Anthropometric Nutrition Survey

Children from 6 to 59 months

And

Infant and Young Child Feeding Practices study

Children from 0 to 23 months

Final Report

Chal and Rustaq districts

Takhar province, Afghanistan

From the 24 th of June to the 2 nd of July 2011

Funded by UNICEF

Islamic Republic of Afghanistan ACKNOWLEDGEMENT

This anthropometric nutrition survey and Infant and Young Child Feeding study could be undertaken in Chal and Rustaq districts, Takhar province through funding by UNICEF. The coordinator of this project was Ms Brigitte Tonon, ACF health - nutrition coordinator supported by Mr. Tariq Khan, ACF nutrition program manager and Dr Asef Ghyasi, CAF nutrition and community development manager. This work would not have been possible without the dedicated efforts of the nutrition community in Afghanistan. We would like to thank:

• The Ministry of Public Health, 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 Takhar province and particularly in the selected districts;

• The entire ACF and CAF Teams for their great support in this project.

2 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 LIST OF ABBREVIATIONS

ACF Action Contre la Faim BPHS Basic Package of Health Services CAF Care for Afghan Families CHW Community Health Worker CI Confidence Interval CMAM Community Management of Acute Malnutrition CSO Censes Statistics Office ENA Emergency Nutrition Assessment GAM Global Acute Malnutrition HF Health Facility HH Household HMIS Health Management Information System IYCF Infant and Young Child Feeding MAM Moderate Acute Malnutrition MoPH Ministry of Public Health Mths Months MUAC Mid Upper Arm Circumference N Sample size NCHS National Centre for Health Statistics NGO Non Governmental Organization NRVA National Risk and Vulnerability Assessment OCHA Office for the Coordination of Humanitarian Affairs OTP Out-patient Therapeutic Program RC Reserve Cluster SAM Severe Acute Malnutrition SMART Standardized Monitoring and Assessment of Relief and Transitions TFU Therapeutic Feeding Unit U5 Under Five UN United Nations UNHCR United Nation High Commissioner for Refugees 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 Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 TABLE OF CONTENTS

EXECUTIVE SUMMARY ...... 5 1. INTRODUCTION ...... 10 1.1. Agencies ...... 10 1.2. Surveyed area...... 10 1.3. Population data - Demography ...... 11 1.4. Climate and geography...... 11 1.5. Administrative organisation...... 11 1.6. Economic – Food security situation ...... 12 1.7. Water and sanitation situation...... 12 1.8. Health situation and interventions...... 13 1.9. Nutrition intervention...... 13 1.10. Humanitarian intervention...... 14 2. SURVEY GOALS AND OBJECTIVES ...... 15 3. METHODOLOGY...... 16 3.1. Sampling strategy: sampling design and sample size calculation...... 16 3.2. First stage sampling: cluster selection ...... 19 3.3. Final stage sampling: Selection of households and children...... 20 3.4. Data collected and measurement techniques ...... 22 3.5. Definition of nutritional status of children 6-59 months:...... 23 3.6. IYCF indicators ...... 25 3.7. Training and supervision...... 26 3.8. Data analysis ...... 27 4. RESULTS ...... 28 4.1. Nutritional status of children 6-59 months (according to WHO standards 2006)...... 28 4.2. Anthropometric results: Pregnant/Lactating women (based on MUAC criterion) ...... 34 4.3. Measles vaccination coverage...... 35 4.4. Vitamin A supplementation coverage...... 35 4.5. IYCF study ...... 36 5. DISCUSSION...... 45 5.1. Constraints and biases ...... 45 5.2. Acute malnutrition – Children 6-59 months old ...... 46 5.3. Chronic malnutrition – Children 6-59 months old ...... 47 5.4. Malnutrition risk - Pregnant/Lactating women...... 48 5.5. Causal analysis...... 49 6. CONCLUSION...... 50 7. RECOMMENDATIONS...... 51 8. REFERENCES ...... 53 9. ANNEXES...... 54 9.1. Annex 1: Map of Takhar province, Afghanistan (Source: MoPH) ...... 54 9.2. Annex 2: 3 Ws (Who is doing What and Where), Takhar province, Afghanistan, September 2011 (Source: OCHA) ...... 55 9.3. Annex 3: Cluster selection, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 57 9.4. Annex 4: Selection of cluster with Probability Proportional to Population Size (PPS) ...... 58 9.5. Annex 5: Household selection sheet – SMART Training Package – Version 2011 ...... 60 9.6. Annex 6: Anthropometric survey – children 6-59 months old and if age not know 65-110 cm, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 ...... 61 9.7. Annex 7: Local event calendar, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 62 9.8. Annex 8: IYCF study – children 0-23 months old, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 ...... 63 9.9. Annex 9: Skip patterns - IYCF study – children 0-23 months old, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 ...... 65 9.10. Annex 10: Plausibility check for AFG_201106_TKH_VF, ENA Delta software Version April 2011, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 ...... 66 9.11. Annex 11: Seasonal calendar and critical events timeline, 2011, Afghanistan – Source: FEWS Net March 2011 ...... 68

4 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 EXECUTIVE SUMMARY

Takhar is one of the 34 provinces of Afghanistan in the north of the country and is composed of 17 districts. The province is located east of Kunduz province and surrounded by Baghlan, Panjshir, and Badakhshan provinces. The north of the province has a border with Tajikistan. Out of the 17 districts, only 2 were included in the survey: Chal and Rustaq districts. The province is largely spread and so could not be fully assessed by conducting a single survey. These 2 districts were selected so as to provide information about the northern and western parts of the province, representing two different contexts. These nutrition survey and IYCF study were conducted jointly by the NGOs ACF and CAF from the 24 th of June to the 2 nd of July 2011.

Methodology A SMART multi-stage cluster sampling method was applied using ENA software version April 2011 for the anthropometric nutrition survey conducted in Chal and Rustaq districts, Takhar province. The IYCF study was based on the guideline ‘ Indicators for Assessing Infant and Young Child Feeding Practices ’ – WHO et al. 2007.

Anthropometric measurements – Children 6-59 months old 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 as a proxy for age, represent the anthropometric survey’s targeted population. To reach the required sample size to correctly estimate the prevalence of acute malnutrition, 517 households were to be surveyed to reach a total of 470 children. In the end a total of 528 households 1 were surveyed, corresponding to 33 clusters of 16 households, with 703 children having been included. However, due to extreme values or potential incorrect measurements, 13 were left out to calculate acute malnutrition in weight for height, leaving a sufficiently high sample size of 690 children. 685 children had a height >= 65 cm, allowing the use of MUAC measurements. The minimum sample size required to estimate the prevalence of chronic malnutrition was largely achieved as 528 households were visited while only 219 were expected as a minimum and 703 children were surveyed while only 200 were required. 27 children were excluded from the sample size due to extreme or incorrect values, still leaving a sample of 676 children.

Anthropometric measurements – Pregnant-Lactating women Following the selection of households for the anthropometric nutrition survey, all pregnant women with children 0-59 months and all lactating women with children 0-5 months were included in the anthropometric survey and found at household level had 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 collection, 84 pregnant women and 88 lactating breastfeeding women were found, for a total of 172 women screened by MUAC.

IYCF study – Children from 0 to 23 months old 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 old, excluded from the anthropometric nutrition survey were equally included in the IYCF questionnaire. 93 infants less than 6 months and 241 children 6-23 months were found in the visited households for a total sample of 334 children aged 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 Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Main results

Anthropometric data are presented according to WHO standards 2006.

Acute malnutrition prevalence – Children from 6 to 59 months old According to Weight for Height index– Children from 6 to 59 months old Prevalence of Acute malnutrition All Z-score 95% CI According to WHO standards N = 690 Prevalence of global acute malnutrition N = 72 10.4 % (7.9 – 13.7 95% C.I.) (<-2 z-score and/or oedema) Prevalence of moderate acute malnutrition N = 58 8.4 % (6.0 – 11.7 95% C.I.) (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe acute malnutrition N = 14 2.0 % (1.0 – 3.9 95% C.I.) (<-3 z-score and/or oedema)

According to MUAC criterion – Children from 6 to 59 months old (with height >= 65 cm) Prevalence of Acute malnutrition All % 95% CI According to MUAC criterion and WHO standards N = 685 Prevalence of global malnutrition N = 48 7.0 % ( 5.0 - 9.7 95% CI) MUAC < 125mm Prevalence of moderate malnutrition N = 36 5.3 % (3.6 – 7.7 95% C.I.) MUAC >=115 <125mm Prevalence of severe malnutrition N = 12 1.8 % ( 1.0- 2.9 95% CI) 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 = 676 Prevalence of stunting N = 365 54.0% [48.5 – 59.4 95% C.I.] (<-2 z-score and >=-3 z-score) Prevalence of moderate stunting N = 219 32.4% [28.6 – 36.4 95% C.I.] (<-2 z-score and >=-3 z-score) Prevalence of severe stunting N = 146 21.6% [18.1 – 25.6 95% C.I.] (<-3 z-score)

Nutritional risk among pregnant/lactating women screened

MUAC Nutritional Risk Pregnant women Lactating women TOTAL in mm Sphere Standards 2 N % N % N % <210 Severe risk 2 2.4% 3 3.4% 5 2.9% ≥210 - <230 Moderate risk 13 15.5% 12 13.6% 25 14.5% ≥230 No risk 69 82.1% 73 83.0% 142 82.6% Total 84 100% 88 100% 172 100%

2 The Sphere Project (2011). Humanitarian Charter and Minimum Standards in Humanitarian Response, Chapter 3: Minimum Standards in Food Security and Nutrition . Geneva: The Sphere Project.

6 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Measles vaccination coverage – Children from 9 to 59 months old All Measles vaccination coverage N (669) N % Confirmed with immunization card 407 60.8% Confirmed verbally by the caregiver but no immunization card to prove it 176 26.3% No immunization according to the caregiver 36 5.4% Unknown 50 7.5% Total 669 100%

Vitamin A supplementation coverage – Children from 6 to 59 months old All Vitamin A supplementation coverage N (703) within the last 6 months N % Vitamin A dose received 648 92.2% Vitamin A dose not received 21 3.0% Unknown 34 4.8% Total 703 100%

IYCF study – Children from 0 to 23 months old CORE INDICATORS DEFINITION N % 95% CI Proportion of children born in the last 23 Early initiation of months who were put to the breast within 221 66.8% (61.4 – 71.8) breastfeeding (n = 331 ) one hour of birth Exclusive breastfeeding Proportion of infants 0-5 months of age 59 63.4% (52.8 – 73.2) under 6 months (n =93) who are fed exclusively with breast milk Continued breastfeeding at Proportion of children 12 – 15 months of 58 95.1% (86.3 – 99.0) 1 year (n = 61 ) age who are still fed with breast milk Introduction of solid, semi- Proportion of infants 6-8 months of age 24 70.6% (52.5 – 84.9) solid or soft foods (n = 34 ) who receive solid, semi-solid or soft foods Proportion of children 6-23 months of age Consumption of iron-rich or who receive an iron-rich food or iron- iron-fortified foods fortified food that is specially designed for 16 6.6% (3.8 – 10.6) (n =241) infants and young children, or that is fortified in the home. OPTIONAL INDICATORS DEFINITION N % 95% CI Children ever breastfed Proportion of children born in the last 24 330 98.8% (96.8 – 99.6) (n = 334) months who were ever breastfed Continued breastfeeding at Proportion of children 20–23 months of age 26 68.4% (51.3 – 82.5) 2 years (n =38) who still receive breast milk

7 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Conclusion It is important to acknowledge that, given the inclusion of only 2 districts out of 17 in the province, the results of this survey are not representative for the whole province, only for those areas surveyed. The nutritional situation in the excluded places should be assessed when feasible for a better view on the whole province. Mid 2011, at the time of report writing, a drought affected most of the northern regions in Afghanistan. Takhar province is identified as ‘Red spot’ for direct intervention’ ‘according to UN agencies and other stakeholders. An Emergency Food Security Assessment (EFSA) was carried out in the 14 provinces of the northern, north-eastern, western and central highlands areas identified as the most drought affected, including Takhar province, in August 2011. The situation is Takhar province was said as of concern, especially taking into account all negative factors such as the inadequate copy mechanisms or the poor household access to food commodities. The survey was conducted in June 2011, corresponding to the period of the main harvest and therefore the end of the hunger gap period. The population was said to be affected already by the drought according to the nutrition survey team and CAF staff based in Takhar province. The harvest is expected to be poorer compared to other years. Hence, the nutrition situation should be closely followed in the coming months, as drought could negatively influence the nutrition status of the population living in this area. Acute malnutrition levels cannot be considered as alarming but still indicate a “risky situation“ (UNHCR/WFP) with requires intervention to deal with the nutritional deficiencies of the population.

This survey does not provide anthropometric information on children under 6 months old, whereas in the Afghanistan context, infants are well recognized as one of the most vulnerable population group. A separate anthropometric nutrition survey should be conducted for this age group. Currently, only one in-patient therapeutic feeding unit is functional in the provincial hospital in Taluqan town, provincial capital and no out-patient therapeutic programmes have been set up. Only one supplementary feeding centre can be found, equally in Taluqan. The high prevalence of stunting is a major concern in Takhar. More than half of the targeted children were found to be chronically malnourished, one quarter even severely stunted. Chronic malnutrition can only be prevented by multiple mitigation measures, such as education, household food security interventions etc. Chronically malnourished children are highly vulnerable to acute malnutrition, especially when their living conditions deteriorate further. Coverage of Vitamin A supplementation was highly satisfactory, whereas the coverage for measles vaccination could be improved. The prevalence of acute malnutrition among pregnant and lactating women must be taken into serious consideration. Almost one fifth of the women included can be considered as malnourished. According to the cycle of hunger, malnutrition among pregnant women can lead to chronic malnutrition in their children. Preventing and dealing with malnutrition in pregnant and lactating women and improving their health and wellbeing will therefore also benefit their children.

8 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Recommendations
To advocate with the Ministry of Public Health and the NGO CAF, BPHS implementer in the studied area, to maintain the satisfactory coverage of Vitamin A supplementation and to improve the measles vaccination coverage. Emphasis should be on out-reach activities so as to cover the population living in remote areas as well as people not seeking care in health facilities;
To expand the CMAM project within the BPHS framework in the whole province in accordance with the national nutrition policy and in collaboration with the several health actors present in the area: o To increase the number of in patient units at district level, one per district, o To start implementing the Out-patient Therapeutic Program (OTP) component in all districts, o To extend the SFP component to all districts, o To extend community mobilization program to remote areas as much as possible;
To monitor the nutrition situation on a regular basis: o To improve the regular collection of anthropometric data through the HMIS in order to better follow nutrition trends, o To conduct more nutrition surveys, in accordance with the nutrition national policy which stipulates that “surveys should be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in the nutritional situation”, o To conduct nutritional surveillance in the coming months to evaluate the impact of the drought if the situation is estimated to be worsening, o To consider infants below 6 months in a separate survey;


To assess the 15 districts excluded by this survey;


To take into consideration the lessons learned and recommendations submitted in the ‘End of Project household survey of IYCF practices from Takhar, Badakhshan and Kunduz provinces’ done by CAF in June 2011.

9 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 1. INTRODUCTION

1.1. Agencies The anthropometric nutrition survey and IYCF study were conducted in partnership between 2 agencies: ACF and CAF. 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 a nutrition surveillance system. A nutrition surveillance project is implemented at national level with 5 nutrition clusters partners since December 2010. As part of this project, ACF provided support to the local NGO CAF to conduct an anthropometric nutrition survey and IYCF study in Takhar province in June 2011.

Care for Afghan Families (CAF) is a non-governmental, non-political, not for profit and independent development national organization. The organization was first registered with the Ministry of Planning on 9th January 2003 and re-registered in 2005 with number 68 with the Ministry of Economy of Afghanistan. The mission of CAF is to enable families to fight against poverty, injustice and unawareness; its vision being ‘Self-reliant, aware and healthy Afghan families’. 4 main strategic directions drive CAF’s intervention: Health, Nutrition, Community Development and Education & Capacity Building. Gender and service to persons with disabilities are cross-cutting issues and integral part of all strategic directions. All employees and members of CAF, as individuals or groups, consider the following principles in all their conducts: a. Accountability and transparency: Able to provide evidences and proves for use of organization’s resources; b. Equity and integrity: Being honest and respect others rights; c. Professionalism: Having required qualifications and using it in performing a job; d. Efficiency: Using resources economically and reasonably to deliver effective outputs;

1.2. Surveyed area Takhar province is located east of Kunduz province and surrounded by Baghlan, Panjshir, and Badakhshan provinces. The north of the province has a border with Tajikistan. It lies on the main route to the northeastern region of Afghanistan. The province covers an area of 12,376 km2 3 and consists of 17 districts. Only 2 districts were included in this survey: Chal and Rustaq districts. The province is widely spread and could therefore not be fully assessed by conducting a single survey (See map – Annex 1).

3 CSO/UNFPA Socio Economic and Demographic Profile

10 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Chal and Rustaq districts were selected to represent areas located in the North as well as in the West part of the province, representing two different contexts. The 2 districts are not composed of the same tribes and do not have the same socio-economic development. For example, more schools are available in Rustaq than in Chal district. The provincial capital is Taluqan City, which has a population of 194,471 inhabitants 4. The transport infrastructure in Takhar is reasonably well developed, with 43.1% of roads in the province able to take car traffic in all seasons and 29.1% able to take car traffic in some seasons. However, in more than a quarter of the province (26.1%) there are no roads at all.

1.3. Population data - Demography In comparison with other Afghan provinces, Takhar has a relatively large urban population, which accounts for around 14.6% of the overall population5. Taluqan and Rustaq Districts are the most populated, with 193,314 and 132,315 inhabitants, respectively. Much of the population is concentrated in the northern and central portions of the province; the far more mountainous southern parts of the province have smaller populations. The major ethnic groups living in Takhar province are Uzbek and Tadjiks followed by Pashtuns and Hazaras 6. Takhar province also has a population of Kuchis or nomads whose numbers vary in different seasons. In winter 172,530 individuals, or 7.1% of the overall Kuchi population, stay in Takhar, which makes it the province with the second highest Kuchi population in winter after Nangarhar province. The Kuchis stay mostly in one area during winter time and do not move around during this season. In the summer season, the Kuchi population moves to different locations in the country, searching for pastures. The Kuchi population was not targeted by this survey. Indeed, Kuchis live outside the villages, mainly settled under tents in pasture fields. A separate survey with a methodology adapted to nomadic lifestyle would be necessary to cover this population group.

1.4. Climate and geography More than half of the province (56.8%) is mountainous or semi mountainous terrain while more than one-third of the area is made up of flat land (36.75) 7. The weather in winter is cool and dry, whereas it’s hot and humid during the summer time. The survey was conducted from the 24 th of June to the 2 nd of July 2011, corresponding to the summer period.

1.5. Administrative organisation Afghanistan is divided in 34 provinces which are then divided into 401 districts, in their turn divided into cities or villages. These cities or villages constitute the smallest administrative organisation. Takhar province is composed of 17 districts, consisting of 1,221 cities/villages. Out of these 17 districts, only 2 were included in the survey: Chal and Rustaq districts, which represent 235 villages/cities in total (cf. table 1, Population figures, p16). The main city is Rustaq town, Takhar provincial capital.

4 CSO 2010/2011 5 CSO 2010/2011 6 http://complexoperations.org/cowiki/Takhar 7 CSO/UNFPA Socio Economic and Demographic Profile

11 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 1.6. Economic – Food security situation Takhar is an agricultural province and is rich in minerals like lapis lazuli, gems, and coal. In terms of industry, one textile and one cement factory are functional in the province. Tadjiks, Uzbeks and a number of Pashtuns are involved in commercial businesses in Takhar. The majority of commercial activity is related to trade in agricultural and livestock products. Agriculture is a major source of revenue for 60% of households in Takhar province, including 65% of rural households and 20% of households in the urban area 8. 61% of rural households and 19% of urban households own or manage agricultural land or garden plots in the province. However, nearly half of households (46%) in the urban areas and one in five of households (20%) in rural areas derive some income from trade and services. More than a third of households in both urban and rural areas (39%) earn income through non-farm related labor. Livestock also accounts for income for almost one in five rural households (19%). The most important field crops grown in Takhar province include wheat, maize, barley, rice, and flax. The most common crops grown in garden plots include fruit and nut trees (53%), grapes (12%) and produce such as vegetables, potatoes, beans and alfalfa, clover or other fodder. Wheat (12%) is also frequently grown in garden plots in the province . The most commonly owned livestock are donkeys, cattle, goats, poultry and oxen. During the years of crisis, markets were lost, forcing many households to restrict themselves to subsistence farming, growing grains and small quantities of vegetables and fruits and keeping cattle. Takhar is one of the most secure provinces in Afghanistan. Until very recently, insurgent activity was almost non existent in Takhar, and insurgent attacks are still rare. Instances of violence between rival militias and political groups are also remarkably low in Takhar, especially in comparison with Northern Provinces further west, which were wracked with inter-factional fighting for years after the fall of the Taliban. However, Takhar province has a fair degree of armed crime and is a key transit area for smuggled goods, including opium, across the northern border. The groups engaged in smuggling are often heavily armed and sometimes are involved in fighting with the Afghan Police and Border Patrol.

1.7. Water and sanitation situation In Takhar province, only 29% of households on average use safe drinking water 9. This rises to 52% in the urban area, and falls to 27% in rural areas. Nearly four in five of households (79%) have direct access to their main source of drinking water within their community, however one in seven households (14%) has to travel for up to an hour to access drinking water, and for 2% travel to access drinking water can take up to 6 hours. On average only 1% of households have access to safe toilet facilities. The situation is better in the urban area where 2% of households have safe toilets. The following table shows the kinds of toilet facilities used by households in the province 10 :

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 7% 10% 32% 51% 1% 0%

8CSO/UNFPA Socio Economic and Demographic Profile 9 NRVA 2005 10 NRVA 2005

12 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 1.8. Health situation and interventions 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 11 : the BPHS, key policy of the MoPH, is being implemented by CAF as leading agency and other stakeholders to tackle the health issues in Takhar province. The EPHS is managed by the MoPH, which runs the provincial hospital located in Taluqan town, capital of Takhar province. Takhar, as one of the remote and hard-to-reach provinces of Afghanistan, has an almost similar health situation compared to other rural parts of the country. Though unique research-based data about potential morbidity and mortality indicators are not solely available for Takhar; high maternal mortality ratio (MMR) and Infant Mortality Rate (IMR) have to be acknowledged in Afghanistan. The prevalence of communicable disease (such as malaria, tuberculosis), water-borne diseases (such as diarrhea, worm infestations) and other diseases due to poor hygiene and sanitation are making the burden on health. In addition, micronutrient deficiency diseases such as goiter and anemia and acute respiratory infection (ARI) are commonly affecting the local population. Though access to health care facilities has remarkably increased over the past years according to humanitarian actors, only 82% of people have direct access to health facilities i.e. within two hours walking distance 12 . Despite improvement, the road condition and the high transportation cost remain barriers to access health facilities, especially for population settled in remote areas. As BPHS implementer, the NGO CAF is currently running 1 mobile health team, 453 Health Posts located in the 17 districts of the province and 54 health facilities in Takhar province including:


3 District Hospitals: located in Rustaq, Dashti Qala and Farkhar districts;


13 Comprehensive Health Centres;


5 Sub-Centres,


33 Basic Health Centres. CAF also provides health care to prisoners at the provincial jail located in Taluqan town. Beside humanitarian agencies, the MoPH is actively involved in running health activities in the province, being in charge of health facilities and especially by managing the provincial hospital located in Taluqan town. Furthermore, the private sector is functional mainly at the provincial center and provides secondary and tertiary health care.

1.9. Nutrition intervention The agency CAF is implementing the nutrition component as part of the BPHS framework within its health facilities. Malnutrition prevention (growth monitoring and nutrition promotion) and assessment are the two broad sub-components being offered to the beneficiaries through health facilities and health posts. Up to April and June 2011, the 2 following projects were implemented by CAF in Takhar province:
Implementation of nutrition “IYCF” project in 12 Comprehensive Health Centers (CHC) and in 120 health posts, Takhar province. This project was supported by UNICEF since the 1 st of October 2009 and ended in April 2011. This project could be maintained after 2012;

11 http://www.etc-crystal.org 12 NRVA 2007/2008

13 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011
Implementation of nutrition “Baby Friendly Village initiative project” in 3 District Hospital, 40 Health Posts and 1 Comprehensive Health Centre in Takhar province. This project was supported by the World Bank and started on the 15 th of October 2009 and ended in June 2011. These projects were integrated into the BPHS – PCH = Partnership Contract for Health. As today, the IYCF component is maintained through Breastfeeding Support Groups implemented at community level. In addition, breastfeeding counsellors and midwives are organizing IYCF activities within health centres as well as at community level. The main objective is to ensure the most optimal environment for breastfeeding mothers and children less than two years. In addition, the following CAF project is ongoing in Takhar province: CGMP (Community Based Growth Monitoring and Promotion), a project supported by BASICS – USAID. This project started in November 2008 and will be continuing up to December 2011. This pilot project is composed of community based growth monitoring and promotion activities implemented in Farkhar district, Takhar province. Regarding direct nutrition intervention, CAF is running one ‘Child survival project’ which is integrated within the BPHS: 2 child survival focal points are in charge to promote growth monitoring and IYCF best practices among the community. Regarding other nutrition interventions:
1 TFU, providing in-patient treatment for severe acutely malnourished children less than five years old, is functional in Taluqan provincial hospital managed by the MoPH and supported by UNICEF;
The NGO Kinderberg is running a SFC for the treatment of moderate acute malnutrition among children 6-59 months. This centre is located in Taluqan town, near the provincial hospital; No Out patient Therapeutic Program (OTP) for the treatment of severe acute malnutrition is available in the whole province. No nutrition centres are implemented at district level in Takhar province. Nevertheless, CAF is willing to implement a full CMAM project (with breastfeeding counsellors and IYCF component) and has submitted a proposal to several donors. The project would include:
Implementation of TFU in district hospitals: 3 district hospitals are run by CAF today. At least 2 TFUs would be set up;
Implementation of SFP and OTP: opening of nutrition centres in 20 health facilities in Takhar province;
Community mobilization as part of the CMAM framework.

1.10. Humanitarian intervention A consequent number of national and international organizations play an active role in promoting development in the province. Ministries and governmental agencies are present as well in the province. According to the last 3Ws (Who is doing What and Where) updated in September 2011 by the UN agency OCHA, numerous organizations are operating in the different districts of Takhar province (See 3Ws – Annex 2).

14 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 2. SURVEY GOALS AND OBJECTIVES

This survey aims to collect representative nutrition and IYCF data at the level of CAF’s work area; this will provide baseline data, allowing monitoring of the population’s nutritional status and IYCF practices as part of CAF’s program requirements. These data will also be part of the nutrition surveillance initiative mentioned previously. In addition, the main objective of the collaboration between ACF and CAF was to ensure the capacity building of CAF’s staff on how to conduct anthropometric nutrition surveys. CAF’s staff were supported by ACF core survey team for the whole survey process.

The objectives of the survey are:

To estimate the prevalence of acute malnutrition in children aged from 6 to 59 months in Chal and Rustaq districts, Takhar province;

To estimate the prevalence of chronic malnutrition in children aged from 6 to 59 months in Chal and Rustaq districts, Takhar province;

To estimate the prevalence of acute malnutrition in pregnant and lactating women from households included in the children anthropometric survey and the Infant and Young Child Feeding study, in Chal and Rustaq districts, Takhar province;

To estimate the measles vaccination coverage in children aged from 9 to 59 months in Chal and Rustaq districts, Takhar province;

To estimate the coverage of vitamin A supplementation for children aged from 6 to 59 months old in Chal and Rustaq districts, Takhar province;

To obtain quantitative data on Infant and Young Child Feeding (IYCF) practices using the WHO IYCF indicators 13 in Chal and Rustaq districts, Takhar province.

13 WHO. Indicators for Assessing Infant and Young Child Feeding Practices - 2007

15 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 3. METHODOLOGY

3.1. Sampling strategy: sampling design and sample size calculation A SMART ©14 multi-stage cluster sampling method was used for the anthropometric nutrition survey and IYCF practices study conducted in Chal and Rustaq districts, Takhar province. The sampling frame consisted of the total villages from Chal and Rustaq districts. The primary sampling unit is the cluster. The smallest administrative unit being the village, clusters always corresponded to villages. The basic sampling unit was the household. A household was defined as all people eating from the same pot (WFP definition).

Population figures for 2010-2011 were provided by the Censes Statistics Office, the data per districts are presented in table 1:

Table 1: Population figures, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 – Source: CSO 2010-2011

District Nber Villages Total pop Pop Male Pop Female Pop U5 Pop PLW Total HH 15 Chal 57 24,598 12,818 11,780 4,920 1,968 4,315 Rustaq 178 132,315 67,704 64,611 26,463 10,585 24,038 TOTAL 235 156,913 80,522 76,391 31,383 12,553 28,353

Overall, the population is sedentary in Takhar province, nevertheless, the migration of Kuchis people started from March-April 2011 after the winter season as mentioned in the paragraph above (Chapter 1.3 Population Data – Demography – page 10). This survey however, targeted the sedentary population rather than the nomadic population.

3.1.1 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 using a 10% global acute malnutrition prevalence estimation with a desired precision of 4% and a design effect equal to 2. The table below explains the reasoning behind the choice of parameters.

Table 2 : Calculation of sample size for Global Acute Malnutrition, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Parameters Value Justification Estimated 10 According to the MoPH National Nutrition Survey-2004, the Global Prevalence of Acute Malnutrition prevalence is estimated at 7% at country level. GAM (%) According to HMIS data for 2009-2010 provided by CAF, the GAM is estimated at 6% in Takhar province. The CAF statistics consider only people seeking treatment at health facilities level and so does not include active screening data collected at household level. The actual GAM was expected to be higher and was therefore estimated at 10%. ± Desired precision 4 For an expected GAM prevalence of 10%, a precision of ± 4% was (%) considered appropriate.

14 Standardized Monitoring and Assessment in Relief and Transition, see web site www.nutrisurvey.de/ena/ena.html 15 HH = Household

16 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Design Effect 2 Different ethnic groups live in the target areas with different cultural habits but similar access to food and social conditions. Access to health facilities can not be estimated as homogenous. The two districts are located quite far away from each other and have different geographical size and population density. Average HH Size 5.5 According to CSO population data 2010-2011. % Children under-5 20 According to the national nutrition policy. N° of children 6 – 59 0,99 The assumption made by ENA software is that children 6-59 months months per HH represent approximately 90% of the population U5. Average n° of children is then calculated taking into consideration average HH size and % of children U5. % Non-response 8 This percentage is based on the fact that due to cultural factors, Households most of the women are not allowed to welcome male strangers at household’s level when male head of households are away. By the presence of female surveyors among the nutrition survey teams, the risk of non-responders could be reduced, since female surveyors would be allowed to interview the women even during the absence of the men. Moreover, women were expected to be at home as their access to outside is limited. Still a certain amount of potential non- responders at the planning stage had to be taken into consideration. Number of children 6-59 months to be included (according to ENA) : 470 Number of households to be included (according to ENA): 517

The sample size for the estimation of the prevalence of chronic malnutrition was a minimum of 200 children and 219 households as presented in the table 3. Table 3 : Calculation of sample size for Chronic Malnutrition, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Estimated Children Average % of non % Households Survey prevalence Desired Design 6-59 to Household Response Children to be areas of chronic precision effect be size Households under five included malnutrition included Chal and Rustaq 60.5% 10% 2 5.5 8% 20% 200 219 districts

At the end of the field data collection, a total of 528 households were surveyed, 39 households did not have children of 6-59 months and 29 households had children of less than 6 months old. 705 children 6-59 months old were found in 460 households, giving an average of 1.34 children 6-59 months per household. This proportion was estimated at only 0.99 children 6-59 months per household at planning stage and according to ENA software and CSO statistics (Table 2 - section % Children Under 5).

If children were absent, the team returned later. Only 2 children 6-59 months were absent on second visit. By excluding these 2 children, the data analysis is done on 703 children, largely exceeding the minimum requirement of 470 children. Due to extreme values or potential incorrect measurements, 13 entries were taken out of the database for acute malnutrition, 27 out of the database for chronic malnutrition.

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 biases due to confusion.

17 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 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.

As for the estimation of the acute malnutrition prevalence, a total of 528 households were visited while 219 were required for the stunting prevalence estimation. A minimum of 200 children were expected to be surveyed for a total of 705 children at the end of the data field collection (including 2 absents).

For both estimations, only 2 children 6-59 months were absent out of 705, corresponding to only 0.28% out of the total sample while the Non-response household rate was fixed at 8% at planning stage. No family refused to take part to the study.

3.1.2 Sampling procedure and sample size for measles immunization coverage study: All children from 9 to 59 months old, included in the anthropometric nutrition survey were 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% 16 . The design effect of this outcome was fixed at 4%. It often happens that some villages are covered by immunization campaign while some others may have not been targeted. The desired precision was set at 10%. No official ratio of % 9-59 months old children in the U5 group was found, but according to the Anthropometric nutrition survey done in Day Kundi province by ACF in October 2010 with a similar methodology 17 , children from 9 to 59 months old represented 95% of the total sample of children 6-59 months, therefore this ration was used.: 0.95 x 0.99 = 0.94 children aged 9 to 59 months per household (that is: 0.94/5.5 = 0.171, or 17.1% of the total population). • Number of units needed from the target group/ ratio of target group per HH: n(HH) = 392/0.94= 396 households. • Apply the Non-response rate (8%, or 0.08): n final = 396/(1-0.08) =431 households Hence, the minimum to reach was fixed at 431 households to survey to find 372 children aged 9 to 59 months. At the end of the data field collection 567 children 9 to 59 months were surveyed, largely reaching the required sample size.

3.1.3 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 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 in addition to the polio vaccine. The desired precision 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 330 households.

16 Afghanistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan 17 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 Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 3.1.4 Sampling procedure and sample size for anthropometric data – Pregnant – Lactating women In the households selected by the anthropometric survey, following pregnant and lactating women were to be included in 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. • All lactating women with children 0-5 months included in the IYCF study; No minimum required sample size was calculated for this result. The goal was to collect data about the nutrition status of pregnant-lactating women more for project design than for nutrition surveillance. At the end of the field data collection, 84 pregnant women with children 6-59 months old and 88 lactating women breastfeeding an infant less than 6 months old (3 mothers were absent at the time of the survey), were found at household level, for a total of 172 women screened by MUAC. No pregnant women with children 0-5 months were found during the data collection. The number of women surveyed to estimate the nutritional risk among pregnant/lactating women is low. Hence results presented further in this report have to be considered with caution.

3.1.5 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. Infants less than 6 months found at those households, although excluded from the anthropometric nutrition survey were included in the IYCF questionnaire. No minimum sample size was calculated. The goal was to collect data about IYCF practices for project design rather than for nutrition surveillance. Taking into consideration the limit of this study, the lack of precision for the IYCF indicators should be acknowledged and results interpreted with caution. At the end of the data collection, 93 infants less than 6 months and 241 children 6-23 months old were found at household level, making a total of 334 children included in the IYCF study.

3.2. 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. It was estimated that teams could survey 16 households per day, creating the need for 33 clusters. Out of 235 villages, 33 villages, corresponding to 33 clusters were included (See annex 3). 4 Reserve Clusters (RCs) were selected to be used only if 10% or more clusters were impossible to reach during the survey. No reserve cluster was used as all 33 pre-selected clusters could be reached. 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 area to be surveyed and other segments were ignored (Annex 4). 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 ‘3.3 Selection of households and children’ part 3.3.3 “Segmentation”. 17 clusters/villages were segmented by applying this methodology.

19 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 3.3. Final stage sampling: Selection of households and children

3.3.1. Household selection A representative sampling method was chosen as the population size was too big for an exhaustive survey. Subjects must be selected at random to ensure the representativeness of the overall target population. 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. Population data per village was provided by the community leaders, which is more accurate than CSO data on village level. From this map, the systematic random sampling method was used for the selection of households to survey.

3.3.2. Final stage selection by using the systematic random sampling method A 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 Chal and Rustaq districts, Takhar province, 17 clusters corresponding to 17 villages were segmented following the methodology further described. 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. The following steps were respected and a household selection sheet was completed in order to ensure the respect of this methodology (Annex 5): 1. The “sampling interval” was determined by dividing the total number of households in the cluster by the number that must be visited (16 households). The sampling interval was rounded to the nearest whole number. 2. The first household was randomly selected by drawing a random start number between 1 and the sampling interval, using a random table. 3. The next household to be visited was found by adding the sampling interval to the first house selected. The team counted the houses along their way while walking in the village and selected the households to survey according to the sampling interval. They repeated the same methodology for each following house. 4. All children in each selected house were measured and their measurements were recorded on the datasheet. 5. All required questionnaires were completed for each household. 6. This process was followed up until reaching the required number of households to survey.

3.3.3. 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 16 households. The villages were divided according to: • Existing administrative sub-divisions. • Natural barriers: river, road, mountain, etc. • Public places: market, schools, mosques,etc.

20 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 The segmentation was done into: • Equal parts: when the area could be divided into parts of roughly equal size. One segment was randomly selected using a random number table giving an equal chance to all households. • 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. One segment was randomly selected using the Probability Proportional to Population Size (PPS) method giving an equal chance to all households to be selected.

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.

3.3.4. Selection of children All children from 6 to 59 months old or if the age was not available height >= 65 cm and < 110 cm in the selected households 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 was not present at the time of the survey, he/she was recorded on the data sheet. The team returned to those households at the end of the day. If the child was still absent, he/she was not replaced.
If a house was empty, the team returned at the end of the day. If it was not possible to return for any reason or was still empty upon return, the house was not substituted by another one. In case of refusal from the parents to include their child in the survey, he/she was not replaced.
Orphan children taken in charge by a family are considered as part of the family and were included in the survey. It was similar for children who are under permanent care of their grandparents or relatives.
Disabled children are eligible and were included whenever possible. If it was not possible to measure their height, weight or MUAC due to deformity or other abnormality, they were given an ID number and whatever data available was recorded.
If a house contained different households (people eating from the same pot), each household was surveyed and registered separately
If several families are part of the same household, all children included in these families were surveyed.
In a compound with several households, each household should be included separately in the list for household selection.
In the households selected for the anthropometric nutrition survey, MUAC was measured for all pregnant women with children 0-59 months old and for all lactating women with children 0- 5 months old.

21 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 3.4. Data collected and measurement techniques

3.4.1. Anthropometric questionnaire for children 6-59 months and pregnant women with children 6-59 months old (Annex 6) 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 parameters 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 were included in the sample. If age was not available, height >= 65 cm and < 110 cm was used as a proxy for age. 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 Takhar province (Annex 7) helped to determine the age. The age was recorded into the questionnaire in months. 2. Sex: M=male and F=female 3. Weight (in kg): Children were weighed to the nearest 0.1 kg by using an Electronic Uniscale. The children who could easily stand were asked to stand on the weighing scale. In a situation when the children could not stand up, the double weighing method was applied. For cultural reasons, it was not possible to weigh children naked. Therefore, a minimum of clothes was accepted, and the weight was corrected by reducing it with 100g to compensate for clothing during data entry, based on the estimated average weight of the most commonly worn outfit (t-shirts and pants). 4. Height (in cm): Measuring boards were used to measure bare headed and barefooted children. The precision of the measurement was 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. MUAC was measured on the left arm, at the mid-point between the elbow and the shoulder. The muscle’s arm should be relaxed. A special measuring tape is placed around the arm. The measurement is read in a window without tightening the tape too much. 6. Oedema: Only children with bilateral pitting nutritional oedema were recorded as having nutritional oedema (corresponding to Kwashiorkor case). In order to determine the presence of oedema, normal thumb pressure is applied to the both feet for three seconds. If a shallow print persists on the both feet, then the child presents nutritional oedema. Record was made as follows: Y= Yes; N= No 7. Measles immunization status For children from 9 to 59 months old, the mother/caretaker was asked if the child had been immunized against measles or not, and if there is a vaccination card to prove it. The analysis excludes children less than 9 months as immunization of measles according to the international protocol is only done from age 9 months onwards. 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/caretaker said that the child has not been immunized ‘N’ was recorded. If the mother/caretaker did not know "DK" was recorded.

22 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 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/caretaker to facilitate the understanding. The record was done as follows: Y = Yes; N= No; DK=Does not know 9. MUAC for Pregnant women with children 6-59 months old: The MUAC for all pregnant women having children between 6-59 months old included in the anthropometric nutrition survey was measured. The pregnancy was checked by asking a pregnancy certificate to women. Nevertheless, MUAC was measured for women obviously pregnant despite the absence of medical certificate. MUAC was recorded in millimetres on the anthropometric questionnaire sheet. Note: In case a women having a child 6-59 months is pregnant and is as well breastfeeding an infant 0-5 months, her MUAC was recorded in the IYCF questionnaire sheet under ‘lactating category’.

3.4.2. IYCF practices questionnaire for children 0-23months old (Annex 8 and Annex 9) All children from 6 to 23 months old included in the anthropometric nutrition survey were included in the IYCF questionnaire. In addition infants less than 6 months old, found at household level were equal included in the IYCF questionnaire. The IYCF questionnaire is based on the WHO guidelines 18 . Additional indicators were incorporated to the questionnaire to enable deeper analysis.

3.4.3. MUAC for Lactating 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) was measured. MUAC was recorded in millimetres on the IYCF questionnaire sheet.

3.5. Definition of nutritional status of children 6-59 months:

3.5.1. Acute malnutrition in children 6-59 months:

3.5.1.1. Wasting in children 6-59 months: Wasting in children 6-59 months can be expressed by using 2 indexes; 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 19 ). The weight-for-height index of a child from the studied population is expressed as a Z-score according to WHO standards as it is considered to be more reliable in terms of statistical theory.

18 WHO. Indicators for Assessing Infant and Young Child Feeding Practices - 2007 19 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

23 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 During the 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.

Mid Upper Arm Circumference (MUAC) The mid upper arm circumference is an indicator of risk of mortality by malnutrition and does not need to be related to any other anthropometric measurement. It 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 4: 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

3.5.1.2. 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 or MUAC.

3.5.1.3. 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 5: Definition of acute malnutrition 20 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 (MAM) 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

3.5.2. Chronic malnutrition in children 6-59 months: The height-for-age index (H/A) indicates if a child of a given age is stunted (growth retardation) 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:

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

24 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 6: 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

3.5.3. Nutritional risk 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 7: Cut offs points of the MUAC – Pregnant /Lactating women, Sphere standards 2011 Target group MUAC (mm) Nutritional status > or = 230 No risk Pregnant/lactating women > or = 210 and < 230 Moderate risk < 210 Severe risk

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

By this study, the following 8 core indicators for IYCF study were expected to be assessed: 1. Early initiation of breastfeeding: Proportion of children born in the last 23 months who were put to the breast within one hour of birth. 2. Exclusive breastfeeding under 6 months : Proportion of infants 0-5 months of age who are fed exclusively with breast milk. 3. Continued breastfeeding at 1 year: Proportion of children 12 – 15 months of age who are fed breast milk. 4. Introduction of solid, semi-solid or soft foods: Proportion of infants 6-8 months of age who receive solid, semi-solid or soft foods. 5. Minimum dietary diversity: Proportion of children 6-23 months of age who receive foods from 4 or more food groups (Children 6-23 months of age who received foods from 4 different food groups during the previous day out of total Children 6-23 months of age). The 7 foods groups used for tabulation of this indicator are:
grains, roots and tubers
legumes and nuts
dairy products (milk, yogurt, cheese)
flesh foods (meat, fish, poultry and liver/organ meats)
eggs
vitamin-A rich fruits and vegetables
other fruits and vegetables 6. Minimum meal frequency: Proportion of breastfed and non-breastfed children 6-23 months of age who receive solid, semi-solid, or soft foods (but also including milk feeds for non breastfed children) the minimum number of times or more Note: Minimum is defined as:


2 times for breastfed infants 6-8 months


3 times for breastfed children 9 -23 months


4 times for non-breastfed children 6-23 months "Meals” include both meals and snacks (other than trivial amounts), and frequency is based on caregiver report.

25 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 7. Minimum acceptable diet: Proportion of children 6-23 months of age who receive a minimum acceptable diet 21 (apart from breast milk). 8. Consumption of iron-rich or iron-fortified foods: Proportion of children 6-23 months of age who receive an iron-rich food or iron-fortified food that is specially designed for infants and young children, or that is fortified in the home.

The following 2 additional indicators for IYCF study were expected to be assessed: 9. Child ever breastfed: Proportion of children born in the last 24 months who were ever breastfed 10. Continued breastfeeding at 2 years: Proportion of children 20–23 months of age who are fed breast milk

Due to problems during data collection, it was not possible to calculate all indicators as expected. A number of them were excluded from the results, so as to safeguard quality as much as possible. Still, due to the low sample size, any results of IYCF indicators must be interpreted with caution.

3.7. Training and supervision Four teams of four members conducted the data collection in Takhar province. Each team was composed of one ACF team leader, one CAF facilitator and two data collectors. In total, 8 ACF team members and 9 CAF team members participated in the project. Each team had at least one female data collector to ensure acceptance of the team amongst the surveyed households. 4 marhams, male relatives of the female staff, 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. The teams were supervised by ACF and CAF nutrition program manager/nutrition focal point on a daily basis. Due to security constraints, ACF Health-Nutrition coordinator could not supervise the field work. The entire team received a 5-days training on the survey methodology and all its practical aspects. The session was managed by ACF Nutrition Program Manager. A standardization test was conducted on the third day in order to evaluate the accuracy and the precision of the team members in taking the anthropometrics measurements. Unfortunately, this test was only done partially and results could not be analyzed. Only 5 children fully participated in the test while 10 are required as minimum for interpreting results. Few caretakers were willing to take part in the exercise and the ones who came left without completing the test, mainly for personal reasons. A field test was conducted by the team in Takhar province on the fourth day, in order to evaluate their work in real field conditions. Feed back on the results was provided to the team. Refresher training on the anthropometric measurement as well as on the filling of the questionnaires and the household’s selection was organized on the last day. 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 in Dari, local language, for better understanding and to avoid direct translation during the data collection. The questionnaires were already used while conducting 2 other anthropometric nutrition surveys in the country in 2011. Hence, they were pre-tested and their quality was ensured.

21 Breastfed children who received at least the minimum dietary diversity and the minimum meal frequency during the previous day and non-breastfed children who received at least 2 milk feedings and the minimum dietary diversity (not including milk feeds) and the minimum meal frequency during the previous day

26 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Refresher training sessions were organized during the data collection. Indeed, analysis of the data collected was done on a daily basis using ENA plausibility check and other evaluation tools. Refresh trainings were organized accordingly when required.

3.8. 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 or the measles immunization coverage were analysed using Excel version 2005 and are expressed in percentage out of the sample surveyed. The IYCF data were analyzed by using EPI Info Software – Version 2008 and Excel version 2005.

27 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 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 10.

4.1. Nutritional status of children 6-59 months (according to WHO standards 2006)

4.1.1. Age and sex distribution of the targeted population

Table 8: Distribution of age and sex of sample, n=703, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Age groups Boys Girls Total Ratio No. % No. % No. % Boy:girl 6-11 months 59 68.6 27 31.4 86 12.2 2.2 12-23 months 94 57.0 71 43.0 165 23.5 1.3 24-35 months 89 49.4 91 50.6 180 25.6 1.0 36-47 months 80 54.4 67 45.6 147 20.9 1.2 48-59 months 66 52.8 59 47.2 125 17.8 1.1 Total 388 55.2 315 44.8 703 100.0 1.2

Boys are more represented than girls corresponding to 55.2% of the total population surveyed. The sex ratio is still acceptable being of 1.2, which validates the representativeness of the sample in terms of sex representation. Nevertheless, according to plausibility check, the overall sex ratio: p = 0.006 indicates a significant excess of boys. Boys are particularly more represented compared to girls for the age category 6-11 months (Sex ratio = 2.2). Overall, men are more represented than female in the target population as shown in the table 1 Population figures. . Figure 1 : Distribution per age of children surveyed, n=703, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

Distribution per age of children surveyed, n= 703, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

30 25.6 23.5 25 20.9 20 17.8

15 12.2 10 Percentage 5 0 6-11 months 12-23 months 24-35 months 36-47 months 48-59 months

Age group

The age distribution is well balanced, except for the age group 6-11 months which looks under represented (only 12.2% out of the total population surveyed – 86 out of 703). However, this age group only covers a period of 6 months while the other age groups cover 12 months.

28 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 4.1.2. Anthropometric results: children (based on WHO standards 2006)

4.1.2.1. Acute malnutrition prevalence according to Weight for Height index The analysis of the malnutrition prevalence based on weight for height index according to WHO standards is done with a sample of 690 children out of the 703 children surveyed, 13 children being excluded as their data have been flagged by the SMART flagging system 22 . Children were weighed with clothes for cultural reasons, as correction, 100 grams were subtracted for each weight measurement in ENA software.

Table 9: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) according to WHO standards, n=690, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Prevalence of Acute malnutrition All Z-score 95% CI According to WHO standards N = 690 Prevalence of global acute malnutrition N = 72 10.4 % (7.9 – 13.7 95% C.I.) (<-2 z-score and/or oedema) Prevalence of moderate acute malnutrition N = 58 8.4 % (6.0 – 11.7 95% C.I.) (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe acute malnutrition N = 14 2.0 % (1.0 – 3.9 95% C.I.) (<-3 z-score and/or oedema)

The Global Acute Malnutrition (GAM) rate is not alarming but reasonably high in Chal and Rustaq districts, Takhar province. This rate is inferior to the emergency threshold of 15% determined by the WHO Expert Committee classification for wasting23 , but still classified as a “risky situation”. According to the MoPH National Nutrition Survey-2004, the Global Acute Malnutrition prevalence was estimated at 7% at country level at that time. Moreover, according to HMIS screening data for 2009-2010 provided by CAF, the GAM among people seeking treatment in health facilities (therefore not representative) was estimated at 6% in Takhar province.

Table 10: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex, WHO standards, n=690, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Prevalence of acute malnutrition All Boys Girls WHO standards n = 690 n = 377 N = 313 (72) 10.4 % (44) 11.7 % (28) 8.9 % Prevalence of global malnutrition (7.9 - 13.7 95% (8.0 - 16.7 95% (6.3 - 12.5 95% (<-2 z-score and/or oedema) C.I.) C.I.) C.I.) (58) 8.4 % (34) 9.0 % (24) 7.7 % Prevalence of moderate malnutrition (6.0 - 11.7 95% (5.7 - 13.9 95% (5.1 - 11.4 95% (<-2 z-score and >=-3 z-score, no oedema) C.I.) C.I.) C.I.) (14) 2.0 % (10) 2.7 % (4) 1.3 % Prevalence of severe malnutrition (1.0 - 3.9 95% (1.3 - 5.5 95% (0.5 - 3.4 95% (<-3 z-score and/or oedema) C.I.) C.I.) C.I.) The prevalence of oedema is 0.1 %.

The difference in prevalence of acute malnutrition between boys and girls is not statistically significant as the confidence intervals are overlapping and the P value > 0.05.

22 SMART flags being considered (+/- 3SD from the observed mean) 23 WHO 1995: percentage of children with weight-for-height <-2 z-score >= 15% is critical

29 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 11: Distribution of acute malnutrition and oedema based on weight-for-height z-scores, WHO standards, n=690, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 <-3 z-score >=-3 z-score Marasmic kwashiorkor Kwashiorkor Oedema present No. 0 (0.0 %) No. 1 (0.1 %) Marasmic Not severely malnourished Oedema absent No. 13 (1.9 %) No. 676 (98.0 %)

Only 1 case of bilateral nutritional pitting oedema was reported on the field and was cross checked by the supervisor team.

Table 12: Prevalence of acute malnutrition by age based on weight-for-height z-scores and/or oedema, WHO standards, n=690, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Moderate wasting Age Severe wasting Normal Total (>= -3 and <-2 z- Oedema groups (<-3 z-score) (> = -2 z score) score ) Mths No. No. % No. % No. % No. % 6-11 80 3 3.8 9 11.3 68 85.0 0 0.0 12-23 159 6 3.8 28 17.6 124 78.0 1 0.6 24-35 180 4 2.2 8 4.4 168 93.3 0 0.0 36-47 147 0 0.0 5 3.4 142 96.6 0 0.0 48-59 124 0 0.0 8 6.5 116 93.5 0 0.0 Total 690 13 1.9 58 8.4 618 89.6 1 0.1

Children 6-23 are more vulnerable to acute malnutrition than older children (Relative risk =3.61 (2.28

Curve 1: Distribution of weight-for-height z-scores vs. reference, WHO standards, n=689, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

The distribution of the weight for height index expressed in Z-score in comparison to the reference curve is slightly shifted to the left meaning that the surveyed children do have a relative weight for height deficit compared to the reference population. The mean ±SD of WHZ (n=689) is -0,52±1.10. The design effect is 1.48 showing the non - homogeneity of the population.

30 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 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 685 children with a height >= 65 cm out of the 703 children surveyed and is presented in the table below. Due to poor quality of the MUAC measurements according to the plausibility check (Score = 15, not acceptable digit preference), the results presented according to MUAC criterion should be considered with caution.

Table 13: Prevalence of acute malnutrition based on MUAC criterion according to WHO standards, n=685, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Prevalence of Acute malnutrition All % 95% CI According to MUAC criterion and WHO standards N = 685 Prevalence of global malnutrition N = 48 7.0 % ( 5.0 - 9.7 95% CI) MUAC < 125mm Prevalence of moderate malnutrition N = 36 5.3 % (3.6 – 7.7 95% C.I.) MUAC >=115 <125mm Prevalence of severe malnutrition N = 12 1.8 % ( 1.0- 2.9 95% CI) MUAC < 115mm

The prevalence of acute malnutrition according to MUAC criterion is not alarming but remains of concern.

Table 14: Prevalence of acute malnutrition based on MUAC criterion and by sex, WHO standards, n=685, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Prevalence of acute malnutrition All Boys Girls MUAC criterion – WHO standards n = 685 N = 379 n = 306 Prevalence of global malnutrition ( 48) 7.0% ( 27) 7.1% ( 21) 6.9% MUAC < 125mm ( 5.0- 9.7 95% CI) ( 4.6-10.9 95% CI) ( 4.2-11.1 95% CI) Prevalence of moderate malnutrition ( 36) 5.3% ( 22) 5.8% ( 3.4- ( 14) 4.6% MUAC >=115 <125mm ( 3.6- 7.7 95% CI) 9.7 95% CI) ( 2.5- 8.1 95% CI) Prevalence of severe malnutrition ( 12) 1.8% ( 5) 1.3% ( 7) 2.3% MUAC < 115mm ( 1.0- 2.9 95% CI) ( 0.6- 3.0 95% CI) ( 1.0- 5.1 95% CI) % of oedema (n=1) : 0.1%

Difference between boys and girls is not statistically significant as confidence intervals are overlapping and the P value > 0.05.

31 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 15: Prevalence of acute malnutrition according to Mid Upper Arm Circumference (MUAC) classification and age groups, WHO standards, n=685, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

Age Total MUAC < 115 mm MUAC >= 115 < 125 mm MUAC >= 125 mm groups N N % N % N % 6-11 0.0% 10.3% 89.7% 68 0 7 61 months ( 0.0- 0.0 95% CI) ( 4.6-21.3 95% CI) (78.7-95.4 95% CI) 12-23 5.5% 15.2% 79.4% 165 9 25 131 months ( 3.0- 9.9 95% CI) (10.5-21.4 95% CI) (71.8-85.4 95% CI) 24-35 1.1% 1.1% 97.8% 180 2 2 176 months ( 0.3- 4.5 95% CI) ( 0.3- 4.5 95% CI) (94.3-99.2 95% CI) 36-47 0.7% 1.4% 98.0% 147 1 2 144 months ( 0.1- 4.9 95% CI) ( 0.2- 9.7 95% CI) (91.5-99.5 95% CI) 48-59 0.0% 0.0% 100.0% 125 0 0 125 months ( 0.0- 0.0 95% CI) ( 0.0- 0.0 95% CI) ( 0.0- 0.0 95% CI) ( 36) 5.3% 1.8% Total 685 36 12 - ( 3.6- 7.7 95% CI) ( 1.0- 2.9 95% CI)

Children 6 to 23 months are clearly more subject to acute malnutrition than older children according to MUAC criterion (Relative risk =11.36 (5.18

Table 16: Prevalence of acute malnutrition according to Mid Upper Arm Circumference (MUAC) classification using height cut off, WHO standards, n=685, Chal and Rustaq districts, Takhar province, Afghanistan, June 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 10 6.0% 2 0.5% 0 0.0% 12 1.8% ≥115- <125 Moderate malnutrition 27 16.3% 9 2.2% 0 0.0% 36 5.3% ≥125 No malnutrition 129 77.7% 397 97.3% 111 100.0% 637 93.0% Total 166 100% 408 100% 111 100% 685 100%

The group of children with a height equal or more than 65cm and less than 75cm is considered as the most vulnerable (relative risk =10.52 (5.49

4.1.2.3. Chronic malnutrition prevalence according to Height for Age index The analysis of the chronic malnutrition prevalence based on height for age index according to WHO standards is done with a sample of 676 children out of the 703 children surveyed, 27 children being excluded due to plausibility check 24 . The plausibility checks of height measurement showed some digit preferences, however the score was still judged as “acceptable”.

24 Extreme values flagged by Ena Sofware ( considering SMARt flags (+/-3SD from the observed mean))

32 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 17: Prevalence of chronic malnutrition based on height-for-age z-scores according to WHO standards, n=676, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Prevalence of Chronic malnutrition All Z-score 95% CI According to WHO standards N = 676 Prevalence of stunting N = 365 54.0% (48.5 – 59.4 95% C.I.) (<-2 z-score and >=-3 z-score) Prevalence of moderate stunting N = 219 32.4% (28.6 – 36.4 95% C.I.) (<-2 z-score and >=-3 z-score) Prevalence of severe stunting N = 146 21.6% (18.1 – 25.6 95% C.I.) (<-3 z-score)

The chronic malnutrition rate is very high. The prevalence of severe stunting is particularly of concern. At planning stage and according to the National Nutrition survey conducted by the MoPH in 2004, the stunting rate was estimated at 60.5% in Takhar province corresponding to the rate found at country level. The prevalence raised by this survey is lower than the expected one, but still remains very high.

Table 18: Prevalence of chronic malnutrition based on height-for-age z-scores and by sex, WHO standards, n=676, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Prevalence of Chronic malnutrition All Boys Girls According to WHO standards N =676 N = 376 N = 300 (365) 54.0 % (193) 51.3 % (172) 57.3 % Prevalence of stunting (48.5 - 59.4 95% (43.7 - 58.9 95% (50.1 - 64.2 95% (<-2 z-score) C.I.) C.I.) C.I.) (219) 32.4 % (111) 29.5 % (108) 36.0 % Prevalence of moderate stunting (28.6 - 36.4 95% (24.7 - 34.9 95% (28.6 - 44.2 95% (<-2 z-score and >=-3 z-score) C.I.) C.I.) C.I.) (146) 21.6 % (82) 21.8 % (64) 21.3 % Prevalence of severe stunting (18.1 - 25.6 95% (16.9 - 27.6 95% (16.4 - 27.2 95% (<-3 z-score) C.I.) C.I.) C.I.)

There is no difference between the nutritional status of boys and girls with regards to stunting prevalence (P Value >0.05).

Table 19 : Prevalence of chronic malnutrition based on height-for-age z-scores according to age groups, WHO standards, n=676, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Age Severe stunting Moderate stunting Normal groups in (<-3 z-score) (>= -3 and <-2 z-score ) (> = -2 z score) Total mths N % N % N %

6-11 81 8 9.9 12 14.8 61 75.3 12-23 159 31 19.5 46 28.9 82 51.6 24-35 172 51 29.7 58 33.7 63 36.6 36-47 140 37 26.4 54 38.6 49 35.0 48-59 124 19 15.3 49 39.5 56 45.2 Total 676 146 21.6 219 32.4 311 46.0

Children from 24 to 59 months are more at risk of chronic malnutrition than younger children (relative risk=0.66 (0.55

33 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Curve 2: Distribution of height-for-age z-scores vs. reference, WHO standards, n=676, Chal and Rustaq districts, Takhar province, Afghanistan, June 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=676) equals -2.05±1.21. The design effect is 1.95 reflecting the non - homogeneity of the population which was forecasted. It is important 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. According to the plausibility check, the overall score for the age distribution was 2 and is considered good.

4.2. Anthropometric results: Pregnant/Lactating women (based on MUAC criterion) 84 pregnant women and 88 lactating women breastfeeding an infant less than 6 months old were found at household level, for a total of 172 women screened by MUAC. Due to sampling issues (not randomly chosen), results are presented in percentage of the women screened. Moreover, the results have to be interpreted with caution as the sample size is not representative. Out of 172, 30 (17.4%) women were at risk of malnutrition, with 5 women with severe risk (2.9%) and 25 women with moderate risk (14.5%). No difference can be noted between the nutritional status of pregnant versus lactating women (P value = 0.541)

34 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 20: Prevalence of nutritional risk amongst pregnant/lactating women based on MUAC criterion according to SPHERE standards, n=172, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

MUAC Nutritional Risk Pregnant women Lactating women TOTAL in mm Sphere Standards N % N % N % <210 Severe risk 2 2.4% 3 3.4% 5 2.9% ≥210 - <230 Moderate risk 13 15.5% 12 13.6% 25 14.5% ≥230 No risk 69 82.1% 73 83.0% 142 82.6% Total 84 100% 88 100% 172 100%

4.3. Measles vaccination coverage Only children from 9 to 59 months old are included in the analysis in line with the international vaccination protocol. The analysis of the measles vaccination coverage is done with a sample of 669 children out of the 703 children surveyed as 34 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.

Table 21: Measles vaccination coverage for children equal or more than 9 months old, n = 669, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 All Measles vaccination coverage N (669) N % Confirmed with immunization card 407 60.8% Confirmed verbally by the caregiver but no immunization card to prove it 176 26.3% No immunization according to the caregiver 36 5.4% Unknown 50 7.5% Total 669 100%

In any case, 60.8% of the children surveyed (407 out of 669 children surveyed) were vaccinated against measles, with the immunization card shown as proof, while only 5.4% (36 out of 669) were not vaccinated. The coverage of confirmed measles vaccination is low compared to the SPHERE standards of 90% 25 . 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 9-59months, the measles immunization coverage as found in this survey is close to the one published by the MoPH in 2006 and remains below the SPHERE standard.

4.4. Vitamin A supplementation coverage The sample used for the analysis of the Vitamin A supplementation coverage within the last 6 months is all children included in the anthropometric nutrition survey, 703 children. The results are presented in the table below.

25 The Sphere_Project_Handbook_2011 26 Afghanistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan

35 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 22: Vitamin A supplementation coverage within the last 6 months, n = 703, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

All Vitamin A supplementation coverage N (703) within the last 6 months N % Vitamin A dose received 648 92.2% Vitamin A dose not received 21 3.0% Unknown 34 4.8% Total 703 100%

The Vitamin A supplementation coverage within the last 6 months is of 92.2% (648 children out of 703) and is superior to the threshold of 90% according to the SPHERE standard 16 . Routine Vitamin A distribution campaigns are regularly ensured by the MoPH at provincial level. 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 found in this study is even higher than the one published by the MoPH about 5 years ago.

4.5. IYCF study In the households selection for the anthropometric nutrition survey, all children from 6 to 23 months old as well as infants less than 6 months were included in the IYCF study. At the end of the data collection, 93 infants less than 6 months and 241 children 6-23 months were found in the households visited for a total sample of 334 children 0-23 months.

Table 23: Children ever breastfed, n=334, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Child ever breastfed N (334) % 95% CI Yes 330 98.8% (96.8 – 99.6) No 4 1.2% (0.4 – 3.2) TOTAL 334 100% -

Out of 334 surveyed children, 330 were breastfed at least once in their life, representing 98.8% (96.8 – 99.6 CI). Only 1.2% (4 children out of 334) (0.4 – 3.2 CI) have never been breastfed. Women who never breastfed their children were asked the reason for not breastfeeding. The table below shows the reasons given by those 4 responders. Since the sample size is very small (n=4), these results are not representative merely indicative.

Table 24: Reasons for not breastfeeding, n=4, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Reason for no-breastfeeding N (4) % Breast milk not good for the child 0 - Pain 0 - No breast milk coming out of the breast 3 75% Refusal of the child to be breastfed 1 25% Child sick 0 - Mother/caretaker sick 0 - Advice of family members 0 - TOTAL 4 100%

36 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011

The following result is based on the sample of children who were ever breastfed (330 children). The mothers were asked how soon after birth they put their children to the breast.

Table 25: Early initiation of breastfeeding after birth, n=330, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Early initiation of breastfeeding after birth N (330) % 95% CI First hour of life 221 67% (61.6 – 72.0) Less than 24 hours after delivery 86 26.1% (21.5 – 31.2) More than 24 hours after delivery 20 6.1% (3.8 – 9.4) Does not know 3 0.9% 0.20 – 2.9 TOTAL 330 100% -

Whereas the majority of children was put to the breast within the first hour life, a significant amount of children were only put to the breast after one hour or even after more than 24 hours. The early initiation of breastfeeding can significantly improve the infants chances of survival as well as contribute to successful breastfeeding later on.

The caretakers were asked if they gave the colostrum and other foods/liquids to their infants during the 3 first days of life. The results are presented in the table below.

Table 26: Administration of colostrum to breastfed children, n=330, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Colostrum given during the 3 first days after delivery N (330) % 95% CI Yes 304 92.1% (88.5 – 94.7) No 19 5.8% (3.6 – 9.0) Does not know 7 2.1% (0.9 – 4.5) TOTAL 330 100% -

Giving colostrum does not only provide the infant with adequate nutrition and fluid, according to its needs, it also gives the infant protection against diseases and is very important for adequate milk production and successful breastfeeding later on. It is therefore good to see that the vast majority of children receive it. Efforts must still be made to ensure that all women give colostrum.

Table 27: Introduction of other liquids/foods during the 3 first days of life to breastfed children, n=330, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Introduction of other liquids/foods during the 3 first days of life N (330) % 95% CI Yes 41 12.4% (9.2 - 16.6) No 298 87.6% (83.5 – 90.9) Does not know 0 - - TOTAL 330 100% -

Even though the majority of children did not receive other fluids or liquids in the first three days, a significant amount of children did, whereas this can be a source of infection, interfere with milk production and compromise the infant’s colostrum intake. Caretakers of the 41 children who received liquids/foods as reported in the table above as well as to the 4 caretakers who never breastfed their children were asked what type of food was given during the first three days.

37 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 28: Type of other liquids/foods to not (exclusively) breastfed infants during the 3 first days of life, n=45, Chal and Rustaq districts, Takhar province, Afghanistan, June 201

Liquids/foods given the 3 first days of life after birth Total % Plain water 2 4.4% Sugar water or glucose water 23 51.1% Powdered or fresh animal milk 12 26.7% Infant fomula (Biomil 1 or 2, Mini 1 or 2, Lailac 1 or 2, Lactogen 1 or 2, Man Ma, Morinaga BF infant formula 0 0.0% Does not know 4 8.9% Others 4 8.9% Tea 3 6.7% Dates 1 2.2% Total answers 45 100%

Table 28 shows it is most common to give glucose water to the child. Any type of water, if not safe, can be a source of infection, especially for such an young infant. Quite worrying is that more than a quarter of these children received powdered or fresh animal milk. Infants cannot digest full cow’s or other animals’ milk. Giving it at that age can trigger symptoms of intolerance or allergy, including diarrhoea and abdominal pain.

The 330 caretakers who ever breastfed their infants were asked if they were still giving the breast to their infants at the time of the survey.

Table 29: Currently breastfeeding, n=330, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Currently breastfeeding N (330) % 95% CI Yes 303 91.8% (88.3 – 94.5) No 27 8.2% (5.6 – 11.8) Does not know 0 - - TOTAL 330 100% -

Out of 330 children ever breastfed the majority of mothers were still breastfeeding their children at the time of the survey. Results related to continued breastfeeding according to age categories are presented in the table below.

Table 30: Currently breastfeeding per age category, n=330, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Yes No Currently breastfeeding % % TOTAL N N Infants less than 6 mths 91 100.0% 0 0.0% 91 Children 6-11 mths 81 97.6% 2 2.4% 83 Children 12-17 mths 74 94.9% 4 5.1% 78 Children 18-23 mths 57 73.1% 21 26.9% 78 TOTAL 303 91.8% 27 8.2% 330

Table 30 shows that whereas all children below 6 months were still breastfeeding, from 6 months onwards the proportion of breastfed children reduced gradually with age. Still, this shows relative satisfactory breastfeeding rates among the target population, even for older children. However,

38 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 this question does not reveal whether breastfeeding is exclusive or not in the first 6 months, neither the proportion of breast milk in the diet of older children.

Additional questions were asked to the 27 caretakers who stopped breastfeeding their children. Indeed, the duration of the breastfeeding, the reasons and way of cessation were asked and reported below. All results considering non-lactating women have to be interpreted with caution due to the low sample size (n=27).

Table 31: Duration of breastfeeding, n=27, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Duration of breastfeeding N (27) % 95% CI Less than 3 months 1 3.7% (0.1 – 19.0) Between 3 and 5 months 3 11.1% (2.4 – 29.2) Between 6 and 11 months 6 22.2% (8.6 – 42.3) Between 12 and 23 months 17 63.0% (42.4 – 80.6) Does not know 0 - - TOTAL 27 100% -

Most of the caretakers breastfed their children for more than a year or more than 6 months, yet it would still have been advisable to continue until the child was 2 years old or older. However, 14.8% of those interviewed stopped breastfeeding before the age of 6 months, which puts these infants at a significant higher risk of disease, malnutrition and death.

Table 32: Reasons for cessation of breastfeeding, n = 27, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Reasons for cessation of breastfeeding N (27) % 95% CI Child too old 7 25.9% 11.1 - 46.3 Pain 2 7.4% 0.9 – 24.3 No enough milk 7 25.9% 11.1 – 46.3 New pregnancy 10 37.0% 19.4 – 57.6 Refusal of the child to be breastfed 0 - - Child sick 0 - - Mother/caretaker sick 0 - - Advice of family members 0 - - Does not know 1 3.7% 0.10 – 19.0 TOTAL 27 100% 0

Most of the interviewees stopped breastfeeding because of a new pregnancy as it is a traditional belief that breastfeeding can harm the foetus; whereas this is not the case. A quarter of the responders stopped because they believed they did not produce enough milk. Breastfeeding counselling by peers or by professionals, could have helped those women to increase their breastmilk production or have confidence in their ability to breastfeed so they could have continued breastfeeding. Another quarter stopped because they believed the child was old enough, indicating the need for more IYCF education in these communities.

39 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Table 33: Way of cessation of breastfeeding, n=27, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Way of cessation of breastfeeding N (27) % 95% CI Abruptly 18 66.7% 46.0 – 83.5 Progressively 8 29.6% 13.8 – 50.2 Does not know 1 3.7% 0.10 – 19.0 TOTAL 27 100% -

It is alarming to see that the majority of the interviewees stopped breastfeeding their children abruptly, meaning that they did not introduce other foods progressively in the daily feeding of their children. This is of great concern, since abrupt weaning can be an important cause of malnutrition, especially among the youngest.

Those 330 mothers still breastfeeding were asked if, aside from breast milk, other foods or liquids were given to the children within the last 24 hours. The recall period started from the morning of the day preceding the interview when the child woke up until the following morning (including foods/liquids given during the night and excluding foods/liquids given since the child woke up at morning).

Table 34: Administration of foods/liquids to breastfed children over a 24hr food recall period by age categories, n=330, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Administration of other foods/liquids over a 24hr food Total Yes % No % recall period N 0 – 5 months 91 32 35.2% 59 64.8% 6 – 23 months 239 198 82.8% 41 17.2% TOTAL 330 230 69.7% 100 30.3%

Table 34 shows that more than one third of the breastfed children of less than 6 months old are not exclusively breastfed. Non-exclusive breastfeeding at this age puts the children at a higher risk of disease, malnutrition and death. The prevalence of exclusive breast feeding among the survey population seems quite low. Surprisingly, 41 children of 6 to 23 months old were said not to have been fed with other foods or liquids over the recall period, whereas from 6 months onwards, additional food is required. This result may reflect mistakes in undertaking the interviews at household level. Taking into account the low prevalence of exclusive breast feeding among infants below 6 months, it would be surprising that children of 6 months and older are not fed with other food/liquids beside breast milk. There may have been biases in recording the food/liquids consumption over the recall period. Hence, all results should be interpreted with caution. Results are not analyzed by using EPI Info Software and are only presented in percentage as indicative information. The meal frequency is not analyzed as well due to the highlighted biases. As consequences, only 5 IYCF core indicators could be expressed despite the willingness at planning stage to study the 8 IYCF core indicators of the WHO recommendations.

Caretakers of the 230 children who received liquids/foods beside breast milk as well as the 4 infants who were never breastfed were asked what types of liquids and foods were given to the children over a 24 hour food recall period.

40 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 In total, 34 children 0-5 months old (including 2 non breastfed infants) and 200 children 6-23 months old (including 2 non breastfed infants) were included in the consumption study giving a total sample of 234 children out of 334 children. Following the methodology, 2 types of liquids consumed by the children over the recall period were recorded, giving a total of 468 answers for 234 children surveyed. The percentages presented in the table below are calculated out of the total number for each category.

Table 35: Types of liquids taken over 24 hour food recall period for children from 0 to 23 months old, n = 234, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Liquids eaten from Children Children Children Total % Total % Total % yesterday during the 0-5 6-23 0-23 Out of N Out of N Out of N day or at night (N=34) (N=200) (n=234) Breast milk 30 88.2% 149 74.5% 179 76.5% Milk - Fresh animal milk and tinned (condensed 24 70.6% 77 38.5% 101 43.2% milk) Milk such as cartons or - 0.0% 4 2.0% 4 1.7% powdered (Nido, klim…) Infant formula 2 5.9% 6 3.0% 8 3.4% Plain water 4 11.8% 67 33.5% 71 30.3% Sugar or glucose water 3 8.8% 3 1.5% 6 2.6% Sour milk or yogurt - 0.0% 17 8.5% 17 7.3% Sugar-Salt-Solution water - 0.0% 2 1.0% 2 0.9% (ORS) Fruit juice 1 2.9% 9 4.5% 10 4.3% Tea/infusions 3 8.8% 36 18.0% 39 16.7% Thin porridge 1 2.9% 29 14.5% 30 12.8% Other (Specify) - 0.0% 1 0.5% 1 0.4% Total answers for all 68 - 400 - 468 - children surveyed

30 infants 0-5 months out of 34 were breastfed over the recall period. According to the results presented above, 2 infants were not breastfed and 32 infants were breastfed but received as well other liquids, meaning that 2 mistakes may have been done while collecting the data for the infants 0-5 months. Mistakes seem to be reflected as well for the children 6-23 as only 149 are said as breastfed while 212 children 6-23 were reported as being currently breastfed in the analysis above. This may highlight some errors in collecting data at field level. As several questions about breastfeeding were asked to the caretakers, they may have considered that breastmilk was obviously given and that they did not have to repeat this. Milk or fresh animal milk and tinned is the most common liquid given to infants less than 6 months, as well as to children 6-23 months. However, undiluted animal milk before the age of 12 months is inappropriate as it can trigger symptoms of intolerance and allergy. Only 2 children 0-5 and 6 children 6-23 months received infant formula, which show a low consumption of this item among the target population, even though it is the most appropriate breast milk substitute, if used correctly and safely. Plain water was also widely given to children from 6 to 23 months, but the questionnaire did not provide any indication on its cleanliness. One child received one other kind of food not included in the pre-list but its specification was not recorded by the nutrition survey teams.

41 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 The caretakers were then asked which kinds of foods were given to their infants and young children over the recall period. Out of the 234 children, 37 children only received liquids but no food items. Only 9 children below 6 months old out of 34 and 188 children 6-23 months out of 200 received foods over the recall period. Hence, the analysis of the food consumption is done with a sample of 197 children. A maximum of 4 types of foods consumed per child was recorded. Still, some children received less than 4 different food items; hence the total used for analysis corresponds to 753 answers for 197 children surveyed. The percentages presented in the table below are calculated out of the total sample for each category.

Table 36: Types of foods taken over 24 hour food recall period for children from 0 to 23 months old, n = 197, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 Total Total Total Children Children Children Types of foods eaten from yesterday % % % 0-5 6-23 0-23 during the day or at night Out of Out of Out of (N=9) (N=188) (N=197) N N N Bread, rice, noodles, or other foods made 7 77.8% 172 91.5% 179 90.9% from grains Pumpkin (squash), carrot, red peppers or other foods that are yellow or orange - 0.0% 68 36.2% 68 34.5% inside White potatoes, turnip and any other - 0.0% 95 50.5% 95 48.2% foods made from roots Any dark green leafy vegetables - 0.0% 31 16.5% 31 15.7% (medium to dark in color) Ripe mangoes, fresh apricots, dried - 0.0% 40 21.3% 40 20.3% apricots Any other fruits or vegetables (e.g. 1 11.1% 48 25.5% 49 24.9% tomatoes, bananas…) Liver, kidney, heart or other organ meats - 0.0% 1 0.5% 1 0.5% Any meat, such as beef, mutton, lamb, - 0.0% 10 5.3% 10 5.1% goat, chicken, or camel Eggs 1 11.1% 64 34.0% 65 33.0% Fresh or dried fish - 0.0% 1 0.5% 1 0.5% Any foods made from beans, peas, - 0.0% 10 5.3% 10 5.1% lentils, or nuts Cheese, yogurt, or other milk products - 0.0% 69 36.7% 69 35.0% Any oil, fats, or butter, or foods made - 0.0% 29 15.4% 29 14.7% with any of these Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or - 0.0% 90 47.9% 90 45.7% biscuits Flavoring such as dry pepper, chilies, - 0.0% - 0.0% - 0.0% spices or herbs Any solid, semi-solid or soft foods made for infants and young children such as: - 0.0% 16 8.5% 16 8.1% Cerelac, Biomil, Mother's Choice, Hero Baby, BP5 biscuit Any Plumpy Nut, Plumpy Doz - 0.0% - 0.0% - 0.0% Total answers for all children 9 - 744 - 753 - surveyed *(note: iron fortified solid, semi-solid or soft foods designed specifically for infants and young children) ** (note: lipid based nutrient supplement available in local setting)

42 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Out of 9 children below 6 months old, 7 received bread, rice, noodles, or other foods made from grains. The 2 other infants were given respectively fruits/vegetables and eggs. With regards to children from 6 to 23 months old, most of them received bread, rice, noodles, or other foods made from grains. Bread and rice are traditional foods eaten on daily basis in Afghanistan. 95 children 6-23 months old received white potatoes, turnip and any other foods made from roots,. White potatoes are considered as vegetables by most of the local population according to several studies 27 but they are not. They are more like cereals, providing mostly energy (carbohydrates) and limited vitamins and minerals. Few children were given fruits or vegetables, therefore lack of main source of micronutrients; whereas micronutrient deficiency is considered as one of the main factors leading to chronic malnutrition. Meat and other organ meats were almost not given to the children 6-23 months. These types of food are one of the main sources of proteins, essential macronutrients required to ensure the normal child development. Fish or dried fish was given to only 1 child 6-23 months. In the mountainous context of Takhar province, fishes or sea products are almost inexistent. Few habitants have access to rivers where they can get fish. The lack of sea products and fishes can lead to iodine deficiency. This deficiency can be prevented by using iodized salt at household level. In Afghanistan, the MoPH, supported by international organizations, is running several projects to ensure that iodized salt certified with a MoPH label is available at provincial level, especially in remote area. Nevertheless according to the anthropometric nutrition survey done by ACF in Day Kundi province, Afghanistan, in October 2011, the use of iodized salt for household cooking was unsatisfactory 90 children out of 188 received sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits, giving a high consumption of carbohydrates, main source of energy, but painfully lacking in micronutrients. No surveyed children received lipid based nutrient supplement and only 16 children 6-23 months received iron fortified solid, semi-solid or soft foods designed specifically for infants and young children.

27 Health food, healthy baby, Lively family – UNFAO, Ministry of Agriculture, Irrigation and Livestock and Ministry of Public Health, Government of Afghanistan - 2008

43 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 As summary, the results are presented according to five IYCF core and two IYCF additional indicators, WHO reference, in the tables below.

Table 37: 5 IYCF core indicators, WHO reference, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011 CORE INDICATORS DEFINITION N % 95% CI Proportion of children born in the last 23 Early initiation of months who were put to the breast within 221 66.8% (61.4 – 71.8) breastfeeding (n = 331 ) one hour of birth Exclusive breastfeeding Proportion of infants 0-5 months of age 59 63.4% (52.8 – 73.2) under 6 months (n =93) who are fed exclusively with breast milk Continued breastfeeding at Proportion of children 12 – 15 months of 58 95.1% (86.3 – 99.0) 1 year (n = 61 ) age who are still fed with breast milk Introduction of solid, semi- Proportion of infants 6-8 months of age 24 70.6% (52.5 – 84.9) solid or soft foods (n = 34 ) who receive solid, semi-solid or soft foods Proportion of children 6-23 months of age Consumption of iron-rich or who receive an iron-rich food or iron- iron-fortified foods fortified food that is specially designed for 16 6.6% (3.8 – 10.6) (n =241) infants and young children, or that is fortified in the home.

Due to all constraints and biases described above, only 5 IYCF core indicators out of 8 could be sorted out by conducting this study. Indeed, the meal frequency and the food consumption over a 24hr food recall period could not be analyzed. Nevertheless, the IYCF study provides enough information to better understand the feeding practices toward infants in Chal and Rustaq districts, Takhar province.

Two IYCF optional indicators could be expressed by conducting this study.

Table 38: 2 IYCF optional indicators, WHO reference, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

OPTIONAL INDICATORS DEFINITION N % 95% CI Children ever breastfed Proportion of children born in the last 24 330 98.8% (96.8 – 99.6) (n = 334) months who were ever breastfed Continued breastfeeding at Proportion of children 20–23 months of age 26 68.4% (51.3 – 82.5) 2 years (n =38) who still receive breast milk

44 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 5. DISCUSSION

5.1. Constraints and biases
Due to security constraints, ACF Health - Nutrition coordinator could not supervise the data collection in the field. Nevertheless, ACF Nutrition program manager and ACF Nutrition team leader have ensured the supervision from the beginning up to the completion of the data collection. However, they could not fully supervise the work done by the four teams at the same time, especially due to transportation constraints, the distance between each selected villages and the limited time allocated per day.
Only 2 districts out of 17 comprised in the province were covered and so are represented by this survey. To remind that according to SMART methodology, the results can not be extrapolated to the whole province but are only representative of the surveyed areas. o This leads to limited picture of the province, but was done in order to ensure the quality and the reliability of the collected data. o One of the main objectives of conducting this survey was to build the capacity of the NGO staff taking part in the project. For reaching the quality requirement and ensuring capacity building of the CAF team members, the decision was taken to limit the covered area, especially taking into account that Takhar province is a wide spread province with limited transportation infrastructures and geographical constraints.
A standardization test was performed during the 5 day training session. Unfortunately, this test was only done partially and results could not be analyzed
The weight of children was measured with clothes. 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, however this does represent a bias.
According to the plausibility check, ENA Delta Software – Version April 2011: o The height measurements showed some digit preferences, classifying its quality as “acceptable” only. This may have led to some biases. o The MUAC measurements showed some digit preference (Score = 15). This may have led to biases in the estimation of the acute malnutrition prevalence according to MUAC criterion. o The index of dispersion has a p<0.05 (p=0.014), meaning that GAM cases are aggregated in some clusters.
The food consumption over a 24 hr food recall period could not be fully analyzed due to incorrect registration. The data could not be considered as realistic. Mistakes could not be completely avoided despite refresher trainings and regular supervision of the data field collection. As consequence, only 5 IYCF core indicators out of 8 could be expressed.

45 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 5.2. Acute malnutrition – Children 6-59 months old The Global Acute Malnutrition (GAM) rate expressed according to WHO standards is of concern, being of 10.4 % (7.9 – 13.7 95% CI) in Chal and Rustaq districts, Takhar province and indicating a risky situation.

Expressing the GAM rate in caseload out of the surveyed population, 2,938 children are estimated as suffering from acute malnutrition according to W/H index and most of them are without nutritional treatment and therefore at risk of further deterioration of their nutritional status. Following the same methodology, 1,978 children are estimated as affected by acute malnutrition according to MUAC criterion. Pockets of malnutrition may exist in the targeted area. Indeed, the index of dispersion shows that it may have bunches of people more affected by acute malnutrition than others in the target area. The survey results do not provide information at village/cluster level, so these pockets could not be identified by conducting a single SMART survey. Survey teams did report that some areas were more vulnerable than others, especially the remote areas where access to socio-economic development is limited. Young children, aged 6-23 months are clearly more vulnerable to acute malnutrition than older children of the 24-59 months age group. Inappropriate infant feeding practices as shown in the IYCF study: late introduction of breastfeeding at birth, low rates of exclusive breastfeeding and presumably poor quality of complementary food consumption may explain this vulnerability but other possible factors need to be deeper explored by conducting a fully dedicated IYCF and malnutrition causal analysis study in the area. Only one Kwashiorkor case was detected while conducting the survey. The Kwashiorkor prevalence is estimated as low by most of the nutrition actors in Afghanistan. The prevalence of acute malnutrition found in Chal and Rustaq districts, Takhar province, is clearly higher than the ones found in other provinces where anthropometric nutrition surveys were conducted in 2010-2011 as shown in the table below 28 .

Table 39: Global Acute Malnutrition prevalence, WHO Standards (2006), Day Kundi, Nangarhar, Laghman and Takhar provinces, from October 2010 to June 2011, Afghanistan Surveyed GAM Provinces Period 95% CI Agencies districts Z-score Day Kundi October Ashtarlay 3.2% (1.9 – 4.5 % C.I) ACF (N = 792) 2010 Nangarhar Beshood, Kama, ACF – HN province Rodat and Dara-I- May 2011 5.3 % (3.6 – 7.8 95% C.I.) TPO (N = 861) Nur Laghman province Mihtarlam and May 2011 8.5 % (5.6 – 12.7 95% C.I.) ACF – SCA (N = 600) Qarghayi Takhar province Chal and Rustaq June 2011 10.4 % (7.9 – 13.7 95% C.I.) ACF – SCA (N = 690)

As complementary information and according to HMIS data provided by CAF, 40,962 children were screened by Community Health Workers (CHW) at community level in the whole province from March 2010 to March 2011. Out of these 40,962 children, 4,216 children were referred to health facilities for further investigation. This gives an average of 10.29% of children referred out of the total screened, which corresponds approximately to the GAM rate raised by this survey.

28 ACF Anthropometric nutrition survey, Astharlay district, Day Kundi province, October 2010 ACF-HN TPO Anthropometric nutrition survey, Beshood, Kama, Rodat and Dara-I-Nur districts, Nangarhar province, May 2011 ACF-SCA Anthropometric nutrition survey, Mihtarlam and Qarghayi districts, Laghman province, May 2011

46 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 In Chal and Rustaq districts and according to the same source of information, the active screening results done by the CHW at community level over the same period are as follows.

Table 40: Active screening done by Community Health Workers from October 2010 to June 2011, CHA, Chal and Rustaq districts, Takhar province, Afghanistan Total Children U5 Total Children U5 % Total Children U5 District names screened referred to HF referred to HF Rustaq district 8,541 1,089 12.75% Chal district 1,558 135 8.66% Total 10,099 1,224 12.12%

More children U5 were referred to health facilities in Rustaq compared to Chal district over the studied period (relative risk=1.47 (1.24

5.3. Chronic malnutrition – Children 6-59 months old The chronic malnutrition rate is considerably high with a prevalence of 54.0% (48.5 – 59.4 95% CI) in Chal and Rustaq districts, Takhar province. The prevalence of severe stunting is especially of concern being of 21.6% (18.1 – 25.6 95% CI). By expressing the stunting rate in caseload out of the surveyed population, 15,252 children are estimated as suffering from chronic malnutrition according to the W/H index. Following the same methodology, 6,101 children are estimated as affected by severe stunting. To remind that the population of only 2 districts of the province are comprised in these results. By comparing the stunting rates found by the 3 other anthropometric nutrition surveys conducted in Afghanistan in 2010-2011, the chronic malnutrition problematic in Chal and Rustaq districts, Takhar province, is considered as similar to the other 3 surveyed locations 29 . The stunting rates are presented according to WHO standards in the table below.

Table 41: Chronic malnutrition prevalence, WHO Standards, Day Kundi, Nangarhar, Laghman and Takhar provinces, from October 2010 to June 2011, Afghanistan Surveyed Stunting Provinces Periods 95% CI Agencies districts Z-score Day Kundi October Ashtarlay 58% (53.1 – 62.9 % C.I) ACF (N = 791) 2010 Nangarhar Beshood, Kama, ACF – HN province Rodat and Dara-I- May 2011 51.6 % (47.0 – 56,2 95% C.I.) TPO (N = 826) Nur Laghman province Mihtarlam and May 2011 39.3 % (34.9 – 43.9 95% C.I.) ACF – SCA (N = 583) Qarghayi Takhar province Chal and Rustaq June 2011 54 % (48.5 – 59.4 95% C.I.) ACF – SCA (N = 676)

29 ACF Anthropometric nutrition survey, Astharlay district, Day Kundi province, October 2010 ACF-HN TPO Anthropometric nutrition survey, Beshood, Kama, Rodat and Dara-I-Nur districts, Nangarhar province, May 2011 ACF-SCA Anthropometric nutrition survey, Mihtarlam and Qarghayi districts, Laghman province, May 2011

47 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 The problem of stunting is well recognized in Afghanistan and remains one of the major public concerns. High stunting prevalence leads to considerable impact on the socio-economic development of a country with a consequent public deficit noticed in most of the affected countries. A clear pattern emerges from the survey statistics. Older children, corresponding to children 24- 59 months, are more affected by chronic malnutrition than younger children (6-23), this corresponding to physiological evidence. Prevention remains the only solution to fight against chronic malnutrition and all its related causes. Multiple factors can lead to chronic malnutrition such as gender discrimination, limited access to food, health care and education and insufficient knowledge about child nutrition, repeated illness in childhood, deficiencies of certain micronutrients and inappropriate feeding or care practices contribute largely to chronic malnutrition.

5.4. Malnutrition risk - Pregnant/Lactating women The prevalence of nutritional risk among pregnant/lactating women raised by this survey should be interpreted with caution due to the low sample size. Nevertheless, 17.4% of the women screened were detected as at risk according to MUAC criterion. This rate raises concerns about the nutritional status of women in the targeted area who seem to suffer from nutritional deficit. No difference could be notified between the nutritional status of pregnant versus lactating women. Acute malnutrition among pregnant women leads to many negative outputs. The most common effects recognized by international nutrition experts are listed as follows:
Miscarriage, pre-eclampsia;
Foetal consequences: Risk of impairment of the development, pre-term birth;
Maternal mortality, obstructed labor, hemorrhage;
Neonatal mortality: Death of baby within three days / within one month
Low birth weight (LBW) of the baby • LBW babies who survive are likely to suffer growth retardation and illness throughout their childhood, adolescence and into adulthood • Growth-retarded adult women are likely to carry on the vicious cycle of malnutrition by giving birth to low birth-weight babies Maternal malnutrition does not affect a mother’s milk production, except if the malnutrition is severe. A malnourished mother will continue to produce milk to the detriment of her own wellbeing. Still, in such case, it is better to treat the mother and let her continue to feed the baby, since the alternatives can be dangerous for the child’s health. Nevertheless, it is well recognized that lactating mothers ideally have an additional nutrient and micronutrient intake for their own health as well as to pass those nutrients and micronutrients to their children via the milk. Moreover, the capacity of taking care of a child can be diminished due to fatigue and/or associated disease. In relation to the chronic malnutrition problem, it can be assumed that malnourished women are giving birth to low birth weight babies who have a higher chance of becoming stunted. This corresponds to the cycle of hunger. In the context of Chal and Rustaq districts, Takhar province, little information about the nutritional status of women is available which shows the need for a deeper analysis. Nevertheless, the ‘End of Project household survey of IYCF practices - Takhar, Badakhshan and Kunduz provinces’ conducted by CAF in June 2011 provides relevant information about women taking care of infants which are presented in the chapters below.

48 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 5.5. Causal analysis Malnutrition remains a multi factorial problematic. In the specific context of Takhar province, 2 main factors leading to malnutrition may be identified as follows.

Food insecurity: The level of economic hardship in Takhar is reasonably high. 41% of the households in the province report having problems satisfying their food needs at least 3–6 times a year, and a further quarter of households (24%) face this problem up to three times a year 30 . Around a quarter of the population in the province (26%) is estimated to receive less than the minimum daily caloric intake necessary to maintain good health. This figure is similar for the rural population (27%) and people living in the urban area (29%). In both rural and urban areas more than half the population (60%) has low dietary diversity and poor or very poor food consumption.

Inappropriate IYCF practices: The IYCF study provides a view on the infant feeding practices among the surveyed population in Chal and Rustaq districts, Takhar province. It is important to take into consideration that inappropriate IYCF practices are one of the main causes of malnutrition, but can also contribute significantly to disease and death. o Late initiation of breastfeeding: Only 66,8% of the infants 0-23 months old were put on the breast within 1 hour after birth; o Low prevalence of exclusive breastfeeding among children below 6 months: Only 63,4% of the infants were exclusively given breast-milk; o Abrupt cessation of breastfeeding without progressive introduction of other liquids/foods: 66.7% of the caretakers said that they stopped breastfeeding their children abruptly; o Poor quality of food consumption for children 6-23 months: few micronutrient-rich foods were given to the children over the 24hr food recall period. In June 2011, CAF has conducted an ‘End of Project household survey of IYCF practices - Takhar, Badakhshan and Kunduz provinces’. The main objective of this survey was to evaluate the impact of an ending project on the IYCF practices (project implemented from October 2009 up to the first quarter of 2011). With regards to the IYCF knowledge and practices, many improvements were highlighted but still, it was notified that some issues were remaining to be tackled, especially in regard to food consumption. Indeed, it was reported at the end of project survey that no egg or meat were given to 44% of the children 6-23 as complementary foods due to some cultural believes that these food items are not good for young children. As shown in the study of the food consumption over a 24hr recall period, the food intake for infants is estimated as poor. Few micronutrient-rich foods (such as fruits and vegetables), almost no iron-rich foods (such as Cerelac or BP5) or iodine-rich foods (such as fishes or sea products) were given to infants. To remind that poor food intake (quality and quantity) has a direct impact on the nutritional status of children leading to acute malnutrition in a short term and to chronic malnutrition in a long term process.

30 NRVA 2005

49 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 6. CONCLUSION

The anthropometric nutrition survey and the IYCF study conducted in Takhar province have limitations. Causes of malnutrition could not be assessed and only assumptions can be made with regards to highlighted results. Acute malnutrition levels can be considered as not alarming but risky. Younger children are more affected by acute malnutrition than older children and hence should be the priority target for nutritional intervention. In Afghanistan context, infants below 6 months old are well recognized as one of the most vulnerable target population, but no recent anthropometric data of this age group is available. Besides acute malnutrition, the prevalence of stunting or chronic malnutrition is the main concern in Takhar context. More than half of the surveyed children were found to be stunted and one quarter of was severely stunted. Chronic malnutrition can only be prevented by multiple mitigation measures. In addition, the prevalence of nutritional risk among women is concerning. According to the cycle of hunger, malnutrition among pregnant women can lead to chronic malnutrition among children. Attention should be paid for the pregnant and lactating women for the benefits of the children as well as for the mothers. It is important to acknowledge that, given the inclusion of only 2 districts out of 17 in the province, 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 the whole province. Mid 2011, at the time of report writing, a drought affected most of the northern regions in Afghanistan. Takhar province is identified as a ‘Red spot’ for direct intervention’ according to UN agencies and other stakeholders. An Emergency Food Security Assessment (EFSA) was carried out in the 14 provinces of the northern, north-eastern, western and central highlands areas identified as the most drought affected, including Takhar province, in August 2011. The situation in this province was said to be of concern, especially taking into account all negative factors such as the inadequate coping mechanisms or the poor household access to food commodities.

The survey was conducted in June 2011, corresponding to the period of the main harvest, the end of the hunger gap, and the population was said to be affected already by the drought according to the nutrition survey team and CAF staff based in Takhar province. The harvest is expected to be poorer as compared to other years. The nutrition situation should hence be closely followed up in the coming months, as drought could negatively influence the nutrition status of the population living in this area. In Afghanistan, the seasonal calendar and critical events timeline for 2011 is presented in the annex 11 31 .

31 FEWS – NET; March 2011

50 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 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 Programmers (SFP) should be established for the management of moderate acute malnutrition in children 6 to 24 months of age.

Moreover, the national nutrition policy advocates for scaling up CMAM component within health intervention all over the country. Nutrition programs are part of the BPHS framework and correspond to one of the 7 pillars of this strategy.

With regards to the main findings of this survey and in respect to the national nutrition policy, the following recommendations are submitted:
To advocate with the Ministry of Public Health and the NGO CAF, BPHS implementer in the studied area, to maintain the satisfactory coverage of Vitamin A supplementation and to improve the measles vaccination coverage. Emphasis should be on out-reach activities so as to cover the population living in remote areas as well as people not seeking care in health facilities;
To expand the CMAM project within the BPHS framework in the whole province in accordance with the national nutrition policy and in collaboration with the several health actors present in the area; o To increase the number of in patient units at district level, one per district, o To start implementing the out-patient Therapeutic Program (OTP) component in all districts, o To extend the SFP component to all districts, o To extend community mobilization program to remote areas as much as possible;
To monitor the nutrition situation on a regular basis. o To improve the regular collection of anthropometric data through the HMIS in order to better follow nutrition trends, o To conduct more nutrition surveys, in accordance with the nutrition national policy that stipulates that surveys should be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in the nutritional situation, o To conduct nutritional surveillance in the coming months to evaluate the impact of the drought if the situation is estimated to be worsening, o To consider infants below 6 months in a separate survey;


To assess the 15 districts excluded by this survey;


To take into consideration the lessons learned and recommendations submitted in the ‘End of Project household survey of IYCF practices from Takhar, Badakhshan and Kunduz provinces’ done by CAF in June 2011; o To run nutrition education / counseling as part of the BPHS strategy; o To set up appropriate training program for Health Facilities staff and CHWs as a main key lessons learned; o To increase knowledge of mothers on the problems related to feeding infants and young children; o To train CHWs on key messages of feeding practices as well as on referring women in need to a well trained midwife for further counseling;

51 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 o To extend Breast Feeding Support Group (BFSG) consisted of CHWs, Traditional Birth Attendants (TBA), religious leaders, mothers in – laws, private drug sellers and other members of the community. Groups only exist today only in 16 Health Facilities; o To involve males in BFSG, which differs from Family Health Action Group (FHAG) where men are not included; o To use other human resources available at community level than the CHWs who are already overloaded; Other community members could be involved in health-nutrition related activities; o To design appropriate messages. People need to understand very simple facts rather than complicated procedures; o To focus on Food Demonstration (FD) for complementary feeding as the knowledge and practice in complementary feeding are estimated as poor;

52 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 8. REFERENCES

A Basic Package Health Service for Afghanistan, 2005/1384, MoPH
ACF Anthropometric nutrition and retrospective mortality survey – Ashtarlay district – Day Kundi province – Afghanistan – October 2010
ACF-HN TPO Anthropometric nutrition survey, Beshood, Kama, Rodat and Dara-I-Nur districts, Nangarhar province, May 2011
ACF-SCA Anthropometric nutrition survey, Mihtarlam and Qarghayi, Laghman province, May 2011
Afghanistan Health Indicators, Fact Sheet – August 2008
Afghanistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan
Afghanistan Information Management System (AIMS), Takhar province Land Cover Map, April 2002 and Nelles Vertlag, Afghanistan 2006
CSO Afghanistan Statistical Yearbook 2010-2011
Emergency Food Security Assessment (EFSA), World Food Program, August 2011
‘End of Project household survey of IYCF practices - Takhar, Badakhshan and Kunduz provinces’ – CAF – June 2010
EPI 5 Stat Calc Software
Famine Early Warning Systems Network (FEWS Net), March 2011
Health and Nutrition Sector Strategy – MoPH Annual Report - 2010
Health food, healthy baby, Lively family – UNFAO, Ministry of Agriculture, Irrigation and Livestock and Ministry of Public Health, Government of Afghanistan - 2008
Malnutrition in Afghanistan – Scale, Scope, Causes and Potential Response – World Bank - 2010
National Risk and Vulnerability Assessment (NRVA), 2005
National Risk and Vulnerability Assessment (NRVA), 2007/2008
NCHS: National Centre for Health Statistics (1977), NCHS growth curves for children birth - 18years. United States Vital Health Statistics. 165. 11 - 74
Nutritional risk in Afghanistan 2006 - Feinstein International Famine Center, Tufts University in collaboration with Ministry of Public Health, Afghanistan
Provincial Development Plan, Takhar provincial profile, Ministry of Rural Rehabilitation and Development (MRRD), 2007
SMART Methodology guideline – Version 2006
SMART Training Package – Version 2011
Standardized Monitoring and Assessment in Relief and Transition, see web sites www.nutrisurvey.de/ena/ena.html www.smartmethodology.org
The Sphere_Project_Handbook_2011
UNDSS, Provincial assessment or UNAMA provincial profiles supplied by UNAMA
Website: www.afghanistan-culture.com/kabul-afghanistan.html
Website: www.complexoperations.org
Website: www.etc-crystal.org
Website: www.foodsecurityatlas.org
Website: www.ocha.org/Afghanistan
WHO: Growth curves for children, 2005
WHO: Indicators for Assessing Infant and Young Child Feeding Practices - 2007
WHO: Use and interpretation of anthropometric indicators of nutritional status, Bulletin of the WHO,64 (6) : 929-941 (1986)

53 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9. ANNEXES

9.1. Annex 1: Map of Takhar province, Afghanistan (Source: MoPH)

54 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.2. Annex 2: 3 Ws (Who is doing What and Where), Takhar province, Afghanistan, September 2011 (Source: OCHA)

Emergency Water, Emergency Food Shelter & Sanitation & Districts Education Telecommu Security & Health Protection* Non-Food Hygiene nications Agricultural Items (WASH)

RSA, ARCS, Merlin, ANDMA, ARCS, ARCS, NRC, ICRC Chah Ab DoE WFP Agriculture WHO, Public UNICEF ANDMA Kunduz Department, Health Mercy Corps Department Mission East, KinderBerg, CONCERN, CONCERN, RSA, ARCS, CONCERN, WHO, Merlin, NRC, ICRC ANDMA, Mission East, Farkhar SCA, DoE WFP ARCS, UNICEF, Kunduz, Agriculture CONCERN ANDMA SCA, ARCS, UNMACCA Department, Public Health Mercy Corps, Department FAO ICRC Kunduz, Merlin, NRC, UNHCR, ARCS, ARCS, UNHCR, Khwaja UNICEF, WFP ARCS, ANDMA, WHO, SCA, ICRC Ghar SCA, DoE ANDMA FAO, RSA, Public Health Kunduz, Agriculture Department UNMACCA Department CONCERN, Merlin, ARCS, CONCERN, ARCS, ANDMA, ICRC Darqad DoE WFP ARCS, WHO, Public WFP, RSA, Kunduz ANDMA Health Agriculture Department Department ARCS, Merlin, UNHCR, ANDMA, ARCS, NRC, ICRC UNICEF, Dashti Qala WFP ARCS, RSA, WHO, SCA, Kunduz, SCA, DoE ANDMA, SFL Agriculture Public Health UNHCR Department Department CONCERN, Merlin, ARCS, NRC, CONCERN, ARCS, UNICEF, ANDMA, CONCERN, Yangi Qala WFP ARCS, WHO, Public CONCERN DoE WFP, RSA, ICRC ANDMA Health Agriculture Kunduz Department Department Merlin, RSA, ARCS, NRC, UNHCR, ARCS, UNICEF, ANDMA, UNHCR, Ishkamish WFP ARCS, WHO, SCA, UNICEF SCA, DoE Agriculture ICRC ANDMA Public Health Department Kunduz Department Mission East, RSA, ARCS, Merlin, ANDMA, ARCS, NRC, ICRC UNICEF, ICRC, Mission East, Bangi WFP FAO, WHO, Public Kunduz, SCA, DoE ANDMA UNICEF Agriculture Health UNMACCA Department, Department Mercy Corps Mission East, KinderBerg, CONCERN, Merlin, CONCERN, RSA, ARCS, NRC, ICRC UNICEF, ARCS, Chal WFP ARCS, ANDMA, Kunduz, DoE WHO, Public ANDMA Agriculture UNMACCA Health Department, Department Mercy Corps

55 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Mission East, CONCERN, CONCERN, RSA, ARCS, CONCERN, SCA, ARCS, CONCERN, ANDMA, Warsaj SCA, DoE WFP ARCS, WHO, Merlin, ICRC CONCERN Agriculture ANDMA Public Health Kunduz Department, Department Mercy Corps, FAO Mission East, Merlin, ARCS, ARCS, ICRC ARCS, ANDMA, Namak Ab DoE WFP WHO, Public Kunduz, ANDMA RSA, Health UNMACCA Agriculture Department Department

RSA, ARCS, KinderBerg, NRC, ANDMA, UNHCR, SCA, ARCS, UNHCR, Mission East, UNICEF, FAO, Baharak WFP ARCS, WHO, Public ICRC UNICEF, SCA, DoE Agriculture ANDMA Health Kunduz, DACAAR Department, Department UNMACCA Mercy Corps ARCS, Merlin, ANDMA, ARCS, ICRC Hazar ARCS, DoE WFP RSA, WHO, Public Kunduz, Mission East Sumuch ANDMA Agriculture Health UNMACCA Department Department Mission East, CONCERN, KinderBerg, NRC, UNHCR, RSA, ARCS, UNICEF, UNHCR, UNICEF, CONCERN, ANDMA, Merlin, WHO, UNICEF, Taluqan UN-Habitat, WFP DACAAR ARCS, FAO, ARCS, SCA, ICRC SCA, DoE ANDMA Agriculture Public Health Kunduz, Department, Department UNMACCA Mercy Corps RSA, ARCS, SCA, ARCS, ANDMA, NRC, ICRC UN-Habitat, SFL, ARCS, WHO, Merlin, Kalfagan WFP Agriculture Kunduz, DACAAR SCA, DoE ANDMA Public Health Department, UNMACCA Department Mercy Corps NRC, CONCERN, CONCERN, UNHCR, UNHCR, UNICEF, RSA, ARCS, SCA, ARCS, CONCERN, CONCERN, CONCERN, Rustaq CONCERN, WFP ANDMA, WHO, Merlin, ARCS, ICRC UNICEF SCA, DoE Agriculture Public Health ANDMA Kunduz, Department Department UNMACCA CONCERN, CONCERN, SCA, ARCS, RSA, ARCS, UNHCR, Khwaja UNHCR, WHO, Merlin, DoE WFP ANDMA, ICRC UNICEF Bahawuddin ARCS, Public Health Agriculture Kunduz ANDMA Department Department * (Human Rights, Child Protection, GBV, Mine Action, HLP)

56 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.3. Annex 3: Cluster selection, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

District Total Total Village Names Cluster Names Population Household Chal ZANBORAK BALA 1,090 185 1 Chal HAZARA SAI 400 79 RC Chal AA 575 107 2 Chal PAMBAK 527 81 RC Chal DAHAN MANDARA 323 52 3 Chal SAMADAB NOW ABAD 827 125 4 Rustaq PASTAKA BALA 701 136 5 Rustaq AGZAK 462 92 6 Rustaq SAYID ABAD 865 168 7 Rustaq ZOHAN BALA 359 71 8 Rustaq SARGHAR JADID 1,029 214 9 Rustaq QADOQ PAYEN 659 118 10 Rustaq HAZAR SUMUCH 3,637 594 11 Rustaq CHAPA KHANA 896 160 12 Rustaq NOW ABAD YAKA TOOT 1,065 202 13 Rustaq DOWN QESHLAQ 1,136 218 14 Rustaq KALTA DARA 347 69 15 Rustaq SHAIR TALA NOWABAD 853 136 16 Rustaq KHOUK ABA 232 36 17 Rustaq DASHT ABI PAYEN 992 160 18 Rustaq DOORMAN 560 108 19 Rustaq KOUNDA EASHANQOUL BAI 1,168 231 20 Rustaq GOZAR CHASHMKA 1,160 199 21 Rustaq NOWABAD SAR RUSTAQ 738 132 22 Rustaq GHUNJ 4,210 618 23 Rustaq BAGHSAR 2,497 418 24 Rustaq NOW ABAD YAL KASHAN 746 139 RC Rustaq GANDA CHASHMAR 907 165 25 Rustaq NOW ABAD BATASH 531 103 26 Rustaq SANG ALI 1,183 215 27 Rustaq KHOJA QASHQAR 421 102 28 Rustaq LALA MAIDAN HAKIM 1,042 199 29 Rustaq CHANAR 184 41 30 Rustaq ABZAN 858 132 RC Rustaq TARA TASH 1,063 194 31 Rustaq RUSTAQ City Nahia 01 9,322 1,341 32,33 TOTAL 43,565 7,340

57 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.4. Annex 4: 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.

58 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 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

59 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.5. Annex 5: 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 1st 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.

60 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.6. Annex 6: Anthropometric survey – children 6-59 months old and if age not know 65-110 cm, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

ANTHROPOMETRIC SURVEY - CHILDREN 6-59 MONTHS AND 65-110 CM - PREGNANT WOMEN TAKHAR PROVINCE, JUNE 2011 DATE: N° CLUSTER: N° TEAM: VILLAGE: MUAC Measles Vitamin A MUAC Weight in Height in N° Sex Age in W/H Oedema for Vaccination last 6 for N° HH kg +/- cm Remarks child (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 Write the name and phone contact of the head of the family where there is no children under 5

61 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.7. Annex 7: Local event calendar, Chal and Rustaq districts, Takhar province,

Local Event Calendar for Takhar Province June 2011

2006 2007 2008 2009 2010 2011 Yearly 1385 1386 1387 1388 1389 1389 Months Event Mths solar Mths solar Mths solar Mths solar Mths solar Mths solar 20 of 20 of 20 of 20 of 20 of 20 of 20 of Dalwa Dalwa Dalwa Dalwa Dalwa Dalwa Dalwa DALW start of 64 start of 52 start of 40 start of 28 start of 16 start of 4 start of Jan Chella Chella Chella Chella Chella Chella Chella khord khord khord khord khord khord khord To blow To blow To blow To blow To blow To blow To blow HOOT the wind 63 the wind 51 the wind 39 the wind 27 the wind 15 the wind 3 the wind Feb of HOOT of HOOT of HOOT of HOOT of HOOT of HOOT of HOOT 1 of 1 of 1 of 1 of 1 of 1 of 1 of HAMAL Hamal 62 Hamal 50 Hamal 38 Hamal 26 Hamal 14 Hamal 2 Hamal March Now rouz Now rouz Now rouz Now rouz Now rouz Now rouz Now rouz

8 of Sour 8 of Sour 8 of Sour 8 of Sour 8 of Sour 8 of Sour 8 of Sour SAUR Islamic 61 Islamic 49 Islamic 37 Islamic 25 Islamic 13 Islamic 1 Islamic Apr revolution revolution revolution revolution revolution revolution revolution

24 of 24 of 24 of 24 of 24 of 24 of 24 of JAWZA Jaoza Jaoza Jaoza Jaoza Jaoza Jaoza Jaoza 60 48 36 24 12 0 May Mather Mather Mather Mather Mather Mather Mather day day day day day day day 15 of 15 of 15 of 15 of 15 of 15 of 15 of SARATAN Saratan Saratan Saratan Saratan Saratan Saratan Saratan 61 49 37 25 13 1 June schools schools schools schools schools schools schools exam exam exam exam exam exam exam 1 of Asad melon 1 of Asad 1 of Asad 1 of Asad 1 of Asad 1 of Asad 1 of Asad ASSAD season 58 melon 46 melon 34 melon 22 melon 10 melon melon July and 20 of season season season season season season Asad Ramazan 20 of 10 of 1 of 18 of 18 of Sonbola Sonbola Sonbola Sonbola Sonbola 18 of first of first of first of Martyr Martyr SUNBOLA Sonbola Ramazan Ramazan Ramazan day and day and 57 45 33 21 9 Aug Martyr and 18 of and 18 of and 18 of 19-21 of 19-21 of day Sonbola Sonbola Sonbola Asad Eid Asad Eid Martyr Martyr Martyr of of day day day Ramazan Ramazan 1 of 21-23 10-12 1-3 MIZAN Mizan is Mizan Mizan Mizan

Sept the holy Eid of Eid of Eid of Ramazan Ramazan Ramazan Ramazan AQRAB Crop of Crop of Crop of Crop of Crop of Crop of Crop of 55 43 31 19 7 Oct weath weath weath weath weath weath weath cold cold cold cold cold cold cold QAUS weather weather weather weather weather weather weather 54 42 30 18 6 Nov without without without without without without without raining raining raining raining raining raining raining 1 of Jadi 1 of Jadi 1 of Jadi 1 of Jadi 1 of Jadi 1 of Jadi 1 of Jadi Chella Chella Chella Chella Chella Chella Chella JADI Calan 53 Calan 41 Calan 29 Calan 17 Calan 5 Calan Calan Dec and and and and and and and snowing snowing snowing snowing snowing snowing snowing Afghanistan, June 2011

62 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.8. Annex 8: IYCF study – children 0-23 months old, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

IYCF SURVEY FOR ALL CHILDREN 0 -23 MONTHS TAKHAR PROVINCE, JUNE 2011

Date: Team No. Cluster No. Village: HH No.: Child No.: Name: Sex (F/M): Age (Months):

1 Has the child ever been breastfed Yes No DK (Go to question 3) (Go to question 2, 6, 12, 13, 14) 2 Why did you never breastfed the child? (Only 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 the family member G Does not know DK

Other ( Specify) 3 How long after birth did you first put the child to the breast? Within first Less than More than DK hour of life 24 hours 24 hours 4 During the first three days after delivery, did you give the yellowdish liquid that came Yes No DK from your breasts? 5 In the first three days after delivery, was the child given anything to Yes No DK drink other than breastmilk? (Go to question (Go to question 6) 7) 6 Which kind of liquids did you give to the child during the first 3 days of life? Plain water A Sugar water or glucose water B Powdered or fresh animal milk C Infant formula (Biomil 1 or 2, Mini 1 or 2, Lailac 1 or 2, Lactogen 1 or 2, Mam Ma, Morinaga BF D infant formuila) Doesn’t Know DK Other (Specify)

Note: Don’t ask questions 7, 8, 9, 10, 11 to women who never breastfed their children. (When No at question 1) Ask question 12 to mother who never breastfed their children. Ask question 7 only to those women that breastfed their children or are still breastfeeding today 7 Are you still breastfeeding the child? Yes No (Go to question 11) (Go to question 8) 8 For how many months did you breastfeed the child? Months: DK

9 Why did you stop breastfeeding? (Only one answer possible) Child too old A Pain B No enough milk C New pregnancy D Refusal of the child to be breastfed E Child dick F Mother / caretaker sick G Advice of family members H Does not know DK Other (Specify)

63 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 10 How did you stop breastfeeding? Progressively Abruptly DK

11 Aside from breastmilk, did the child get anything at all to eat or Yes No DK drink yesterday or last night? (Go to question 12) (Go to question 14)

12 What liquids from following list did your child drink yesterday during the day and night, How many times per even if it was taken along with other foods? (Maximum two answers possible) day? Breast milk A Milk - Fresh animal milk and tinned (condensed milk) B Milk such as cartons or powdered (Nido, klim…) C Infant formula D Plain water E Sugar or glucose water F Sour milk or yogurt G Sugar-Salt-Solution water (ORS) H Fruit juice I Tea/infusions J Thin porridge K Other (Specify) 13 Did the child eat food yesterday during day and night? (Maximum four answers possible) How many times per day? Bread, rice, noodles, or other foods made from grains A Pumpkin (squash), carrot, red peppers or other foods that are yellow or orange inside B White potatoes, turnip any other foods made from roots? C Any dark green leafy vegetables (medium to dark in color) D Ripe mangoes, fresh apricots, dried apricots E Any other fruits or vegetables (e.g. tomatoes, bananas…) F Liver, kidney, heart or other organ meats G Any meat, such as beef, mutton, lamb, goat, chicken, or camel H Eggs I Fresh or dried fish J Any foods made from beans, peas, lentils, or nuts K Cheese, yogurt, or other milk products L Any oil, fats, or butter, or foods made with any of these M Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits N Flavouring such as dry pepper, chilies, spices or herbs O Any solid, semi-solid or soft foods made for infants and young children such as: Cerelac, Biomil Cereal, Mother’s Choice, Hero Baby, BP5 biscuits (note: iron fortified solid, semi-solid or soft foods designed specifically for infants and young children. P Any Plumpy’Nut, Plumpy’Doz? (show picture)

(note: lipid based nutrient supplement available in local setting) Q Any other foods? (specify)

14 Record the MUAC for lactating women with child of 0-5 months or pregnant women having child of 0-5 but not lactating. MUAC for Lactating women having child of 0-5 months and still breastfeeding

MUAC for Pregnant women having child 0-5 months and not breastfeeding Note: MUAC for pregnant women having child of 6-59 months is recorded in Anthropometric sheet.

64 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.9. Annex 9: Skip patterns - IYCF study – children 0-23 months old, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

IYCF questionnaire - Skip patterns

Question 1 Has (NAME) ever been breastfed?

Yes No

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

Question 4 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?

Question 6 Which kind of liquids did you give to (NAME) during the 3 first days of life?

Question 7 Are you still breastfeeding (NAME)? Skip questions 7-8-9-10-11for women that never breastfed their children No Yes (No at question N*1). Ask only the questions 12-13-14 Question 8 For how many months did you breastfeed (NAME)?

Question 9 Why did you stop breastfeeding?

Question 10 How did you stop breastfeeding?

Question 11 Aside from breast milk, did (NAME) get anything at all to eat or drink yesterday or last night?

Question 12 Did (NAME) drink liquids yesterday during the day or at night?

Question 13 Did (NAME) eat foods yesterday during the day or at night?

Question 14 MUAC measurement for lactating women (Yes at question N*7 and child 0-5mths) or pregnant women with child 0-5mths

65 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 9.10. Annex 10: Plausibility check for AFG_201106_TKH_VF, ENA Delta software Version April 2011, Chal and Rustaq districts, Takhar province, Afghanistan, June 2011

Plausibility check for: AFG_201106_TKH_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 (1.9 %) Overall Sex ratio Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 4 (p=0.006) Overall Age distrib Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 2 (p=0.061) Dig pref score - weight Incl # 0-5 5-10 10-20 > 20 0 2 4 10 0 (5) Dig pref score - height Incl # 0-5 5-10 10-20 > 20 0 2 4 10 4 (15) Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >1.20 0 2 6 20 2 (1.10) Skewness WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (-0.08) Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (-0.17) Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <0.000 0 1 3 5 1 (p=0.015) Timing Excl Not determined yet 0 1 3 5 OVERALL SCORE WHZ = 0-5 5-10 10-15 >15 13 %

At the moment the overall score of this survey is 13 %, this is acceptable.

There were no duplicate entries detected.

Percentage of children with no exact birthday: 100 %

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

Age cat. mo. boys girls total ratio boys/girls ------6 to 11 6 59/45.4 (1.3) 27/36.9 (0.7) 86/82.3 (1.0) 2.19 12 to 23 12 94/88.6 (1.1) 71/71.9 (1.0) 165/160.5 (1.0) 1.32 24 to 35 12 89/85.9 (1.0) 91/69.7 (1.3) 180/155.6 (1.2) 0.98 36 to 47 12 80/84.5 (0.9) 67/68.6 (1.0) 147/153.1 (1.0) 1.19 48 to 59 12 66/83.6 (0.8) 59/67.9 (0.9) 125/151.5 (0.8) 1.12 ------6 to 59 54 388/351.5 (1.1) 315/351.5 (0.9) 1.23

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

Overall sex ratio: p = 0.006 (significant excess of boys) Overall age distribution: p = 0.061 (as expected) Overall age distribution for boys: p = 0.077 (as expected) Overall age distribution for girls: p = 0.035 (significant difference)

66 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011 Overall sex/age distribution: p = 0.000 (significant difference)

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

. no exclusion exclusion from exclusion from . reference mean observed mean . (WHO flags) (SMART flags) WHZ Standard Deviation SD: 1.22 1.18 1.10 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 11.7% 11.6% 10.3% calculated with current SD: 12.1% 11.3% 8.9% calculated with a SD of 1: 7.6% 7.6% 7.0%

HAZ Standard Deviation SD: 1.40 1.37 1.21 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 53.6% 53.4% 54.0% calculated with current SD: 51.1% 50.6% 51.7% calculated with a SD of 1: 51.6% 50.8% 52.1%

WAZ Standard Deviation SD: 1.13 1.10 1.00 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 30.5% 30.3% calculated with current SD: 34.5% 33.5% calculated with a SD of 1: 32.6% 32.1%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.166 HAZ p= 0.001 p= 0.002 p= 0.001 WAZ p= 0.000 p= 0.000 p= 0.454 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)

Skewness WHZ -0.32 -0.34 -0.08 HAZ 0.11 0.25 0.19 WAZ -0.45 -0.20 -0.10 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 1.71 0.48 -0.17 HAZ 0.60 0.34 -0.42 WAZ 1.97 1.00 -0.07 (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.

67 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011

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

WHZ < -2: ID=1.64 (p=0.015) WHZ < -3: ID=1.08 (p=0.353) Oedema: ID=1.00 (p=0.466) GAM: ID=1.65 (p=0.014) SAM: ID=1.45 (p=0.052) HAZ < -2: ID=1.22 (p=0.193) HAZ < -3: ID=1.45 (p=0.054) WAZ < -2: ID=1.27 (p=0.144) WAZ < -3: ID=1.43 (p=0.059)

Subjects with SMART flags are excluded from this analysis.

The Index of Dispersion (ID) indicates the degree to which the cases are aggregated into certain clusters (the degree to which there are "pockets"). If the ID is less than 1 and p < 0.05 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.

9.11. Annex 11: Seasonal calendar and critical events timeline, 2011, Afghanistan – Source: FEWS Net March 2011

68 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Chal and Rustaq districts, Takhar province – Afghanistan – June 2011