAME)?

No more question asked to the Question 4 mother/caretaker During the first three days after delivery, did you give (NAME) the liquid that came from your breasts?

Question 5 In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

If Yes Question 6 Are you still breastfeeding (NAME)? If No

Question 7 For how many months did you breastfeed (NAME)?

Question 8 Why did you stop breastfeeding?

Question 9 How did you stop breastfeeding?

Question 10 MUAC measurement for lactating women (Yes at question N*6 and child 0-5mths) or pregnant women with child 0-5mths

66 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.11 Annex 11: Standardization test results, ENA Delta software version April 2011

Report for Evaluation of Enumerators

Weight:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [W2-W1] [Superv.(W1+W2)- Enum.(W1+W2]

Supervisor 0.68 1/6 Enumerator 1 80.46 POOR 87.30 POOR 4/7 6/3 Enumerator 2 8.36 POOR 24.64 POOR 3/7 6/5 Enumerator 3 0.43 OK 0.45 OK 2/8 8/2 Enumerator 4 0.61 OK 0.19 OK 1/7 2/1 Enumerator 5 1.55 POOR 181.47 POOR 1/8 8/2 Enumerator 6 Error Error 7/2 3/8 Enumerator 7 Error Error 5/4 6/5 Enumerator 8 36103.80 POOR 36294.70 POOR 2/9 9/2 Enumerator 9 4.41 POOR 3.25 POOR 1/7 6/3 Enumerator 10 1.52 POOR 1.42 OK 0/9 8/2 Enumerator 11 6.66 POOR 4.42 POOR 3/6 8/2

Height:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [H2-H1] [Superv.(H1+H2)- Enum.(H1+H2]

Supervisor 2.17 3/6 Enumerator 1 7990.78 POOR 8209.97 POOR 5/4 1/9 Enumerator 2 10.08 POOR 12.43 POOR 6/3 4/7 Enumerator 3 3.10 OK 2.67 OK 3/4 5/5 Enumerator 4 1.88 OK 0.13 OK 5/4 3/1 Enumerator 5 Error Error 3/3 3/7 Enumerator 6 Error Error 4/3 2/9 Enumerator 7 85.44 POOR 111.01 POOR 4/3 3/7 Enumerator 8 1.02 OK 12.81 POOR 0/3 4/6 Enumerator 9 0.01 OK 10.32 POOR 1/0 5/4 Enumerator 10 89.88 POOR 116.09 POOR 4/3 3/7 Enumerator 11 7211.84 POOR 10571.00 POOR 3/5 3/8

MUAC:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [MUAC2-MUAC1] [Superv.(MUAC1+MUAC2)- Enum.(MUAC1+MUAC2]

67 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Supervisor 279.00 7/4 Enumerator 1 273.00 OK 2236.00 POOR 7/2 6/3 Enumerator 2 1486.00 POOR 1501.00 POOR 3/6 3/7 Enumerator 3 206.00 OK 111.00 OK 4/6 1/8 Enumerator 4 319.00 OK 14.00 OK 6/4 4/1 Enumerator 5 23797.20 POOR 24267.80 POOR 6/3 6/4 Enumerator 6 Error Error 6/2 5/5 Enumerator 7 567.00 POOR 1372.00 POOR 5/3 6/4 Enumerator 8 5.00 OK 498.00 OK 2/3 4/7 Enumerator 9 82.00 OK 575.00 OK 0/2 7/4 Enumerator 10 264.00 OK 625.00 OK 6/3 5/5 Enumerator 11 311.25 OK 190.25 OK 7/4 2/5

For evaluating the enumerators the precision and the accuracy of their measurements is calculated. For precision the sum of the square of the differences for the double measurements is calculated. This value should be less than two times the precision value of the supervisor. For the accuracy the sum of the square of the differences between the enumerator values (weight1+weight2) and the supervisor values (weight1+weight2) is calculated. This value should be less than three times the precision value of the supervisor. To check for systematic errors of the enumerators the number of positive and negative deviations can be used.

68 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.12 Annex 12: Plausibility check for AFG_201105_LGH_VF.as

Plausibility check for: AFG_201105_LGH_VF.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 >5.0-10 >10 (% of in-range subjects) 0 5 10 20 0 (1.6 %) Overall Sex ratio Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 0 (p=0.571) Overall Age distrib Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 10 (p=0.000) Dig pref score - weight Incl # 0-5 5-10 10-20 > 20 0 2 4 10 0 (4) Dig pref score - height Incl # 0-5 5-10 10-20 > 20 0 2 4 10 2 (8) Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >1.20 0 2 6 20 0 (1.03) Skewness WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (-0.10) Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (0.04) Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <0.000 0 1 3 5 5 (p=0.000) Timing Excl Not determined yet 0 1 3 5 OVERALL SCORE WHZ = 0-5 5-10 10-15 >15 17 %

At the moment the overall score of this survey is 17 %, this is problematic.

There were no duplicate entries detected.

Percentage of children with no exact birthday: 100 %

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=6/ID=24: HAZ (1.347), Age may be incorrect Line=17/ID=4: HAZ (6.510), WAZ (2.220), Age may be incorrect Line=19/ID=5: HAZ (3.851), WAZ (2.017), Age may be incorrect Line=48/ID=16: HAZ (5.656), WAZ (2.256), Age may be incorrect Line=49/ID=18: HAZ (-6.226), WAZ (-4.954), Age may be incorrect Line=50/ID=17: HAZ (-6.282), WAZ (-4.757), Age may be incorrect Line=57/ID=14: WAZ (-4.561), Age may be incorrect Line=73/ID=14: HAZ (-7.085), WAZ (-5.580), Age may be incorrect Line=74/ID=2: HAZ (-5.303), Height may be incorrect Line=79/ID=4: HAZ (1.617), WAZ (1.878), Age may be incorrect

69 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Line=81/ID=5: HAZ (1.707), WAZ (1.792), Age may be incorrect Line=108/ID=11: HAZ (-4.787), Age may be incorrect Line=157/ID=6: HAZ (-5.273), Age may be incorrect Line=178/ID=23: HAZ (1.364), Age may be incorrect Line=184/ID=11: WHZ (3.960) , WAZ (2.190), Weight may be incorrect Line=189/ID=4: HAZ (-5.839), WAZ (-5.257), Age may be incorrect Line=200/ID=18: HAZ (-5.618), Height may be incorrect Line=224/ID=12: HAZ (4.400), WAZ (2.150), Age may be incorrect Line=266/ID=13: HAZ (1.391), Age may be incorrect Line=338/ID=1: HAZ (3.555), Age may be incorrect Line=343/ID=16: HAZ (1.762), Age may be incorrect Line=355/ID=31: HAZ (2.073), Height may be incorrect Line=381/ID=24: HAZ (-6.045), WAZ (-4.673), Age may be incorrect Line=384/ID=3: WHZ (2.466) , Weight may be incorrect Line=423/ID=11: WHZ (-8.652) , WAZ (-6.249), Weight may be incorrect Line=428/ID=8: WHZ (-9.079) , WAZ (-6.382), Weight may be incorrect Line=440/ID=13: HAZ (1.709), Age may be incorrect Line=451/ID=5: HAZ (-5.768), Age may be incorrect Line=452/ID=1: WHZ (4.217) , HAZ (-6.532), Height may be incorrect Line=469/ID=28: HAZ (-5.314), Age may be incorrect Line=492/ID=26: HAZ (3.076), Age may be incorrect Line=567/ID=13: WHZ (-4.376) , Weight may be incorrect Line=571/ID=8: HAZ (-5.044), WAZ (-4.646), Age may be incorrect Line=593/ID=17: WHZ (-3.725) , Weight may be incorrect Line=595/ID=26: WHZ (-3.948) , Weight may be incorrect Line=603/ID=20: WHZ (-3.751) , WAZ (-4.359), Weight may be incorrect Line=606/ID=21: WHZ (-3.760) , WAZ (-4.628), Weight may be incorrect

Percentage of values flagged with SMART flags:WHZ: 1.6 %, HAZ: 4.4 %, WAZ: 3.0 %

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 : ######## Month 21 : ########## Month 22 : ################# Month 23 : ############ Month 24 : ############################ Month 25 : ############# Month 26 : ################# Month 27 : ############## Month 28 : #############

70 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 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 : ##########

Age ratio of 6-29 months to 30-59 months: 1.34 (The value should be around 1.0).

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

Age cat. mo. boys girls total ratio boys/girls ------6 to 11 6 37/34.9 (1.1) 49/36.5 (1.3) 86/71.4 (1.2) 0.76 12 to 23 12 69/68.0 (1.0) 98/71.2 (1.4) 167/139.3 (1.2) 0.70 24 to 35 12 81/66.0 (1.2) 73/69.0 (1.1) 154/135.0 (1.1) 1.11 36 to 47 12 60/64.9 (0.9) 53/68.0 (0.8) 113/132.9 (0.9) 1.13 48 to 59 12 51/64.2 (0.8) 39/67.2 (0.6) 90/131.4 (0.7) 1.31 ------6 to 59 54 298/305.0 (1.0) 312/305.0 (1.0) 0.96

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

Overall sex ratio: p = 0.571 (boys and girls equally represented) Overall age distribution: p = 0.000 (significant difference) Overall age distribution for boys: p = 0.155 (as expected) Overall age distribution for girls: p = 0.000 (significant difference) Overall sex/age distribution: p = 0.000 (significant difference)

Digit preference Weight:

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

71 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Digit .1 : ############################ Digit .2 : ################################## Digit .3 : ########################## Digit .4 : ################################## Digit .5 : ################################ Digit .6 : ############################ Digit .7 : ############################ Digit .8 : #################################### Digit .9 : ############################

Digit Preference Score: 4 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

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: 8 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Digit preference MUAC:

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

Digit Preference Score: 5 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

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: 1.21 1.11 1.03 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 9.5% 9.2% 8.5% calculated with current SD: 12.1% 9.8% 8.1% calculated with a SD of 1: 7.9% 7.5% 7.4%

72 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan

HAZ Standard Deviation SD: 1.50 1.41 1.19 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 39.7% 39.2% 39.3% calculated with current SD: 41.1% 39.8% 39.4% calculated with a SD of 1: 36.8% 35.8% 37.4%

WAZ Standard Deviation SD: 1.18 1.15 1.02 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 25.1% 24.8% 24.0% calculated with current SD: 29.0% 28.0% 25.1% calculated with a SD of 1: 25.6% 25.1% 24.7%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.001 p= 0.475 HAZ p= 0.000 p= 0.000 p= 0.071 WAZ p= 0.000 p= 0.000 p= 0.773 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)

Skewness WHZ -1.02 -0.02 -0.10 HAZ 0.40 0.44 -0.04 WAZ -0.33 -0.14 -0.05 If the value is: -below minus 2 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 2 and minus 1, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 1 and plus 1, the distribution can be considered as symmetrical. -between 1 and 2, there may be an excess of obese/tall/overweight subjects in the sample. -above 2, there is an excess of obese/tall/overweight subjects in the sample

Kurtosis WHZ 7.30 1.08 0.04 HAZ 3.18 2.04 -0.45 WAZ 1.61 1.03 -0.01 (Kurtosis characterizes the relative peakedness or flatness compared with the normal distribution, positive kurtosis indicates a relatively peaked distribution, negative kurtosis indicates a relatively flat distribution) If the value is: -above 2 it indicates a problem. There might have been a problem with data collection or sampling. -between 1 and 2, the data may be affected with a problem. -less than an absolute value of 1 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=2.30 (p=0.000) WHZ < -3: ID=2.28 (p=0.000) GAM: ID=2.30 (p=0.000) SAM: ID=2.28 (p=0.000) HAZ < -2: ID=1.37 (p=0.102) HAZ < -3: ID=0.92 (p=0.572) WAZ < -2: ID=1.67 (p=0.019) WAZ < -3: ID=1.24 (p=0.185)

Subjects with SMART flags are excluded from this analysis.

73 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 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 < 0.05 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p value is higher than 0.05 the cases appear to be randomly distributed among the clusters, if 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 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: 1.36 (n=26, f=1) ######################## 02: 0.91 (n=26, f=0) ##### 03: 1.12 (n=26, f=1) ############## 04: 1.11 (n=26, f=0) ############# 05: 1.32 (n=26, f=0) ###################### 06: 1.89 (n=26, f=1) ############################################## 07: 1.34 (n=26, f=1) ####################### 08: 1.16 (n=26, f=0) ############### 09: 1.87 (n=26, f=1) ############################################# 10: 1.43 (n=26, f=1) ########################### 11: 1.09 (n=26, f=1) ############ 12: 1.25 (n=26, f=1) ################### 13: 1.31 (n=26, f=1) ##################### 14: 1.27 (n=26, f=0) #################### 15: 1.06 (n=25, f=0) ########### 16: 0.92 (n=25, f=0) ##### 17: 1.02 (n=25, f=1) ######### 18: 0.83 (n=24, f=0) # 19: 1.03 (n=22, f=0) ######### 20: 1.02 (n=19, f=0) ######### 21: 1.08 (n=16, f=0) ############ 22: 0.75 (n=15, f=0) 23: 1.18 (n=13, f=0) OOOOOOOOOOOOOOOO 24: 1.04 (n=12, f=0) OOOOOOOOOO 25: 0.73 (n=10, f=0) 26: 0.89 (n=09, f=0) OOOO 27: 0.98 (n=08, f=0) OOOOOOO 28: 0.88 (n=07, f=0) OOO 29: 0.84 (n=05, f=0) ~~ 30: 1.44 (n=04, 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 n = 168 203 132 107 Percentage of values flagged with SMART flags: WHZ: 1.2 1.0 3.0 1.9 HAZ: 6.0 3.9 4.5 2.8 WAZ: 2.4 3.0 4.5 1.9 Age ratio of 6-29 months to 30-59 months: 1.18 0.77 3.13 1.89 Sex ratio (male/female): 0.77 1.01 1.00 1.14

74 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Digit preference Weight (%): .0 : 11 10 10 11 .1 : 5 10 11 12 .2 : 15 9 15 4 .3 : 7 9 5 14 .4 : 12 10 9 13 .5 : 10 11 11 11 .6 : 10 6 14 7 .7 : 10 10 7 9 .8 : 11 12 10 14 .9 : 10 12 8 4 DPS: 9 6 10 12 Digit preference score (0-5 good, 5-10 acceptable, 10- 20 poor and > 20 unacceptable) Digit preference Height (%): .0 : 18 8 3 21 .1 : 15 9 12 7 .2 : 14 14 12 20 .3 : 11 6 16 13 .4 : 7 10 12 4 .5 : 7 9 4 13 .6 : 11 9 16 11 .7 : 9 7 9 5 .8 : 3 16 11 2 .9 : 5 11 5 5 DPS: 16 9 15 21 Digit preference score (0-5 good, 5-10 acceptable, 10- 20 poor and > 20 unacceptable) Digit preference MUAC (%): .0 : 8 4 11 8 .1 : 8 14 7 16 .2 : 16 8 9 13 .3 : 13 7 13 8 .4 : 10 8 5 14 .5 : 8 7 20 11 .6 : 10 10 8 5 .7 : 11 14 11 8 .8 : 7 15 4 4 .9 : 10 11 11 13 DPS: 9 11 15 14 Digit preference score (0-5 good, 5-10 acceptable, 10- 20 poor and > 20 unacceptable) Standard deviation of WHZ: SD 1.11 1.06 1.24 1.49 Prevalence (< -2) observed: % 6.0 9.4 13.6 10.3 Prevalence (< -2) calculated with current SD: % 6.6 10.5 15.1 19.0 Prevalence (< -2) calculated with a SD of 1: % 4.7 9.3 10.0 9.5 Standard deviation of HAZ: SD 1.60 1.52 1.56 1.23 observed: % 47.0 36.5 37.1 37.4 calculated with current SD: % 43.8 41.5 40.9 35.3 calculated with a SD of 1: % 40.1 37.2 35.9 32.1

75 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan

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 11 6 11/8.5 (1.3) 13/11.1 (1.2) 24/19.7 (1.2) 0.85 12 to 23 12 14/16.7 (0.8) 29/21.7 (1.3) 43/38.4 (1.1) 0.48 24 to 35 12 17/16.2 (1.1) 26/21.0 (1.2) 43/37.2 (1.2) 0.65 36 to 47 12 15/15.9 (0.9) 18/20.7 (0.9) 33/36.6 (0.9) 0.83 48 to 59 12 16/15.7 (1.0) 9/20.5 (0.4) 25/36.2 (0.7) 1.78 ------6 to 59 54 73/84.0 (0.9) 95/84.0 (1.1) 0.77

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

Overall sex ratio: p = 0.090 (boys and girls equally represented) Overall age distribution: p = 0.182 (as expected) Overall age distribution for boys: p = 0.873 (as expected) Overall age distribution for girls: p = 0.030 (significant difference) Overall sex/age distribution: p = 0.003 (significant difference)

Team 2:

Age cat. mo. boys girls total ratio boys/girls ------6 to 11 6 12/11.9 (1.0) 7/11.8 (0.6) 19/23.8 (0.8) 1.71 12 to 23 12 21/23.3 (0.9) 23/23.1 (1.0) 44/46.4 (0.9) 0.91 24 to 35 12 24/22.6 (1.1) 25/22.4 (1.1) 49/44.9 (1.1) 0.96 36 to 47 12 20/22.2 (0.9) 22/22.0 (1.0) 42/44.2 (0.9) 0.91 48 to 59 12 25/22.0 (1.1) 24/21.8 (1.1) 49/43.7 (1.1) 1.04 ------6 to 59 54 102/101.5 (1.0) 101/101.5 (1.0) 1.01

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

Overall sex ratio: p = 0.944 (boys and girls equally represented) Overall age distribution: p = 0.701 (as expected) Overall age distribution for boys: p = 0.917 (as expected) Overall age distribution for girls: p = 0.642 (as expected) Overall sex/age distribution: p = 0.483 (as expected)

Team 3:

Age cat. mo. boys girls total ratio boys/girls ------6 to 11 6 12/7.7 (1.6) 17/7.7 (2.2) 29/15.5 (1.9) 0.71 12 to 23 12 16/15.1 (1.1) 29/15.1 (1.9) 45/30.1 (1.5) 0.55 24 to 35 12 20/14.6 (1.4) 10/14.6 (0.7) 30/29.2 (1.0) 2.00 36 to 47 12 11/14.4 (0.8) 6/14.4 (0.4) 17/28.7 (0.6) 1.83 48 to 59 12 7/14.2 (0.5) 4/14.2 (0.3) 11/28.4 (0.4) 1.75 ------6 to 59 54 66/66.0 (1.0) 66/66.0 (1.0) 1.00

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

Overall sex ratio: p = 1.000 (boys and girls equally represented) Overall age distribution: p = 0.000 (significant difference) Overall age distribution for boys: p = 0.064 (as expected) Overall age distribution for girls: p = 0.000 (significant difference)

76 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan Overall sex/age distribution: p = 0.000 (significant difference)

Team 4:

Age cat. mo. boys girls total ratio boys/girls ------6 to 11 6 2/6.7 (0.3) 12/5.9 (2.0) 14/12.5 (1.1) 0.17 12 to 23 12 18/13.0 (1.4) 17/11.4 (1.5) 35/24.4 (1.4) 1.06 24 to 35 12 20/12.6 (1.6) 12/11.1 (1.1) 32/23.7 (1.4) 1.67 36 to 47 12 14/12.4 (1.1) 7/10.9 (0.6) 21/23.3 (0.9) 2.00 48 to 59 12 3/12.3 (0.2) 2/10.8 (0.2) 5/23.1 (0.2) 1.50 ------6 to 59 54 57/53.5 (1.1) 50/53.5 (0.9) 1.14

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

Overall sex ratio: p = 0.499 (boys and girls equally represented) Overall age distribution: p = 0.000 (significant difference) Overall age distribution for boys: p = 0.002 (significant difference) Overall age distribution for girls: p = 0.001 (significant difference) Overall sex/age distribution: p = 0.000 (significant difference)

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: 1.67 (n=07, f=1) #################################### 02: 1.21 (n=07, f=0) ################# 03: 0.57 (n=07, f=0) 04: 0.93 (n=07, f=0) ###### 05: 1.04 (n=07, f=0) ########## 06: 0.69 (n=07, f=0) 07: 2.12 (n=07, f=1) ####################################################### 08: 0.74 (n=07, f=0) 09: 1.11 (n=07, f=0) ############# 10: 1.28 (n=07, f=0) #################### 11: 1.22 (n=07, f=0) ################## 12: 0.67 (n=07, f=0) 13: 1.44 (n=07, f=0) ########################### 14: 0.87 (n=07, f=0) ### 15: 1.01 (n=07, f=0) ######### 16: 0.92 (n=07, f=0) ##### 17: 0.64 (n=07, f=0) 18: 0.65 (n=07, f=0) 19: 1.32 (n=07, f=0) ###################### 20: 1.29 (n=06, f=0) #################### 21: 1.31 (n=05, f=0) ##################### 22: 0.75 (n=05, f=0) 23: 0.95 (n=04, f=0) OOOOOO 24: 1.21 (n=04, f=1) OOOOOOOOOOOOOOOOO 25: 0.06 (n=03, f=0) 26: 0.15 (n=02, f=0) 27: 0.87 (n=02, f=0) ~~~ 28: 1.51 (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)

Team: 2

77 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan

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: 0.95 (n=07, f=0) ###### 02: 0.46 (n=07, f=0) 03: 1.30 (n=07, f=1) ##################### 04: 0.83 (n=07, f=0) # 05: 1.46 (n=07, f=0) ############################ 06: 0.84 (n=07, f=0) ## 07: 1.15 (n=07, f=0) ############### 08: 1.13 (n=07, f=0) ############## 09: 0.56 (n=07, f=0) 10: 1.98 (n=07, f=1) ################################################# 11: 0.58 (n=07, f=0) 12: 1.07 (n=07, f=0) ########### 13: 0.84 (n=07, f=0) # 14: 1.58 (n=07, f=0) ################################# 15: 1.44 (n=07, f=0) ########################### 16: 0.92 (n=07, f=0) ##### 17: 0.67 (n=07, f=0) 18: 1.25 (n=07, f=0) ################### 19: 1.07 (n=07, f=0) ########### 20: 1.00 (n=07, f=0) ######## 21: 1.27 (n=07, f=0) #################### 22: 0.92 (n=07, f=0) ##### 23: 0.89 (n=07, f=0) #### 24: 0.67 (n=07, f=0) 25: 0.79 (n=06, f=0) 26: 0.93 (n=06, f=0) ###### 27: 0.83 (n=05, f=0) # 28: 0.84 (n=04, f=0) OO 29: 0.97 (n=04, f=0) OOOOOOO 30: 1.70 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

(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)

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: 0.70 (n=07, f=0) 02: 1.06 (n=07, f=0) ########### 03: 1.41 (n=07, f=0) ######################### 04: 1.17 (n=07, f=0) ################ 05: 1.84 (n=07, f=0) ############################################ 06: 1.41 (n=07, f=0) ########################## 07: 0.69 (n=07, f=0) 08: 1.48 (n=07, f=0) ############################ 09: 0.77 (n=07, f=0) 10: 0.83 (n=07, f=0) # 11: 1.50 (n=07, f=1) ############################# 12: 1.30 (n=07, f=1) ##################### 13: 1.73 (n=07, f=1) ####################################### 14: 1.12 (n=07, f=0) ############## 15: 0.93 (n=06, f=0) ###### 16: 0.77 (n=06, f=0) 17: 1.70 (n=06, f=1) ###################################### 18: 0.79 (n=05, f=0) 19: 0.38 (n=04, f=0) 20: 0.93 (n=04, f=0) OOOOOO 21: 0.71 (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)

Team: 4

78 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 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: 1.21 (n=05, f=0) ################# 02: 0.55 (n=05, f=0) 03: 0.65 (n=05, f=0) 04: 1.37 (n=05, f=0) ######################## 05: 0.64 (n=05, f=0) 06: 3.51 (n=05, f=1) ################################################################ 07: 1.00 (n=05, f=0) ######## 08: 1.09 (n=05, f=0) ############ 09: 3.44 (n=05, f=1) ################################################################ 10: 1.33 (n=05, f=0) ###################### 11: 0.49 (n=05, f=0) 12: 0.78 (n=05, f=0) 13: 0.85 (n=05, f=0) ## 14: 1.72 (n=05, f=0) ####################################### 15: 0.96 (n=05, f=0) ####### 16: 0.74 (n=05, f=0) 17: 0.57 (n=05, f=0) 18: 0.35 (n=05, f=0) 19: 0.51 (n=04, f=0) 20: 0.38 (n=02, f=0) 21: 0.47 (n=02, f=0) 22: 0.08 (n=02, f=0) 23: 1.45 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOO

(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)

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

79 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan 9.13 Annex 13: Districts affected by floods – Eastern provinces – August 2010 – Source: OCHA

80 Anthropometric nutrition survey and Infant and Young Child Feeding Study Mihtarlam and Qarghayi districts - Laghman province – May 2011 - Afghanistan