MUAC Survey Report
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MUAC Survey Report Yawan, Raghistan and Kohistan Districts Badakhshan Province July 16 – 29, 2011 1. Introduction 1.1. Background Medair’s nutrition programme (Integrated Nutritional Treatment and Community Health & Nutrition Education in Badakhshan Province – Afghanistan, AFG125) is covering three districts of Badakhshan (Yawan, Raghistan and Kohistan). The set up started in April 2011, with a centre opening in Yawan health clinic (Yawan district), followed by Ziriaki (Raghistan district) in May, and Paspul (Kohistan district) in June. The fourth centre, Shingan (Yawan district) then opened mid July. As part of the project a baseline nutrition survey was planned, to be followed at intervals by ongoing monitoring of key indicators across the project catchment areas. The staggered approach in setting up these centres was necessary to achieve quality screening, admission and treatment of malnourished women and children. The survey was planned for July before the onset of Ramadan in August, but because of further delays not enough time was available to do a full baseline survey. Ramadan started on August first and would clearly affect both survey results and the ability of staff to carry out the survey. Therefore it was decided to proceed with a quick MUAC cluster survey in order to at least establish baseline malnutrition rates before the beginning of Ramadan. 1.2. Survey objectives • To quantify the nutritional status of children 6-59 months based on Mid Upper Arm Circumference (MUAC) measurements • To quantify the nutritional status of pregnant and lactating women (PLW) based on MUAC measurements • To estimate the coverage of the feeding programme • To collect basic additional information needed to make recommendations for future programming 1.3. Geography Badakhshan is one of the 34 provinces of Afghanistan, located in the north eastern part of the country. It is one of the larger provinces but relatively sparsely populated and remote. The Ragh region (Yawan, Raghistan and Kohistan districts) is one of those isolated areas within the province. It is defined by high mountains with altitudes between 1400 and 3000 meters. Many villages can only be reached on small trails by horse or on foot. The main roads that connect the district centres with each other and the provincial capital Faizabad are poorly maintained and can only be driven in the summer. Many villages are completely inaccessible for up to seven months in the winter. For more information on geography see appendix 2 – map of the area. The survey was carried out in Yawan, Raghistan and Kohistan districts of Badakhshan Province. Villages within a 2 hour catchment area of the health clinics have been considered for cluster selection. A list of villages for the sampling frame can be found in Appendix 1. 1.4. Population According to the provincial profile the three districts Yawan, Raghistan and Kohistan have a total population of 71,830 people. The total population of the surveyed areas is 33,239 (11,585 people for Yawan, 3,743 for Shingan, 12,686 for Raghistan, and 5225 for Kohistan - figures based on EPI data 2011). The majority of the communities belong to the Tajik ethnic group with Dari as their main language. The communities live in isolated areas with little economic activity, limited access to markets and health care services, and poor access to safe drinking water. The population relies primarily upon subsistence farming and small scale livestock rearing. Medair - rapid MUAC survey, July 2011 Page 2 of 21 1.5. Primary health care and nutrition From 2002 – 2009 Medair implemented the Basic Package of Health Services (BPHS) in Yawan, Raghistan, Khwahan and Kohistan districts of Badakhshan province. In 2010 Medair handed the program over to Care for Afghan Families (CAF). In August 2009 high numbers of malnutrition were seen in these areas and Medair started a nutrition intervention. The Community Management of Acute Malnutrition (CMAM) project began in 2010 in Raghistan district, working through 9 sub-centres. Starting in January 2011 the CMAM nutrition program was integrated into 4 Ministry of Public Health (MoPH) / CAF health facilities in Raghistan, Kohistan and Yawan districts: Yawan (Yawan District), Ziriaki (Raghistan District), Paspul (Kohistan District) and Shingan (Yawan District). Children 6-59 months with GAM and PLW with a MUAC of < 23 cm are the target beneficiaries of this project. At the time of the survey nutrition programs were functioning in the district centres Yawan, Ziriaki and Paspul. In Shingan the nutrition clinic was in the process of being set up. In addition, nutrition and health education is delivered at household level in the target villages using the Care Group Model to encourage behaviour change. 1.6. Food security In 2008 there was a country wide drought, the most significant in recent years. In the Ragh region the population resorted to a range of coping strategies during the winter of 2008/2009. In spring 2009 the rainfall was unusually heavy and combined with late snow melt caused flash flooding and landslides. Because of that farmers in higher altitudes were unable to plant in time. In October 2009 the growing season ended prematurely due to the early onset of winter. Consequently the harvest was minimal for many people in the high altitudes of the Ragh region. The harvest in 2010 has been average to good, and the population started to recover from the previous 2 bad years. The first half of 2011 has been drier than usual. Areas are affected differently; the impact is localized and depending on the timing of planting and altitude. Fields in the Ragh region are mostly rain fed and therefore vulnerable to drought. It is still early to predict the outcome and effects since in most of the area the harvest has just started. According to Famine Early Warning System (FEWS) Badakhshan is stressed and there is a possibility of localized crop failure (June 2011 FEWS food security alert). For a seasonal calendar see appendix 5. 1.7. Security Badakhshan is rated as one of the more secure provinces in Afghanistan; however 2011 has seen deterioration in the general security situation, partly due to some resurgence of opium cultivation and trade in the area 1 and local conflicts, and partly due to increased movements of anti-government/opposition groups through the province. Prior to the survey 4 villages have been excluded for cluster selection because they have declined the assistance of foreign NGOs. One of the villages originally selected to be surveyed had to be excluded and replaced with another village because of community issues with the nutrition education programme. Originally 3 clusters have been included for the Shingan catchment area, however due to ongoing security problems in that region only 2 could be surveyed and the other had to be replaced with another randomly selected cluster. 1 Opium poppy strikes back: The 2011 Return of Opium in Balkh and Badakhshan Provinces (AREU, 2011) Medair - rapid MUAC survey, July 2011 Page 3 of 21 1.8. Past and current interventions of NGOs and UN agencies Table 1. NGOs and UN agencies in Yawan, Raghistan and Kohistan Districts Agency Activity Concern National Solidarity Programme (NSP) in all 3 districts Food security and vocational training activities CAF Support of the MoPH clinics in all 3 districts – BPHS implementer GIZ Infrastructure and power supply projects across the 3 districts, mainly in Yawan Medair CMAM and nutrition education project in all 3 districts WASH in Kohistan (2010/11), Raghistan and Yawan (2009/10) Food aid project in Kohistan (2010) Emergency survey and response (2011) WFP Food For Work (FFW) programs 2. Methodology 2.1. General approach and sampling procedures The survey has been conducted in the second half of July 2011, which corresponded with the beginning of the wheat harvest. SMART methodology and STATA11 were used in the planning, collection and analysis of the data. A 2-stage cluster sampling method was chosen with the clusters being randomly selected proportional to population distribution. All villages of the 4 clinic catchment areas have been included in the sampling frame. In total 30 clusters have been selected from the area. A list of villages included in the final sampling frame (with cluster selection) can be found in appendix 2. MUAC was measured and additional data collected and analyzed for 900 children aged 6-59 months and for 210 PLW. MUAC measurement has been chosen because it is relatively simple and more reliable to carry out than weight / height measurements, and can be completed in a short time. It also is the screening tool used in the communities and primary criteria for admission to the feeding programme. In order to explore potential barriers to the feeding programme the data collectors have been debriefed regularly throughout the survey about their informal findings when talking to the women in the villages. 2.2. Sampling procedure and sample size for the anthropometric data For the children 6-59 months the standard sample size of 900 (30 clusters x 30 children) has been chosen. For the PLW the sample size has been calculated using ENA “nutrisurvey” software for SMART methodology, assuming a 50% prevalence of malnutrition, precision of +/- 10%, and a design effect of 2. The sample size needed (192) was then rounded up to 210 (30 clusters x 7 PLW). 30 clusters were randomly selected by “nutrisurvey” proportional to the estimated population size. In each of the selected clusters, a minimum of 30 children and 7 PLW were measured. 2.3. Selection of households and children / respondents The EPI method was used in the random selection of households. The centre of the village or section was identified and a pen spun to determine a starting direction. The team then moved along in that direction to the periphery of the village or section, counting all the houses along the way.