Anthropometric nutrition survey
Children from 6 to 59 months
Pregnant – Lactating women
And
Infant and Young Child Feeding Practices study
Children from 0 to 23 months
Final Report
Saighan, Yakawlang and Panjab districts
Bamyan province, Afghanistan
From the 23 rd up to the 31 st 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 Saighan, Yakawlang and Panjab districts, Bamyan province with funding from 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 Saber Safi HMIS/Technical manager. This work would not have been possible without the dedicated efforts of the nutrition community and the local population in Afghanistan. We would like to thank:
• The Ministry of Public Health and particularly the Public Nutrition Department, for their collaboration in this project;
• The Nutrition Cluster body for their support;
• The community representatives of the surveyed villages who have supported the nutrition survey teams during the field data 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 Bamyan province and particularly in the selected districts;
• The entire ACF and AADA Teams for their great support in this project.
2 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 LIST OF ABBREVIATIONS
AAADA Agency for Assistance and Development of Afghanistan ACF Action Contre la Faim AKF Agha Khan Foundation BPHS Basic Package of Health Services CHC Comprehensive Health Centre CI Confidence Interval CMAM Community Management of Acute Malnutrition CSO Censes Statistics Office ENA Emergency Nutrition Assessment GAM Global Acute Malnutrition 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 TABLE OF CONTENTS
EXECUTIVE SUMMARY ...... 5 1. INTRODUCTION ...... 10 1.1. Agencies ...... 10 1.2. Surveyed area...... 11 1.3. Population data – Demography ...... 11 1.4. Geography – Climate ...... 11 1.5. Administrative organisation...... 12 1.6. Economic – Food security situation ...... 12 1.7. Water and sanitation situation...... 13 1.8. Health situation and intervention...... 13 1.9. Nutrition intervention...... 14 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...... 20 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: ...... 24 3.6 IYCF indicators ...... 25 3.7 Training and supervision...... 27 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 – Children 9-59 months...... 35 4.4. Vitamin A supplementation coverage – Children 6-59 months ...... 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...... 48 5.4 Nutritional risk - Pregnant/Lactating women ...... 49 5.5 Causal analysis...... 49 6. CONCLUSION...... 52 7. RECOMMENDATIONS...... 53 8. REFERENCES ...... 54 9. ANNEXES...... 55 9.1 Annex 1: Map of Bamyan province, Afghanistan (Source: MoPH) ...... 55 9.2 Annex 2: 3 Ws (Who is doing What and Where), Bamyan province, April 2011 (Source: OCHA).. 56 9.3 Annex 3: Cluster selection, Saygan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 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, Bamyan province, Afghanistan, July 2011 ...... 61 9.7 Annex 7: Local event calendar, Bamyan province, Afghanistan, July 2011...... 62 9.8 Annex 8: IYCF study – children 0-23 months old, Bamyan, Afghanistan, July 2011 ...... 63 9.9 Annex 9: Skip patterns - IYCF study – children 0-23 months old, Bamyan province, Afghanistan, July 2011...... 65 9.10 Annex 10: Plausibility check – AFG_201107_BAY_VF.as, Afghanistan, July 2011...... 66 9.11 Annex 11: Estimated percentage of population consuming a diet with very poor food group diversity, NRVA, Afghanistan, September 2005...... 69 9.12 Annex 12: Estimation food security conditions, 4 th quarter 2011 (October – December 2011) - FEWS Net...... 70
4 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 EXECUTIVE SUMMARY is one of the 34 provinces of Afghanistan. It is located in the ( ن :Bamyan Province (Persian central region of the country. Its capital city is also called Bamyan. The province is surrounded by other Afghan provinces: Ghor and Sari Pul to the west, Samangan to the north, Baghlan to the north-east, Parwan and Wardak to the east, and Day Kundi to the south. The province is composed of 7 districts. Out of the 7 districts, three were targeted by the anthropometric nutrition survey and IYCF study: Saighan, Yakawlang and Panjab districts. This decision was taken in regard to AADA’s area of intervention and the feasibilities to cover the districts. Indeed, to cover the whole province was not feasible as Bamyan is a large area with few road infrastructures and geographical constraints.
Methodology A SMART multi-stage cluster sampling method was applied using ENA software version April 2011 for the anthropometric nutrition survey and an IYCF study, based on “Indicators for Assessing Infant and Young Child Feeding Practices”, WHO et al. 2007.
Anthropometric measurements – Children 6-59 months 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 of 527 children, 31 clusters of 17 households were expected to be completed yet 2 clusters could not be finalized as the areas were not accessible during the data collection. In the end, a total of 493 households 1 were surveyed, while 521 were planned. Nevertheless, the minimum of 527 children was reached, since 567 children were included in the survey. However, due to extreme values or potential incorrect measurements, 12 entries were excluded to calculate acute malnutrition in weight for height, leaving a sufficiently high sample size of 555 children. 548 children had a height >= 65 cm, allowing the use of MUAC measurements. The minimum sample size of 198 households and 200 children required to estimate the prevalence of chronic malnutrition prevalence was largely achieved. 13 entries were excluded due to extreme values or potential incorrect measurements, leaving a final sample size of 549. Anthropometric measurements – Pregnant-Lactating women Following the selection of households for the anthropometric nutrition survey, all pregnant women with children 0-59 months and lactating women with children 0 to 5 months old included in the anthropometric survey and/or IYCF study and found at household level were to have their MUAC measured. No minimum sample size was calculated, the number depending 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, 39 pregnant women and 61 lactating women’s MUAC was measured, for a total of 100 women. The small sample size indicates that results are interpreted with caution. IYCF study No specific sample size was calculated, the number of children depending on the number of children 0-23 months old found at household level while conducting the anthropometric nutrition survey. At the end of the data collection, 67 infants less than 6 months and 173 children aged 6- 23 months for a total sample of 240 children 0-23 months were included in this study. Due to the small sample size, results must be interpreted with caution.
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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Main results
Anthropometric data are presented referring to WHO standards 2006.
Acute malnutrition prevalence – Children from 6 to 59 months old According to Weight for Height index– Children from 6 to 59 months old Prevalence of Acute malnutrition All Z-score 95% CI According to WHO standards – 2006 N = 553 Prevalence of global acute malnutrition N = 27 4.9 % (3.3 – 7.2 95% C.I.) (<-2 z-score and/or oedema) Prevalence of moderate acute malnutrition N = 22 4.0 % (2.5 – 6.3 95% C.I.) (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe acute malnutrition N = 5 0.9 % (0.4 – 2.1 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 WHO standards – 2006 N = 549 Prevalence of global malnutrition N = 32 5.8 % (3.6 – 9.4 95% C.I.) MUAC < 125mm Prevalence of moderate malnutrition N = 23 4.2 % (2.6 – 6.8 95% C.I.) MUAC >=115 <125mm Prevalence of severe malnutrition N = 9 1.6 % (0.7 – 3.5 95% C.I.) MUAC < 115mm
Chronic malnutrition prevalence – Children from 6 to 59 months old Prevalence of Chronic malnutrition All Z-score 95% CI According to WHO standards – 2006 N = 549 Prevalence of stunting N = 332 60.5% (54.4 – 66.3 95% C.I.) (<-2 z-score) Prevalence of moderate stunting N = 204 37.2% (32.7 – 41.9 95% C.I.) (<-2 z-score and >=-3 z-score) Prevalence of severe stunting N = 128 23.3% (18.9 – 28.4 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 0 0.0% 0 0.0% 0 0.0% ≥210 - <230 Moderate risk 5 12.8% 4 6.6% 9 9.0% ≥230 No risk 34 87.2% 57 93.4% 91 91.0% Total 39 100% 61 100% 100 100%
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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Measles vaccination coverage – Children from 9 to 59 months old All Measles vaccination coverage N (550) N % Confirmed with immunization card 309 56.2% Confirmed verbally by the caregiver but no immunization card to prove it 174 31.6% No immunization according to the caregiver 29 5.3% Unknown 38 6.9% Total 550 100%
Vitamin A supplementation coverage – Children from 6 to 59 months old All Vitamin A supplementation coverage N (610) within the last 6 months N % Vitamin A dose received 510 89.9% Vitamin A dose not received 21 3.7% Unknown 36 6.4% Total 567 100%
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 189 80,4% (74.8 – 85.3) breastfeeding (N=235*) one hour of birth Exclusive Proportion of infants 0-5 months of age who breastfeeding under 6 54 80,6% (69.1 – 89.2) are fed exclusively with breast milk months (N = 67) Continued Proportion of children 12 – 15 months of age breastfeeding at 1 40 88,9% (75.9 – 96.3) who are fed with breast milk year (N = 45) Introduction of solid, Proportion of infants 6-8 months of age who semi-solid or soft 12 66,7% (41.0 – 86.7) receive solid, semi-solid or soft foods foods (N =18) Proportion of children 6-23 months of age Consumption of iron- who receive an iron-rich food or iron-fortified rich or iron-fortified food that is specially designed for infants and 21 12,1% (7.7 – 18.0) foods (N =173 ) young children, or that is fortified in the home. OPTIONAL DEFINITION N % 95% CI INDICATORS Children ever Proportion of children born in the last 24 237 98,8% (96.4 – 99.7) breastfed (N =240) months who were ever breastfed Continued Proportion of children 20–23 months of age breastfeeding at 2 33 70,2% (55.1 – 82.7) who are fed with breast milk years (N =47) *5 entries “ I don’t know” excluded from denominator
7 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Conclusion
The anthropometric nutrition survey and the IYCF study conducted in Bamyan province have limitations. Causes of malnutrition could not be assessed and only assumptions can be made with regards to highlighted results. Acute malnutrition levels are not indicating an alarming or at risk situation, but still the nutrition situation trends need to be followed closely on a regular basis. The population in this province is categorized as chronically food insecure and hence is considerably vulnerable to changes of the socio-economic environment. The alarming rate of chronic malnutrition reflects the nutritional deficiency affecting the population on a long term process. More than half of the surveyed children were found to be stunted and almost one quarter was severely stunted. By intervening at an early stage through a multi- sectorial approach, chronic malnutrition can be prevented. Despite the mentioned limitations of this study, the prevalence of nutritional risk among women is concerning. According to State of the World Mothers report - Save the Children published in 2011, Afghanistan has been ranked the worst place in the world to be a mother. Performance on most of the other indicators places Afghanistan among the lowest-ranking countries in the world. Afghanistan has the highest lifetime risk of maternal mortality and the lowest female life expectancy in the world. It also places second to last on skilled attendance at birth, under-5 mortality and gender disparity in primary education. In addition, daily stressors (as poverty, unemployment, limited services...) and series of traumatic situations (conflict, insecurity, loss…) have a clear impact on the mental health conditions of people. This fragile psychosocial condition has a clear impact on child nutritional and health status, through care practices deterioration. Hence, special attention should be paid to women with the goal to improve the well being of the mothers and through them the well development of their children. Special attention should be paid to infants below 6 months old. Recent anthropometric data are almost not available at country level for this target group. Learnt from the ACF expertise over many years in Afghanistan, childcare practices appear to be especially involved in the aetiology of malnutrition and child survival and hence should be incorporated in the management of infants. It is important to acknowledge that, given the inclusion of 3 districts out of 7 in the province, the results of this survey are not representative for the whole province. The malnutrition situation in the excluded places should be assessed when feasible to provide a better view on the whole province. The drought affecting most of the northern regions in Afghanistan has not been reported to affect Bamyan province. Nevertheless, the situation in the coming months may deteriorate and for this reason the nutrition trends should be closely followed. The survey was conducted in July 2011, corresponding to the period of the main harvest, 2 months after the hunger gap, and when people are considered at the most food secure period of the year. Bamyan benefits from its stable security context with more opportunities and feasibilities to implement humanitarian projects compared to other places in Afghanistan. Numerous organizations are operating in this area in different fields of intervention. Only in the nutrition sector, 3 NGOs and 2 UN agencies are providing services to the population. This context allows expanding intervention to uncovered areas without facing the challenges that may impact interventions in other less stable provinces.
8 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Recommendations With regards to the main findings of this survey and in line with the national nutrition policy, the following recommendations are submitted:
To advocate to the Ministry of Public Health and the other health agencies operating in the studied area, to maintain the satisfactory Vitamin A supplementation coverage and to improve the measles vaccination coverage; out reach activities should be emphasized to cover population living in remote areas as well as people not seeking cares in health facilities;
To scale up CMAM project within the BPHS framework in the whole province in accordance with the national nutrition policy and in collaboration between the several health-nutrition actors present in the area; o In patient units should be implemented in all districts. 4 TFU are currently functional whereas not covering the 7 districts in Bamyan province; o Out patient Therapeutic Program (OTP) component should be implemented in each district. OTP distribution sites are only located in 1 district in the whole province; o SFP component should be extended to all districts. SFP distribution sites are only located in 4 districts; o Community mobilization program should be extended to remote areas as much as possible according to feasibilities;
To monitor the nutrition situation on regular basis. o To improve the regular collection of data through the HMIS to enable the monitoring of nutrition trends on a regular basis; o To conduct further nutrition surveys. According to the nutrition national policy, surveys should be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in nutritional situation; Areas excluded from this survey should be considered while conducting further surveys; o To conduct nutrition surveys in the coming months to evaluate the drought impact if the situation is worsening according to the humanitarian community; o To use follow-up surveys to compare the nutritional situation between 2 periods; o To evaluate the nutritional status of infants below 6 months in a separate survey;
To improve IYCF education, counselling by health professionals and peer support groups, so as to improve IYCF practices and through them the children’s health;
9 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 1. INTRODUCTION
1.1. Agencies The anthropometric nutrition survey and IYCF study were conducted in partnership between 2 agencies: ACF and AADA.
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 AADA to conduct an anthropometric nutrition survey and IYCF study in Bamyan province in July 2011.
Agency for Assistance and Development of Afghanistan (AADA) is a non-political, non profit and independent organization founded in September 2005. The organization was registered with the NGOs Department of the Ministry of Economy of the Islamic Republic of Afghanistan on 8 th of September 2005 with the registration # 33. AADA aims to contribute to the development of Afghanistan through provision of developmental and humanitarian services in public health, agriculture and community development sectors; and training and capacity/skill building of Afghans – both professionals and laypersons – in various disciplines and skills. The vision of AADA is to contribute to peace and prosperity in Afghanistan through empowerment of Afghan communities. AADA is working towards realization of its vision through various strategic approaches that are believed to be context-specific, technically sound and practically achievable. AADA has a well- defined mission which will help the organization to realize its dream of “Prosperity and health for all”. The mission statement of AADA is “To serve as a centre of excellence committed to improving the lives of Afghan communities, especially women, children and the other vulnerable groups – youth, Internal Displaced People’s, drug addicts, and ethnic minorities”. The three main strategic objectives of AADA outlined below are based on the striking needs of the mostly underprivileged people of Afghanistan, and at the same time, are in line with the overall developmental objectives of the government of Afghanistan. 1. To contribute to the achievement of lower maternal, under-five and infant mortality rates as targeted by the government of Afghanistan; 2. To contribute to the achievement of better standards of living for Afghans, as recommended by the millennium declaration of the United Nations, and will be indicated by improvement in socio-demographic indicators and indices; and 3. To significantly improve level of knowledge and skills of professional and common Afghans in issues and skills related to development of individuals and the community.
10 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 AADA is working mainly through 3 interrelated, yet distinct strategic approaches to reach to its objectives. These approaches are: 1. Design and implementation of community development programs; 2. Provision of primary and secondary health services according to the standards of the Ministry of Public Health of the Islamic Republic of Afghanistan; 3. Building capacities and skills of common Afghans and professional of different fields and sectors.
1.2. Surveyed area is one of the 34 provinces of Afghanistan. It is located in the ( ن :Bamyan Province (Persian central region of the country. Its capital city is also called Bamyan. The province is surrounded by other Afghan provinces: Ghor and Sari Pul to the west, Samangan to the north, Baghlan to the north-east, Parwan and Wardak to the east, and Day Kundi to the south (Map – Annex 1). The province is composed of 7 districts. Out of the 7 districts, three were targeted by the anthropometric nutrition survey and IYCF study: Saighan, Yakawlang and Panjab districts. This decision was taken with regards to AADA’s area of intervention and the feasibilities to cover the districts. Indeed, it would have been complicated to cover the whole province as Bamyan is a large wide-spread area with few road infrastructures and many geographical constraints.
1.3. Population data – Demography According to CSO Population Data 2010/2011, 343,537 inhabitants are living in Bamyan province forming around 56,720 households (giving an average of 6.0 people per HH). The majority of the population living in Bamyan province is Hazaras, with Sadat, Tadjiks, Pashtuns and Tatars in smaller numbers. Bamyan is the largest province in the Hazarajat region of Afghanistan and is the cultural capital of the Hazara ethnic group that is predominant in the area. Dari is spoken by 96% of the population. In several other villages, the main language spoken is Pashtu. According to CSO Data 2010-2011, 100% of the population lives in rural areas; indeed there is no urban centre in the whole province. The majority of the province's population lives within the river valleys that cut through the high plateaus and mountains of the province. The Bamyan river valley, that runs through Bamyan, Shibar, and Saighan, is the most populated, second is the Band-e Amir valley, Yakawlang District. Bamyan province is only a summer area for Kuchi nomads, no Kuchi people stay there during winter. In the summer, migratory Kuchis come to Bamyan province from Nangarhar, Logar and Balkh provinces. Few households are coming from Khost, Samangan, and Saripul. Bamyan is said to be one of the preferred summer areas for the Kuchi population.
1.4. Geography – Climate Bamyan province lies on the highlands of Afghanistan. The province covers an area of 17.414 km 2 of mostly dry, mountainous terrain with a number of rivers, the largest being the Punjab. Almost the whole province is mountainous (77,5%) or semi mountainous (16,1%), while only 1.8% of the area is made up of flat land 3.
3 CSO/UNFPA Socio Economic and Demographic Profile
11 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Two rivers dominate the province: the Band-e Amir river valley and the Bamyan river valley, where most of the population is concentrated. The transport infrastructures in Bamyan are not well developed, with few roads in the province able to take car traffic in all seasons, and a slightly higher proportion which can take car traffic in some seasons. In nearly 21% of the province there are no roads at all 4.
1.5. Administrative organisation Afghanistan is divided in 34 provinces which are then divided into 401 districts, on their turn divided into cities or villages. These cities or villages constitute the smallest administrative organisation. Bamyan province is composed of 7 districts, comprising 1852 cities/villages according to CSO population data 2010/2011. Out of these 7 districts, only 3 were included in the survey: Saighan, Yakawlang and Panjab districts, which represent 853 villages in total. Out of these 853, 31 villages corresponding to 31 clusters were selected as a representative sample for the three districts.
1.6. Economic – Food security situation The majority of commercial activity in Bamyan is related to trade in agricultural and hand craft. Agriculture is the major source of revenue for most of the households. Almost all households own or manage agricultural land or garden plots in the province. A very small proportion of households in rural areas derive some income from trade and services. Around half of households earn income through non-farm related labour. Livestock also accounts for the income of more than one-third of rural households. The production of industrial commodities such as cotton, sugar, sesame, tobacco, olives and sharsham is restricted to a few villages in the whole province. Most of these villages are concentrated in the Waras and Saighan districts. Small industries are scarce in Bamyan Province; a few exist in Bamyan, and in Panjab districts. Some industries are engaged in the production of honey, silk, confection, Karakul skins, sugar candy, dried sugar and sugar sweets. Bamyan has been particularly famous for its potatoes. The region is also known for a "shuttle system" of planting, wherein seed potatoes are grown in winter in Nangarhar province, a warm area of eastern Afghanistan, and then transferred to Bamyan for spring re-planting. Handicrafts, on the other hand, are produced in all districts in Bamyan province but particularly in Waras, Panjab, and in Bamyan. Rugs, shawl making, jewelry and carpets are the main productions. Almost all households in the province own livestock or poultry. The most commonly owned livestock are donkey, cattle, sheep, goats and oxen. With regards to security context and military intervention, Bamyan is recognized as one of the safest provinces in the country. At the time of this report writing, it is the base of operations for the New Zealand peacekeeping force, a Provincial Reconstruction Team (PRT) codenamed Task Group Crib, which is part of the network of Provincial Reconstruction Teams throughout Afghanistan.
4 CSO/UNFPA Socio Economic and Demographic Profile
12 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 1.7. Water and sanitation situation
In Bamyan province, only 8% of households on average use safe drinking water. More than nine- tenths (91%) of households have direct access to their main source of drinking water within their community, however nearly one-tenth (9%) of households has to travel for up to an hour to access drinking water 5 According to NRVA – 2005, no one in the whole province has access to safe toilet facilities. The following table shows the kinds of toilet facilities used by households in the province.
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 % 15 7 46 32
1.8. Health situation and intervention 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.
Today, the agency AADA is the BPHS implementer in Bamyan province. AADA activities are implemented in the 7 districts of the province (Bamyan, Yakawlang, Shibar, Kahmard, Saighan, Waras and Panjab) following the BPHS framework and the National Health policy. In addition, the agencies IbnSina and Agha Khan Foundation (AKF) are bolstering both BPHS and EPHS components of the health system in Bamyan province in Shibar and Bamyan districts. Based on this framework, a basic infrastructure of health services exists in Bamyan province. According to HMIS information provided in 2011, there were 53 health centres and 4 hospitals with a total of 189 beds in the province. There are also 49 doctors and 144 nurses employed by the Ministry of Health working in this area. Accessibility to healthcare is rather difficult for a large proportion of the population, and just fewer than two of thirds of residents have to travel over 5kms to get medical attention (85%) 6. Based on HMIS statistics, the main diseases affecting children below five years are diarrheal diseases and acute respiratory infections. The main diseases affecting pregnant and lactating women are anaemia and infectious diseases. Malaria and acute watery diarrhoea are reported as well as affecting the local population. Immunization services are provided to the population living in Bamyan province through the existing health facilities. In addition, regular vaccination campaigns are conducted all over the country by the MoPH and partner agencies. For instance, the last polio immunization campaign including Vitamin A supplementation was conducted in September 2011. Actors such as AADA, Provincial Public Health Department (MoPH), UNICEF, WHO and AKF are participating in these campaigns in Bamyan province.
5 NRVA 2005 6 NRVA 2005
13 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 1.9. Nutrition intervention Regarding nutrition activities, several actors are involved in the prevention and treatment of acute malnutrition such as AADA, Save the Children UK, and AKF. UNICEF and WFP are supporting these projects which correspond to the Community based Management of Acute Malnutrition (CMAM) framework and are implemented as follows:
Save the Children UK’s project: Treatment of Severe Acute Malnutrition in Outpatient Therapeutic Program (OTP) with 4 distribution points in Yakawlang district running only since April 2011; AKF’s project: Treatment of Severe Acute Malnutrition in Inpatient - Therapeutic Feeding Unit (TFU) located in Bamyan Provincial Hospital; AADA’s project: Treatment of Severe Acute Malnutrition in 3 Inpatient - Therapeutic Feeding Unit (TFU) located in three district hospitals (Panjab ,Waras and Yakawlang). These units are functional since 2009; Treatment of Moderate Acute Malnutrition in Supplementary Feeding Program (SFP) implemented in 24 distribution points in 4 districts: Waras, Panjab, Yakawlang and Bamyan. The distribution points are located in 8 Comprehensive Health Centers, 13 Basic Health Centers and 3 District Hospitals. Treatment is provided for children 6-59 months old and pregnant-lactating women. These SFP centers have only been running since 2009;
No Stabilization Centers are functional in the whole province. Both AADA and Save the Children UK are implementing community mobilization projects. Save the Children UK runs the community mobilization component as part of the CMAM framework in their target district of Yakawlang. AADA implements community mobilization as per BPHS policy recommendation in its areas of operation in the whole province. At the time of this report writing, AADA was conducting a household survey to assess the community growth monitoring in children under five years old. This survey was conducted through BASICS Demonstration Project only in two health facilities’ catchment area in Bamyan districts (Sadat and Foladi Comprehensive Health Centers).
1.10. Humanitarian intervention Multiple humanitarian organizations are operating in Bamyan province. The province is considered as one of the safest area in Afghanistan, allowing agencies to implement projects efficiently. The 3Ws (Who is doing What and Where) released by the UN agency OCHA in April 2011 summarizes the organizations operating in different fields of intervention in the province and is presented in annex 2.
E
14 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 2. SURVEY GOALS AND OBJECTIVES
The current survey aims to collect representative nutrition and IYCF data at the level of AADA’s work area; this will allow monitoring the population’s nutritional status and IYCF practices as part of AADA’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 AADA was to ensure the capacity building of AADA’s staff on how to conduct anthropometric nutrition surveys. AADA’s staff was supported by ACF core survey team for the whole survey process. Further objectives are:
To estimate the prevalence of acute malnutrition in children aged from 6 to 59 months in Saighan, Yakawlang and Panjab districts, Bamyan province.
To estimate the prevalence of chronic malnutrition in children aged from 6 to 59 months in Saighan, Yakawlang and Panjab districts, Bamyan province.
To estimate the nutritional risk in pregnant and lactating women from households included in the anthropometric survey and the Infant and Young Child Feeding study, in Saighan, Yakawlang and Panjab districts, Bamyan province.
To estimate the measles vaccination coverage in children aged from 9 to 59 months in Saighan, Yakawlang and Panjab districts, Bamyan province.
To estimate the coverage of vitamin A supplementation for children aged from 6 to 59 months old in Saighan, Yakawlang and Panjab districts, Bamyan province.
To obtain quantitative data on Infant and Young Child Feeding (IYCF) practices using the WHO IYCF indicators 7 in Saighan, Yakawlang and Panjab districts, Bamyan province.
7 WHO. Indicators for Assessing Infant and Young Child Feeding Practices - 2008
15 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 3. METHODOLOGY
3.1. Sampling strategy: sampling design and sample size calculation
A SMART ©8 multi-stage cluster sampling method was used for the anthropometric nutrition survey and IYCF practices study conducted in Saighan, Yakawlang and Panjab districts, Bamyan province. The sampling frame consisted of the total villages from Saighan, Yakawlang and Panjab districts. The primary sampling unit is the cluster. The smallest administrative unit being the village, clusters always corresponded to villages, or several villages where the number of households was too low. The basic sampling unit was the household. Here, a household was defined as all people eating from the same pot, according to WFP definition. According to population figures provided in 2010-2011 by the Censes Statistics Office, the data per districts are presented in the table 1 as follows.
Table 1: Population figures, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 – Source: CSO 2010-2011
District Nber Villages Total pop Pop Male Pop Female Pop U5 Pop PLW Total HH 9 Saighan 62 23,215 11,779 11,436 4,643 1,857 3,793 Yakawlang 351 66,158 33,195 32,963 13,232 5,293 10,755 Panjab 440 48,397 24,118 24,279 9,679 3,872 8,080 TOTAL 853 137,770 69,092 68,678 27,554 11,022 22,628
Overall, the population is sedentary. Nevertheless, some Kuchi nomads migrate to this province during the summer time. The population movement is not considerable and hence does not lead to consequent changes in the area. The survey targets the sedentary 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 15% global acute malnutrition prevalence estimation with a desired precision of 4.5% and a design effect equal to 2. The table below explains the reasoning behind all parameters used for sample size calculation.
Table 2 :Calculation of Sample Size for Global Acute Malnutrition, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Parameters Value Justification Estimated 15 According to the HMIS screening data on 35,467 children in the Prevalence of 3 target districts in 2010 provided by AADA, 12.3% were GAM (%) moderately malnourished and 0.8% severe. These rates may under estimate the actual prevalence as it represents only passive screening data at health facilities level and not nutritional data collected at community level. Taking this into consideration, the GAM prevalence was estimated at 15%.
8 Standardized Monitoring and Asses sment in Relief and Transition, see web site www.nutrisurvey.de/ena/ena.html 9 HH = Household
16 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 ± Desired precision 4.5 For an expected GAM of 15%, a precision of 4.5% was (%) considered appropriate. Design Effect 2 The target area is wide spread and densely populated. Population is considered as heterogeneous with regards to access to socio-economic development. Average HH Size 6.1 According to the CSO statistics, the average household size is around 6.1 members in Saighan, Yakawlang and Panjab districts. % Children under-5 20 According to the national nutrition policy N° of children 6 – 1.1 The assumption made by ENA software is that children 6-59 59 months per HH months represent approximately 90% of the population U5. Average n° of children is then calculated taking in to 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 had to be considered at planning stage. Children 6-59 months to be included (according to ENA) : 527 Households to be included (according to ENA): 521
The sample size for the determination of the chronic malnutrition prevalence was estimated at minimum of 200 children and 198 households based on the calculations shown in table 3. According to the National Nutrition survey conducted by the MoPH in 2004, the stunting is estimated at 60.5% and no more recent data concerning stunting are available.
Table 3 : Population expected to be surveyed for anthropometric nutrition survey and the estimation of chronic malnutrition, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Estimated Average % of non % Children Households Survey prevalence Desired Design Household Response Children 6-59 to be to be areas of chronic precision effect size Households under five included included malnutrition Saighan, Yakawlang and 60.5% 10% 2 6.1 8% 20% 200 198 Panjab districts
At the end of the data collection, only 493 households were visited. This was due to the cancelation of 2 clusters (17 households per cluster) as they could not be reached. 38 households did not have children under five. 455 households had children under five, including 24 households with only infants less than 6 months old. A final sample of 569 children 6-59 months including 2 absentees and 47 infants less than 6 months old were found in the 455 visited households. By excluding these 2 children 6-59 absent, the data analysis is done on 567 children, exceeding the minimum requirement of 527 children. Due to extreme values or potential incorrect measurements, 14 entries were taken out of the database for acute malnutrition, 18 out of the database for chronic malnutrition.
17 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 According to these statistics, the average of children 6-59 months per household is 1.3 while it was estimated at 1.1 according to ENA software and CSO statistics (Table 2 – Number Children 6-59 months per HH). 2 children were absent at the time of the survey and no household refused to take part, leading to a non-response rate of nearly 0; much lower than the expected 8%. Traditional habits in Bamyan province are less restrictive toward women than in other provinces. The nutrition survey teams were welcome in all visited places even during the absence of the male head of household. Children absent at the time of the visit were searched again by the nutrition survey team before leaving the place. In addition, the population was cooperative bringing in missing children where required and where possible.
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. 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.
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 survey. At national level and for children from 12 to 23 months old, the measles vaccine coverage is estimated at 62.6% 10 . The design effect of this outcome was fixed at 4. Indeed, it often happens that some villages are covered by immunization campaign while some others may have not been targeted. The desired precision was set at 10%. o 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 11 , 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 1.1 = 1.04 children aged 9 to 59 months per household o That is: 1.04/6.1 = 0.171, or 17.1% of the total population. The sample size needed was 372 children. Number of units needed from the target group/ ratio of target group per HH: o N (HH) = 388/1.04 = 373 households. Application of the non-response rate (8%, or 0.08): o N final = 373/(1-0.08) =406 households Hence, the minimum to reach was fixed at 406 households to find 372 children aged 9 to 59 months. At the end of the data field collection 550 children 9 to 59 months were surveyed, largely reaching the required sample size. The proportion of children 9-59 months out of the total sample of children 6-59 months is 97%, which is slightly higher than the estimation provided by the anthropometric survey done in Day Kundi in October 2010 of 95%.
10 Afghanistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan 11 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 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 expected to be included in the Vitamin A supplementation coverage study. At national level and according to the MoPH Health survey done in 2006, more than three quarters (76.5%) of children 6-59 months of age received Vitamin A in the last six months. Indeed, Vitamin A is often given during polio campaigns. 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 not have been targeted. With a desired precision of 10% and an expected coverage of 76.5%, the sample size was estimated at 301 children and 298 households. Indicators such as the average of household size, the percentage of non response households and the proportion of children under five, were similar to the ones used for the calculation of the anthropometric sample size. At the end of the data collection, 493 households were visited and 567 children were included in the data analysis; largely reaching the minimum requirement of 301 children.
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 data collection, only 39 pregnant women with children 6-59 months old and 61 lactating women breastfeeding an infant less than 6 months old were found at household level, for a total of 100 women screened by MUAC. No pregnant women with children 0-5 months were found. The sample size used for estimating the prevalence of nutritional risk according to MUAC criterion among pregnant/lactating women is considerably 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. The infants less than 6 months found at those households, although excluded from the anthropometric survey, were still included in the IYCF study. 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 these limits of the study, the lack of precision for the IYCF indicators should be acknowledged. Hence results presented further in this report have to be interpreted with caution. At the end of the data field collection, 67 infants less than 6 months and 173 children 6-23 months were found in the visited households for a total sample of 240 children 0-23 months.
19 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 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 17 households per day, taking into consideration transportation time to reach the clusters and other factors such as the time needed to meet the community leaders as well as the time to conduct the interview, estimated at 25 minutes. This created the need for 31 clusters. Out of 853 villages, 31 villages, corresponding to 31 clusters were included in the survey and are listed in annex 3. 4 Reserve Clusters (RCs) were selected by ENA software, to be used only if 10% or more clusters were impossible to reach during the survey. In that case, all RCs should be surveyed. Due to difficulties of access, 2 clusters could not be completed: cluster number 7 corresponding to Hazar Chasma Ganda Jowi village and cluster number 31 corresponding to Dahan Taher village. No reserve cluster was surveyed as less than 10% of the total sample was cancelled by excluding the 2 mentioned clusters (6,4%). If several clusters were to be surveyed in one village, then the village was divided into surveyable segments of 150 households or less using the Probability Proportional to Population Size (PPS) methodology. Selected segments became the clusters to be surveyed and other segments were ignored (Annex 4). This methodology was not applied as no selected village contained more than one cluster. In villages having only one selected cluster and the size of the area to survey was equal or over 150 households or scattered, a second selection could be launched according to the SMART segmentation methodology. This methodology was not applied as only one village had more than 150 households but segmentation was not required as households were located close to each other and the data collection could be performed easily.
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. Subjects must nevertheless 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 teams to conduct their work by providing information about the village as the geographical organization or the number of households. A map of the selected village was drawn when arriving in the cluster. From this map, the systematic random sampling method was used for the selection of households to survey.
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. Since the population size in the selected villages was equal to or below 150 households and not scattered, no intermediate step to subdivide the population into segments was necessary. The households included in the cluster were selected by using the systematic random selection as described below. The following steps were respected and a household selection sheet was completed in order to ensure the respect of this methodology (Annex 5):
20 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 1. The “sampling interval” was determined by dividing the total number of households in the cluster by the number that must be visited (17 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. 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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 are often linked to sex and age. For each selected child, the following information was collected:
1. Age (in months): Only children between 6 and 59 months old or if the age was not available height >= 65 cm and < 110 cm as a proxy for age were included in the sample. Age was confirmed by showing a vaccination card or a birth certificate. If these documents were not available, the use of a local event calendar built for Bamyan province helped to determine the age (Annex 7). The age was recorded into the questionnaire in months. 2. Sex: M=male and F=female 3. Weight (in kg): Children were weighed by using an Electronic Uniscale. The children who could easily stand were asked to stand on the weighing scale and their weight was recorded. 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 100 grs 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 has been immunized against measles or not, and if there is a vaccination card to prove it. The analysis excludes children less than 9 months 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.
22 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 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. 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 excluded from the anthropometric nutrition survey were equally included in the IYCF questionnaire. The IYCF questionnaire is based on the WHO guidelines 12 . Additional indicators were incorporated to the questionnaire to enable deeper analysis.
3.4.3 MUAC for Lactating women with children 0-5 months 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.
12 WHO. Indicators for Assessing Infant and Young Child Feeding Practices - 2008
23 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 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 13 ). 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.
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.
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.
13 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
24 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 5: Definition of acute malnutrition 14 according to weight-for-height index (W/H), expressed as a Z- score according to WHO standards Severe Acute Malnutrition ( SAM) z-score W/H <-3 z-score and /or bilateral oedema and/or MUAC < 115 mm Moderate Acute Malnutrition z-score W/H <-2 z-score and >= -3 z-score and absence of bilateral oedema and/or MUAC >= 115mm and <125mm Global Acute Malnutrition (GAM) z-score W/H <-2 z-score and /or bilateral oedema and MUAC < 125 mm
3.5.2 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:
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 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.
14 WHO, use and interpretation of anthropometric indicators of nutritional status, Bulletin of the WHO,64 (6) : 929-941 (1986)
25 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 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). o 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. 7. Minimum acceptable diet: Proportion of children 6-23 months of age who receive a minimum acceptable diet (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.
26 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 3.7 Training and supervision Four teams of four members conducted the data collection in Bamyan province. Each team was composed of one ACF team leader, one AADA facilitator and two data collectors. 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 nutrition program manager and ACF nutrition team leader on a daily basis. Due to security constraints, ACF health-nutrition coordinator could not supervise the field work. Nevertheless, a short visit was organized at the mid term of the data collection to check the completed clusters and to organize refresher training sessions accordingly. Moreover, the ACF health-nutrition coordinator has supervised the work at village level during one day (1 cluster conducted by 1 team). Due to their heavy workload, AADA could not provide a nutrition focal point to follow up the whole survey process. The entire team received a 5-days training on the survey methodology and all its practical aspects. The session was managed by the ACF nutrition team leader. 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 6 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 Bamyan town on the fourth day, in order to evaluate the work in real field conditions. Feed back was provided to the team with regards to the field test. 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 guidelines 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 3 other anthropometric nutrition surveys in the country in 2011. Hence, they were pre-tested and their quality was ensured. Refresher training sessions were organized during the data collection. Indeed, analysis of the data collected was done on a daily basis using different evaluation tools. Refresher 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 - 2006 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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=567, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Age groups Boys Girls Total Ratio No. % No. % No. % Boy:girl 6-11 months 25 61 16 39 41 7.2 1.6 12-23 months 64 47.8 70 52.2 134 23.6 0.9 24-35 months 66 52 61 48 127 22.4 1.1 36-47 months 62 46.6 71 53.4 133 23.5 0.9 48-59 months 64 48.5 68 51.5 132 23.3 0.9 Total 281 49.6 286 50.4 567 100 1
The sex ratio of 1.0 (0.98) is acceptable and validates the representativeness of the sample in terms of sex representation. Moreover, the sex distribution is well balanced according to age groups except for the age group 6-11 months. 61% of the children 6-11 months were boys while only 39% were girls. 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=567, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011
Distribution per age of children surveyed, n= 567, Saighan, Yakaw lang and Panjab districts, Bamyan province, Afghanistan, July 2011
23.6 23.5 25 22.4 23.3
20
15
10 7.2 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 7.2% out of the total sample). 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 4.1.2 Anthropometric results: children (based on WHO standards 2006)
4.1.2.1 Acute malnutrition prevalence expressed in Z-score The analysis of the malnutrition prevalence based on weight for height according to WHO standards is done with a sample of 553 children out of the 567 children surveyed, 14 children being excluded as their data were more likely to be aberrant than actual values according to the SMART flagging system 15 . The results are presented in the table below. It is important to take into account that children were weighed with a minimum of clothes. 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=553, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Prevalence of Acute malnutrition All Z-score 95% CI According to WHO standards N = 553 Prevalence of global acute malnutrition N = 27 4.9 % (3.3 – 7.2 95% C.I.) (<-2 z-score and/or oedema) Prevalence of moderate acute malnutrition N = 22 4.0 % (2.5 – 6.3 95% C.I.) (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe acute malnutrition N = 5 0.9 % (0.4 – 2.1 95% C.I.) (<-3 z-score and/or oedema)
The Global Acute Malnutrition (GAM) rate expressed according to WHO standards can be considered as low, being of 4.9 % [3.3 – 7.2 95% CI] in Saighan, Yakawlang and Panjab districts, Bamyan province. This rate is well inferior to the threshold of 15% determined by the WHO Expert Committee classification for wasting 16 . The GAM was estimated at 15% at planning stage according to AADA data. The difference between the expectation and the results raised by this survey can be partially explained due to difference in methodologies for gathering the data used as reference. The statistics provided by AADA reflect the nutritional status of children seeking care in health facilities, thus supposedly ill children, while this survey is reflecting the state of children found at household level. Hence, the expected GAM was over-estimated. The index of dispersion has a p>0.05 (p=0.367), meaning that GAM cases are not aggregated in some clusters and so that no pockets of malnutrition were identified within the target area.
Table 10: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex, WHO standards, n=553, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Prevalence of acute malnutrition All Boys Girls WHO standards N = 553 N = 272 N = 281 (27) 4.9 % (12) 4.4 % (15) 5.3 % Prevalence of global malnutrition (3.3 - 7.2 95% (2.4 - 8.0 95% (3.2 - 8.8 95% (<-2 z-score and/or oedema) C.I.) C.I.) C.I.) (22) 4.0 % (9) 3.3 % (13) 4.6 % Prevalence of moderate malnutrition (2.5 - 6.3 95% (1.6 - 6.9 95% (2.5 - 8.3 95% (<-2 z-score and >=-3 z-score, no oedema) C.I.) C.I.) C.I.) (5) 0.9 % (3) 1.1 % (2) 0.7 % Prevalence of severe malnutrition (0.4 - 2.1 95% (0.4 - 3.2 95% (0.2 - 2.9 95% (<-3 z-score and/or oedema) C.I.) C.I.) C.I.)
15 SMART flags being considered (+/- 3SD from the observed mean) 16 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 The difference in prevalence of acute malnutrition between boys and girls is not statistically significant as the confidence intervals are largely overlapping and p>0.05. No cases of bilateral oedema were reported by the teams on the field.
Table 11: Prevalence of acute malnutrition by age based on weight-for-height z-scores and/or oedema, WHO standards, n=553, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 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 36 0 0.0 3 8.3 33 91.7 0 0.0 12-23 133 3 2.3 12 9.0 118 88.7 0 0.0 24-35 124 1 0.8 3 2.4 120 96.8 0 0.0 36-47 131 0 0.0 0 0.0 131 100.0 0 0.0 48-59 129 1 0.8 4 3.1 124 96.1 0 0.0 Total 553 5 0.9 22 4.0 526 95.1 0 0.0
Young children are more vulnerable to acute malnutrition than older children. 18 children from 6 to 23 months old out of 169 were detected as acutely malnourished (representing 10.69%) while only 9 children from 24 to 59 months old were acutely malnourished out of 384 (corresponding to 2.34%) (Relative risk = 4.54 (2.08 Curve 1: Distribution of weight-for-height z-scores vs. reference, WHO standards (WHZ), n=553, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 The distribution of the weight for height index expressed in Z-score in comparison to the reference curve is almost similar to the reference curve, meaning that the surveyed children do not have a relative weight for height deficit compared to the reference population. The observed mean ± SD for WHZ (n=553) equals -0.33 ±0.98. The design effect WHZ is 1.08, reflecting the homogeneity of the population. 30 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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 549 children with a height >= 65 cm out of the 567 children surveyed. These results have to be interpreted with caution as the confidence intervals are wide. The plausibility check shows some digit preference for MUAC measurements, potentially leading to bias (Score = 11, considered as poor). Table 12: Prevalence of acute malnutrition based on MUAC criterion according to WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Prevalence of Acute malnutrition All % 95% CI According to WHO standards – 2006 N = 549 Prevalence of global malnutrition N = 32 5.8 % (3.6 – 9.4 95% C.I.) MUAC < 125mm Prevalence of moderate malnutrition N = 23 4.2 % (2.6 – 6.8 95% C.I.) MUAC >=115 <125mm Prevalence of severe malnutrition N = 9 1.6 % (0.7 – 3.5 95% C.I.) MUAC < 115mm The prevalence of acute malnutrition according to MUAC criterion is low, similar to the acute malnutrition rate expressed in weight for height z-score. Table 13: Prevalence of acute malnutrition based on MUAC criterion and by sex, WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Prevalence of acute malnutrition All Boys Girls MUAC criterion - WHO standards N = 549 N = 273 N = 276 Prevalence of global malnutrition (32) 5.8 % ( 9) 3.3 % (23) 8.3 % MUAC < 125mm (3.6 – 9.4 95% C.I.) ( 1.7- 6.2 95% CI) (5.1 – 13.2 95% C.I.) Prevalence of moderate malnutrition ( 23) 4.2% ( 7) 2.6% ( 16) 5.8% MUAC >=115 <125mm ( 2.6- 6.8 95% CI) ( 1.2- 5.6 95% CI) ( 3.7- 9.1 95% CI) Prevalence of severe malnutrition ( 9) 1.6% ( 2) 0.7% ( 7) 2.5% MUAC < 115mm ( 0.7- 3.5 95% CI) ( 0.2- 3.0 95% CI) ( 1.1- 5.9 95% CI) Girls seem more affected by acute malnutrition than boys according to MUAC criterion (Relative risk = 2.53 (1.19 Table 14: Prevalence of acute malnutrition according to Mid Upper Arm Circumference (MUAC) classification and age groups, WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Age Total MUAC < 115 mm MUAC >= 115 < 125 mm MUAC >= 125 mm groups n N % N % N % 6-11 12.5% 12.5% 75.0% months 24 3 ( 3.8-34.0 95% CI) 3 ( 3.6-35.5 95% CI) 18 (53.2-88.8 95% CI) 12-23 4.5% 12.0% 83.5% months 133 6 ( 1.8-10.9 95% CI) 16 ( 6.6-21.0 95% CI) 111 (72.2-90.7 95% CI) 24-35 0.0% 2.4% 97.6% months 127 0 ( 0.0- 0.0 95% CI) 3 ( 0.7- 7.3 95% CI) 124 (92.7-99.3 95% CI) 36-47 0.0% 0.0% 100.0% months 133 0 ( 0.0- 0.0 95% CI) 0 ( 0.0- 0.0 95% CI) 133 ( 0.0- 0.0 95% CI) 48-59 0.0% 0.8% 99.2% months 132 0 ( 0.0- 0.0 95% CI) 1 ( 0.1- 5.5 95% CI) 131 (94.5-99.9 95% CI) Total 1.6% 4.2% 549 9 ( 0.7- 3.5 95% CI) 23 ( 2.6- 6.8 95% CI) 517 - 31 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 According to results shown in the table above, young children 6-23 are more affected by acute malnutrition than older children according to MUAC criterion, as is the case for the results in z- score. (Relative risk = 17.48 (6.23 Table 15: Prevalence of acute malnutrition according to Mid Upper Arm Circumference (MUAC) classification using height cut off, WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 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 8 8.6% 1 0.4% 0 0.0% 9 1.6% ≥115- <125 Moderate malnutrition 16 17.2% 6 2.2% 1 0.5% 23 4.2% ≥125 No malnutrition 69 74.2% 266 97.4% 182 99.5% 517 94.2% Total 93 100% 273 100% 183 100% 549 100% Children more or equal 65cm and less than 75cm are more subject to acute malnutrition according to MUAC criterion compared to other height groups (Relative risk = 14.71 (6.82 According to standard height cut offs points, children 6-11 months correspond to children 65- 75cm and their vulnerability has already been raised in the table above. Nevertheless, the results according to age groups as well as to height groups have to be interpreted with caution as MUAC picks up malnutrition earlier in younger children than in older ones. 4.1.2.3 Chronic malnutrition prevalence expressed in Z-score The analysis of the chronic malnutrition prevalence based on height for age according to WHO standards is done with a sample of 549 children out of the 567 children surveyed, 18 children being excluded as their data were more likely to be aberrant than actual values according to the SMART flagging system 17 . The results are presented in the table 16. The plausibility checks of height measurements showed some digit preference, however the score (12) was still judged as “acceptable”. 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. 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. The Muslim lunar calendar is used in Afghanistan while ages are analysed in ENA software referring to the Gregorian solar calendar. The birth dates should have been converted from the lunar system to the solar one which could have led to error. Despite these precautions and according to plausibility check, the age determination was not very precise with preferences for 36 and 48 months. Nevertheless, the overall age distribution score is acceptable (Score = 4). 17 SMART flags being considered (+/- 3SD from the observed mean) 32 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 16: Prevalence of chronic malnutrition based on height-for-age z-scores according to WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Prevalence of Chronic malnutrition All Z-score 95% CI According to WHO standards N = 549 Prevalence of stunting N = 332 60.5% (54.4 – 66.3 95% C.I.) (<-2 z-score) Prevalence of moderate stunting N = 204 37.2% (32.7 – 41.9 95% C.I.) (<-2 z-score and >=-3 z-score) Prevalence of severe stunting N = 128 23.3% (18.9 – 28.4 95% C.I.) (<-3 z-score) The chronic malnutrition rate found is very high and corresponds with the findings of the MoPH National Nutrition Survey 2004 (equally 60,5%) despite the fact that both surveys were done with almost 7 years of interval. The fact that almost a quarter of the children in the sample are severely stunted is of particular concern and warrants attention. Table 17: Prevalence of chronic malnutrition based on height-for-age z-scores and by sex, WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Prevalence of Chronic malnutrition All Boys Girls According to WHO standards N = 549 N = 272 N = 277 (332) 60.5 % (165) 60.7 % (167) 60.3 % Prevalence of stunting (54.4 - 66.3 95% (52.6 - 68.1 95% (53.5 - 66.7 95% (<-2 z-score) C.I.) C.I.) C.I.) (204) 37.2 % (100) 36.8 % (104) 37.5 % Prevalence of moderate stunting (32.7 - 41.9 95% (31.5 - 42.4 95% (32.2 - 43.2 95% (<-2 z-score and >=-3 z-score) C.I.) C.I.) C.I.) (128) 23.3 % (65) 23.9 % (63) 22.7 % Prevalence of severe stunting (18.9 - 28.4 95% (18.4 - 30.4 95% (17.9 - 28.4 95% (<-3 z-score) C.I.) C.I.) C.I.) There is no statistical difference in the stunting prevalence between boys and girls (p>0.05). Table 18 : Prevalence of chronic malnutrition based on height-for-age z-scores according to age groups, WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Age Severe stunting Moderate stunting Normal groups in (<-3 z-score) (>= -3 and <-2 z-score ) (> = -2 z score) Total months No. % No. % No. % 6-11 38 5 13.2 13 34.2 20 52.6 12-23 132 30 22.7 52 39.4 50 37.9 24-35 121 32 26.4 46 38.0 43 35.5 36-47 128 34 26.6 55 43.0 39 30.5 48-59 130 27 20.8 38 29.2 65 50.0 Total 549 128 23.3 204 37.2 217 39.5 No disparities can be highlighted in the nutritional status according to age classification. Moreover, stunting prevalence seems lower in children 6-11 but this comparison is not statically significant (p = 0.086). Nevertheless, acute malnutrition is generally higher in younger children (less stock), but chronic malnutrition is higher in older children since they have had more time to accumulate growth retardation. 33 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Curve 2: Distribution of height-for-age z-scores vs. reference (HAZ), WHO standards, n=549, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 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 lower height for age than the reference population. The mean ± SD of HAZ (n=549) equals -2.20±1.15. The design effect is 1.96 while it was fixed at 2 at the planning stage. Although, there is a height determination bias, stunting rate is so high that the problematic of very high level of chronic malnutrition has to be acknowledged. 4.2. Anthropometric results: Pregnant/Lactating women (based on MUAC criterion) 39 pregnant women with children 6 to 59 months old and 61 lactating women breastfeeding an infant less than 6 months old were found at household level, for a total of 100 women screened by MUAC. Since the women were not randomly chosen this sample cannot be considered as representative and results are presented in percentage of the women screened. Moreover, these results have to be considered with caution due to the low sample size and the absence of confidence intervals. Table 19: Prevalence of nutritional risk amongst pregnant/lactating women based on MUAC criterion according to Sphere standards, n=100, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 MUAC Nutritional Risk Pregnant women Lactating women TOTAL in mm Sphere Standards N % N % N % <210 Severe risk 0 0.0% 0 0.0% 0 0.0% ≥210 - <230 Moderate risk 5 12.8% 4 6.6% 9 9.0% ≥230 No risk 34 87.2% 57 93.4% 91 91.0% Total 39 100% 61 100% 100 100% Out of 100, only 9 (9%) women were at moderate risk and none were severely at risk with MUAC criterion. This however, does not provide any insight on stunting prevalence or micro-nutrient deficiencies. 34 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 4.3. Measles vaccination coverage – Children 9-59 months 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 550 children out of the 567 children surveyed as 17 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 20: Measles vaccination coverage for children equal or more than 9 months old, n=550, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 All Measles vaccination coverage N (550) N % Confirmed with immunization card 309 56.2% Confirmed verbally by the caregiver but no immunization card to prove it 174 31.6% No immunization according to the caregiver 29 5.3% Unknown 38 6.9% Total 550 100% In any case, 56.2% of the children surveyed (309 out of 550 children surveyed) were vaccinated against measles, with the immunization card shown as proof, while only 6.9% (38 out of 550) were not vaccinated. Only 6.9% of the caretakers interviewed (38 out of 550) could not say whether their children were immunized against measles or not. At national level and for children from 12 to 23 months old, the measles vaccine coverage was estimated at 62.6% 18 in 2006. Since the age groups covered by these results are different, it is not possible to compare the two. In the age group of 12 to 23 months of this sample (134 children), 79 (59%) have confirmed vaccination status, which is close to the MoPH 2006 results. The coverage of confirmed measles vaccination is very low compared to the SPHERE standards of 90%. Nevertheless, taking into account the children who were said to be immunized without card to prove it, the coverage is estimated 87.8%. Immunization cards are often not well kept by the caretakers who could not find back this official document at the time of the interview. 4.4. Vitamin A supplementation coverage – Children 6-59 months The sample used for the analysis of the Vitamin A supplementation coverage within the last 6 months is similar to the total number of children included in the anthropometric survey, so 567 children. The results are presented in the table below. Table 21: Vitamin A supplementation coverage within the last 6 months, n=567, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 All Vitamin A supplementation coverage N (567) within the last 6 months N % Vitamin A dose received 510 89.9% Vitamin A dose not received 21 3.7% Unknown 36 6.4% Total 567 100% 18 Afganistan Health Survey 2006, Ministry of Public Health, Islamic Republic of Afghanistan 35 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 The Vitamin A supplementation coverage within the last 6 months is satisfactory being of 89.9%. Routine Vitamin A distribution campaigns are regularly ensured by the MoPH at provincial level. Only a small amount of children did not receive Vitamin A and 6.4% of the caretakers interviewed could not say whether their children received a Vitamin A dose within the last 6 months. At national level and according to the MoPH Health survey done in 2006, 76.5% of children 6-59 months of age received Vitamin A in the last six months. The coverage expressed by this study is even higher than the one published by the MoPH about 5 years ago and is almost equal to the threshold of 90% determined by SPHERE standard. 4.5. IYCF study In the households selected 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 questionnaire. At the end of the data collection, 67 infants less than 6 months and 173 children 6-23 months were found in the visited households for a total sample of 240 children 0-23 months. The results were analyzed by using EPI Info Software – Version 2008 and Excel version 2005 and the “ Indicators for Assessing Infant & young Child Feeding Practices” WHO et al. 2007, were used as guidelines. Table 22: Children ever breastfed, n=240, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Child ever breastfed N (240) % 95% CI Yes 237 98.8 (96.4 – 99.7) No 3 1.2 (0.3 – 3.6) TOTAL 240 100 Out of 240 children surveyed, 237 were breastfed at least once in their life, representing 98.8% (96.4 – 99.7 95% CI). Only 1.2% (3 children out of 240) (0.3 – 3.6 95% 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 3 responders. Since the sample size is very small (N = 3), these results are not representative, merely indicative. Table 23: Reasons for not breastfeeding, n=3, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Reason for no-breastfeeding N (3) % Breast milk not good for the child 0 - Pain 0 - No breast milk coming out of the breast 1 33.3% Refusal of the child to be breastfed 1 33.3% Child sick 0 - Mother/caretaker sick 0 - Advice of family members 0 - Others 1 33.3% TOTAL 3 100% 36 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 The following result is based on the sample of children who were ever breastfed as presented in the table above, including 237 children. The caretakers were asked how soon after birth they put their children to the breast. Table 24: Early initiation of breastfeeding after birth, n=237, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Early initiation of breastfeeding after birth N (237) % 95% CI Within first hour of life 189 79.7 (74.1 – 84.7) Less than 24 hours after delivery 28 11.8 (8.0 – 16.6) More than 24 hours after delivery 15 6.3 (3.6 – 10.2) Does not know 5 2.2 (0.7 – 4.9) TOTAL 237 100 - 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. This whereas initiating breastfeeding early can significantly improve the infant’s chances of survival as well as can 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 25: Administration of colostrum, n=237, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Colostrum given during the 3 first days after delivery N (237) % 95% CI Yes 221 93.2 (89.3 – 96.1) No 14 5.9 (3.3 – 9.7) Does not know 2 0.9 (0.1 – 3.0) TOTAL 237 100 - 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. Further education, counselling and encouraging efforts must still be made to ensure that all women give colostrum. Table 26: Introduction of other liquids/foods during the 3 first days of life of breastfed children, n=237, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Introduction of other liquids/foods during the 3 first days of life N (237) % 95% CI Yes 45 19 (14.2 – 24.6) No 192 81 (75.4 – 85.8) TOTAL 237 100 - 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 45 children who received liquids/foods as reported in the table above as well as the 3 caretakers who never breastfed their children were asked what type of liquids/foods they gave their children during the first 3 days of life,. 37 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 27: Type of other liquids/foods during the 3 first days of life for breastfed and non-breastfed children, n=48, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Liquids/foods given the 3 first days of life after birth Total % Plain water 0 0.0% Sugar water or glucose water 16 33.3% Powdered or fresh animal milk 12 25.0% Infant fomula (Biomil 1 or 2, Mini 1 or 2, Lailac 1 or 2, 1 2.1% Lactogen 1 or 2, Man Ma, Morinaga BF infant formula Does not know 1 2.1% Others 18 37.5% Butter 5 10.4% Cheese 12 25.0% Herbal medicines 1 2.1% Total answers 48 100% Table 27 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 a young infant. Quite worrying is that 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. Age appropriate infant formula is more adapted to the infant’s needs, but only if used with safe water of the correct temperature, correctly diluted, given in sufficient quantities and fed through a clean recipient. If this is not the case, it can equally represent a significant risk for the child’s health. Few children were given cheese and butter, which are commonly eaten in parts of Afghanistan where livestock are available but are not suitable for so young infants. Traditional herbal medicines were given to only 1 child. The following question was asked to the 237 caretakers who ever breastfed their infant. The interviewees were asked if they are still breastfeeding at the time of the survey. Table 28: Currently breastfeeding, n=237, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Currently breastfeeding N (237) % 95% CI Yes 215 90.7 (86.3 – 94.1) No 22 9.3 (5.9 – 13.7) TOTAL 237 100 - Out of 237, 215 caretakers, representing 90.7% (86.3 – 94.1 95% CI), 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 29: Currently breastfeeding according to age categories, n=237, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Currently breastfeeding Yes % No % TOTAL Infants less than 6 mths 66 100.0% 0 0.0% 66 Children 6-11 mths 40 97.6% 1 2.4% 41 Children 12-17 mths 56 91.8% 5 8.2% 61 Children 18-23 mths 53 76.8% 16 23.2% 69 TOTAL 215 90.7% 22 9.3% 237 38 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 29 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, this question does not reveal whether breastfeeding is exclusive or not in the first 6 months, neither the proportion of breastmilk in the diet of older children. Additional questions were asked to the 22 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 regarding non-breastfed children have to be interpreted with caution due to the low sample size (N = 22). Table 30: Duration of breastfeeding, n=22, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Duration of breastfeeding N (22) % 95% CI Less than 3 months 1 4.5 (0.1 – 22.8) Between 3 and 5 months 0 0 - Between 6 and 11 months 7 31.8 (13.9 – 54.9) Between 12 and 23 months 13 59.1 (36.4 – 79.3) Does not know 1 4.5 (0.1 – 22.8) TOTAL 22 100 - 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. One infant stopped breastfeeding before the age of 3 months putting it at a significant higher risk of disease, malnutrition and death. Table 31: Reasons for cessation of breastfeeding, n=22, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Reasons for cessation of breastfeeding N (22) % 95% CI Child too old 2 9.1 (1.1 – 29.2) Pain 0 0 - Not enough milk 3 13.6 (2.9 – 34.9) New pregnancy 15 68.2 (45.1 – 86.1) Refusal of the child to be breastfed 2 9.1 (1.1 – 29.2) Child sick - - - Mother/caretaker sick - - - Advice of family members - - - Does not know - - - TOTAL 22 100 - 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. Three mothers 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. Adequate counselling might also have helped those two mothers who reported that their children refused the breast. All these reasons reported indicate the need for more IYCF education in these communities. 39 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 32: Way of cessation of breastfeeding, n=22, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Way of cessation of breastfeeding N (22) % 95% CI Abruptly 11 50.0 (28.2 – 71.8) Progressively 10 45.5 (24.4 – 67.8) Does not know 1 4.5 (0.1 – 22.8) TOTAL 22 100% - It is alarming to see that halve 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 mothers still breastfeeding were asked if aside from breast milk, other foods or liquids were given to the children over a 24hr food recall period. The recall period started on the morning of the day preceding the conduction of the interview when the child woke up and continued until the following morning (including foods/liquids given during the night and excluding foods/liquids given since the child woke up this morning). The 3 infants who were never breastfed were automatically excluded for this analysis. The sample size is 237 children, including 66 children below 6 months old and 171 children equal to or more than 6 months old. Table 33: Administration of foods/liquids to breastfed children over a 24hr food recall period by age categories, n=237, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Administration of other foods/liquids over a 24hr food recall period Yes % No % TOTAL 0 – 5 months 12 18.2% 54 81.8% 66 6 – 23 months 160 93.6% 11 6.4% 171 TOTAL 172 72.6% 65 27.4% 237 Table 33 shows that only one fifth of the children less than 6 months old were not exclusively breastfed, a reasonable result. Still it would have been better than none of the children in that age group received other foods or liquids. Surprisingly 11 children equal to or more than 6 months old out of 171 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. The next step was to ask about the types of liquids and foods given to the children over a 24 hour food recall period for the 172 children who received liquids/foods beside breast milk as well as to the 3 children who were never breastfed. In total, 13 children 0-5 months old (including 1 non breastfed infant) and 162 children 6-23 months old (including 2 non breastfed children) were included in the consumption study giving a total sample of 175 children out of 240 children (excluding 65 children 0-23 months who did not received any liquids/foods over the recall period). Following the methodology, 2 types of liquids given to the infants were expected to be recorded. Nevertheless, 10 infants below 6 months and 10 infants 6-23 only received 1 type of liquid. Hence, the total answer is 330 answers for 175 children surveyed. 40 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 34: Types of liquids taken over 24 hour food recall period for children from 0 to 23 months old, n=175, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Types of liquids eaten from Children Children Children Total % Total % Total % yesterday during the day or at 0-5 6-23 0-23 out of N out of N Out of N night (N=13) (N=162) (N=175) Breast milk 7 53.8% 115 71.0% 122 69.7% Milk – Fresh animal milk and 3 23.1% 58 35.8% 61 34.9% tinned (condensed milk) Milk such as cartons or powdered 3 23.1% 6 3.7% 9 5.1% (Nido, klim…) Infant formula 0 0.0% 2 1.2% 2 1.1% Plain water 1 7.7% 41 25.3% 42 24.0% Sugar or glucose water 0.0% 1 0.6% 1 0.6% Sour milk or yogurt 0.0% 17 10.5% 17 9.7% Sugar-Salt-Solution water (ORS) 0.0% 1 0.6% 1 0.6% Fruit juice 0.0% 8 4.9% 8 4.6% Tea/infusions 1 7.7% 54 33.3% 55 31.4% Thin porridge 1 7.7% 11 6.8% 12 6.9% Other (Specify) 0.0% 0 0.0% 0 0.0% Total answers for all children 16 - 314 - 330 - surveyed This table reflects some inconsistencies compared with previous results: out of the 13 infants less than 6 months old in this sample, only 1 infant was not breastfed, yet only 7 of them indicated the consumption of breastmilk here. This is the same for the group of 6 to 23 months old, where only 122 recorded the consumption of breast milk although the prevalence of breastfeeding among this target group was estimated higher in the results presented above. This may highlight some mistakes in collecting data at field level. As several questions about breastfeeding were asked to the caretakers, they may have considered that breast-milk was obviously given and they did not have to repeat this. It could also be, especially for older children, that the proportion of breastmilk in their daily diet is so small, that the consumption of the other 4 foods mentioned above exceeds it. Milk is the most common liquid given to infants less than 6 months, as well as to children more than 6 months old. However, undiluted animal milk before the age of 12 months is inappropriate as it can trigger symptoms of intolerance and allergy. None of the infants 0-5 received infant formula and only 2 infants 6-23 received it. Tea and infusions are culturally accepted and widely consumed in Afghanistan. Water is equally often given, especially to the older children, yet no investigation to the safety of the water was made. The caretakers were then asked which kinds of foods were given to their children over the recall period. Only 8 children aged less than 6 months received additional food, creating a very small sample size. In addition, 7 infants 6-23 months did not receive additional food, leaving a sample of 155 children 6-23 months old. The analysis of the food consumption is done on a sample of 163 children. Per child, maximum 4 types of foods consumed in the previous 24 hours were recorded. Some children received less than 4 food items; hence the total used for analysis corresponds to 448 answers for 163 children surveyed. 41 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 35: Types of foods taken over 24 hour food recall period for children from 0 to 23 months old, n=163, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Types of foods eaten from Children Children Children Total % Total % Total % yesterday during the day or at 0-5 6-23 0-23 out of N out of N out of N night (N=8) (N=155) (N=163) Bread, rice, noodles, or other foods 1 12.5% 138 89.0% 139 85.3% made from grains Pumpkin (squash), carrot, red peppers or other foods that are yellow or orange 0.0% 21 13.5% 21 12.9% inside White potatoes, turnip and any other 25.2% 23.9% foods made from roots 0.0% 39 39 Any dark green leafy vegetables (medium to dark in color) 0.0% 11 7.1% 11 6.7% Ripe mangoes, fresh apricots, dried apricots 1 12.5% 18 11.6% 19 11.7% Any other fruits or vegetables (e.g. tomatoes, bananas…) 0.0% 8 5.2% 8 4.9% Liver, kidney, heart or other organ 0.0% 2 1.3% 2 1.2% meats Any meat, such as beef, mutton, lamb, 0.0% 10 6.5% 10 6.1% goat, chicken, or camel Eggs 0.0% 20 12.9% 20 12.3% Fresh or dried fish 0.0% 6 3.9% 6 3.7% Any foods made from beans, peas, 0.0% 12 7.7% 12 7.4% lentils, or nuts Cheese, yogurt, or other milk products 1 12.5% 49 31.6% 50 30.7% Any oil, fats, or butter, or foods made 37.5% with any of these 3 22 14.2% 25 15.3% Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or 3 37.5% 58 37.4% 61 37.4% biscuits Flavoring such as dry pepper, chilies, spices or herbs 0 0.0% 0 0.0% 0 0.0% Any solid, semi-solid or soft foods made for infants and young children 25.0% such as: Cerelac, Biomil, Mother's 2 21 13.5% 23 14.1% Choice, Hero Baby, BP5 biscuit* Any Plumpy Nut, Plumpy Doz** 1 12.5% 1 0.6% 2 1.2% Total answers for all children 12 - 436 - 448 - 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) 37.5% of the 8 children 0 to 6 months old received oil, fats, or butter, or foods made with any of these and respectively and an equal amount received sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits. Both food items are highly inappropriate. Only 2 of them (25%) were given any solid, semi-solid or soft foods made for infants and young children. One child aged 5 months received Plumpy Nut or Plumpy Doz, products for the treatment or prevention of acute malnutrition, which are however, not to be consumed by children under the age of 6 months. 42 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 For the older children aged 6-23 months, 37.9% of them equally received sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits. This shows a high consumption of carbohydrates with very little to no nutritional value. The quantity given could not be evaluated, but it is important to mention that high consumption of such kind of foods is not appropriate for children below 2 years. Bread, rice, noodles, or other foods made from grains were given to most children 6-23 months. Surprisingly, only 1 infant 0-5 out of 8 received this type of food while bread and rice are widely consumed by Afghan families. Food such as white potatoes, turnip and any other foods made from roots were given to 25.2%. White potatoes are considered as vegetables by most of the local population according to several studies 19 . Few children were given fruits or vegetables, which constitute one of the main sources of micronutrients (only 8 children out of 155, representing 4.9% of the total sample). Micronutrient deficiency is considered as one of the main factors leading to chronic malnutrition. As highlighted above, chronic malnutrition is the main nutritional problem in Bamyan province. It can be assumed that the low consumption of fruits and vegetables may be one of the causes of the high stunting prevalence. Meat and other organ meats were almost not given to the children 6-23 months. Indeed, only 2 children received organ meats such as liver, kidney or heart (1.2%) and only 10 received any meat, such as beef, mutton, lamb, goat, chicken, or camel (6.1%). 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 6 children aged 6-23 months. In the mountainous context of Bamyan province, fishes or sea products are almost inexistent. Few habitants have access to rivers where they can get fish, especially the population living close to Bamyan River. The lack of sea products and fishes can lead to iodine deficiency, the only source of iodine. 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. 23 surveyed children (14.1% out of total sample) received iron fortified solid, semi-solid or soft foods designed specifically for infants and young children and only 2 children 0-23 months (1.2%) received lipid based nutrient supplement. 19 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 As summary, the results are presented according to IYCF five core and two additional indicators, WHO reference, in the tables below. Table 36: IYCF 5 core indicators, WHO reference, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 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 189 80,4% (74.8 – 85.3) breastfeeding (N = 235*) one hour of birth Exclusive breastfeeding Proportion of infants 0-5 months of age 54 80,6% (69.1 – 89.2) under 6 months (N = 67) who are fed exclusively with breast milk Continued breastfeeding Proportion of children 12 – 15 months of 40 88,9% (75.9 – 96.3) at 1 year (N = 45) age who are fed with breast milk Introduction of solid, Proportion of infants 6-8 months of age 12 66,7% (41.0 – 86.7) semi-solid or soft foods (N who receive solid, semi-solid or soft foods =18) Proportion of children 6-23 months of age Consumption of iron-rich who receive an iron-rich food or iron- 21 12,1% (7.7 – 18.0) or iron-fortified foods fortified food that is specially designed for (N =173 ) infants and young children, or that is fortified in the home. *5 entries who answered “ don’t know” were removed from denominator 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 understand better the feeding practices toward infants in the surveyed area. Table 37: IYCF 2 optional indicators, WHO reference, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 OPTIONAL INDICATORS DEFINITION N % 95% CI Children ever breastfed Proportion of children born in the last 24 237 98,8% (96.4 – 99.7) (N =240) months who were ever breastfed Continued breastfeeding Proportion of children 20–23 months of 33 70,2% (55.1 – 82.7) at 2 years (N =47) age who are fed with breast milk 44 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 5. DISCUSSION 5.1 Constraints and biases Due to security constraints, ACF health - nutrition coordinator could supervise only one day 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 3 districts out of 7 comprised in the province were covered and therefore are represented by this survey. 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 a 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. To reach the quality requirement and ensure capacity building of the AADA team members, the decision was taken to limit the covered area, especially taking into account that Bamyan province is a wide spread province with limited transportation infrastructures and many 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, so a minimum of clothing, mainly t-shirt and pants was accepted. 100 grams were subtracted from each weight before data entry, based on an average. Clothes of several children were weighed to estimate the average weight to subtract. Still this represents a bias. According to the plausibility check, ENA Delta Software – Version April 2011: o The height measurements showed some digit preferences, classifying their quality as acceptable to poor (Digit preference score = 12). This may lead to biases in the estimation of the acute and chronic malnutrition. o The MUAC measurements showed some digit preference, (Digit preference score = 11). This may lead to biases in the estimation of the acute malnutrition prevalence according to MUAC criterion. Nevertheless and still according to the plausibility check, ENA Delta Software – Version April 2011: o The weight measurements are estimated as acceptable (Digit preference score = 6); o The standard deviation after exclusion of SMART flagged values is 0.98, so between 0.8 and 1.2 and then considered as excellent; o No difference can be notified between the performances of each nutrition survey teams; o The overall score of data quality for this survey is good (10%) 45 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 5.2 Acute malnutrition – Children 6-59 months old The Global Acute Malnutrition (GAM) rate of 4.9 % [3.3 – 7.2 95% CI] in Saighan, Yakawlang and Panjab districts, Bamyan province expressed according to WHO standards can be considered as acceptable. This rate is well inferior to the alarm threshold of 15% determined by the WHO Expert Committee classification for wasting 20 . Expressing the GAM in caseload out of the surveyed population of the 3 targeted district means 1,215 children of 6-59 months are suffering from acute malnutrition and in need of treatment. (according to W/H index). 1,438 children are estimated as affected by acute malnutrition according to MUAC criterion. These estimates correspond only to the population living in 3 districts out of 7 in the whole province. The prevalence of acute malnutrition does not reflect any difference between the nutritional status of boys and girls. GAM was estimated at 15% at planning stage based on AADA screening results. According to the passive screening data collected from January 2010 to December 2010 provided by AADA, 35,467 children U5 were screened by MUAC in the 7 districts of the province. Out of them, 4,351 children U5 were found moderately acute malnourished (corresponding to 12.3% out of the total sample) and 281 children were found as severely acute malnourished (representing 0.8% of the total sample, giving an average of 13.1% of the screened children detected as acute malnourished. The actual GAM found in this survey proved to be lower. In Saighan, Yakawlang and Panjab districts and according to the same source of information, the passive screening results done by AADA over the same period are as follows. Table 38: Passive screening – Children U5, from October 2010 to June 2011, AADA, Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan Total District Children Total Total % GAM % MAM Total SAM % SAM names U5 GAM MAM screened Panjab 10,530 1,500 14.2% 1,355 12.9% 145 1.4% Saighan 5,135 176 3.4% 137 2.7% 39 0.8% Yakawlang 19,802 2,956 14.9% 2,859 14.4% 97 0.5% Total 35,467 4,632 13.1% 4,351 12.3% 281 0.8% The nutrition status of children U5 is worse in Panjab district (Relative risk = 4.16 (3.55 20 WHO 1995: percentage of children with weight-for-height <-2 z-score >= 15% is critical 46 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Table 39: TFP Monthly admission – Children U5, from March 2011 to July 2011, Bamyan province, Afghanistan – ‘CMAM Data analysis’, Afghanistan Nutrition Cluster, September 2011 Location Mar-11 Apr-11 May-11 Jun-11 Jul-11 Total Bamyan province 12 162 159 97 67 497 The number of TFP admissions decreased in June and July 2011, going down from 162 monthly admissions in April to only 67 in July 2011. This decrease may be linked to the seasonal fluctuation as the lean period is from April to May every year. Nevertheless, other factors may have impacted the number of admissions, such as the general running of the project or the management of community mobilization based projects. While conducting the anthropometric survey, no cases of bilateral oedema were reported by the teams on the field. The Kwashiorkor prevalence is estimated as low by most of the nutrition actors in Afghanistan. Only 1 oedema case was found while conducting 4 other anthropometric nutrition surveys in Afghanistan in 2010-201 21 . Young children aged 6-23 months are clearly more subject to acute malnutrition according to W/H index as well as according to MUAC criterion than older children 24-59. Inappropriate infant feeding practices may explain this vulnerability but other possible factors need to be deeper explored by conducting a fully dedicated IYCF in the area. In comparison to the GAM rates found by these 4 other anthropometric nutrition surveys conducted in Afghanistan in 2010-2011, the prevalence of acute malnutrition in Saighan, Yakawlang and Panjab districts, Bamyan province, is considered as among the least alarming. The GAM prevalence are expressed according to WHO standards – 2006 in the table below. Table 40: Global Acute Malnutrition prevalence, WHO Standards, Day Kundi, Nangarhar, Laghman, Takhar and Bamyan provinces, from October 2010 to July 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) Saighan, Bamyan province Yakawlang and July 2011 4.9 % (3.3 – 7.2 95% C.I.) ACF – AADA (N = 553) Panjab Indeed, the prevalence of acute malnutrition found in Saighan, Yakawlang and Panjab districts, Bamyan province, is inferior to the ones found in other provinces, except in Day Kundi province. Day Kundi province is located beside Bamyan province and their general contexts are considered to be similar. Hazara people constitute the main population living in these 2 provinces. The weather conditions, the geographical environment and the socio-economic development are considered as similar in both provinces. 21 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 ACF-CAF Anthropometric nutrition survey, Chal and Rustaq districts, Takhar province, June 2011 47 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Nevertheless, Bamyan province is said to be better covered by humanitarian assistance than Day Kundi province, where less humanitarian organizations are operational. 5.3 Chronic malnutrition – Children 6-59 months old The chronic malnutrition rate is high in Saighan, Yakawlang and Panjab districts, Bamyan province with a prevalence estimated at 60.5% (54.4 – 66.3 95% CI) and corresponds to the one of the most important nutritional problems in the area. At planning stage and according to the National Nutrition survey conducted by the MoPH in 2004, the stunting rate was estimated at 60.5%. The prevalence raised by this survey is similar to that one despite the fact that both surveys were done with almost 7 years of interval. By expressing the stunting rate in caseload out of the surveyed population, an estimated 15,003 children are suffering from chronic malnutrition according to the W/H index. Following the same methodology, an estimated 5,778 children are affected by severe stunting. This only covers the population of the 3 districts of the province surveyed. By comparing the stunting rates found by the 4 other anthropometric nutrition surveys conducted in Afghanistan in 2010-2011, the prevalence of chronic malnutrition in Saighan, Yakawlang and Panjab districts, Bamyan province, is higher than in the other 4 surveyed locations 22 . The stunting rates are presented according to WHO standards in the table below. Table 41: Chronic malnutrition prevalence, WHO Standards, Day Kundi, Nangarhar, Laghman, Takhar and Bamyan provinces, from October 2010 to July 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) Saighan, Bamyan province ACF – Yakwalang and July 2011 60.5 % (54.4 – 66.3 95% C.I.) (N = 549) AADA Panjab 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), since they have had more time to accumulate growth retardation. 22 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 ACF-CAF Anthropometric nutrition survey, Chal and Rustaq districts, Takhar province, June 2011 48 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 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 Nutritional risk - Pregnant/Lactating women The prevalence of nutritional risk among pregnant/lactating women as shown by this survey should be interpreted with caution due to sampling issues (not randomly chosen) and the low sample size. Nevertheless, 9% of the women screened (9 out of 100) 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 some nutritional deficit. No difference could be notified between the nutritional statuses of pregnant versus lactating women. This rate does not give any appreciation on stunting and/or micronutrient deficiencies among pregnant and lactating women, whereas both are common problems in the Afghanistan context that endanger the health of both women and their children. Acute malnutrition among pregnant and lactating women leads to many negative outputs such as miscarriage, low birth weight, maternal and neonatal mortality, stunted children etc. Nutritional support may prevent these negative outputs. Special attention should be paid to women when designing nutrition projects. Caring for the well being of mothers allows them to care for the well being of their children. 5.5 Causal analysis Malnutrition remains a multi factorial problem. Despite the limitations of this survey, 3 main factors leading to malnutrition may be identified in the specific context of Bamyan province as follows. Food insecurity: Based on the latest dietary diversity data from the NRVA 2005, 24% of the Afghan population has very poor diversity in their food consumption. The rural areas with very poor food consumption are Day Kundi, Bamyan, Nuristan, Ghor, Uruzgan, Zabul and Nimroz Provinces. Bamyan and Nuristan's populations have the second highest poor food consumption at 61- 80% 23 (Map – Annex 11). In comparison to NRVA 2005 dietary diversity findings, the 2003 dietary diversity findings were similar in the above mentioned provinces except for Nuristan and Nimroz. The consistency of 2005 and 2003 NRVA data and other previous food security assessments indicate that food insecurity in these provinces is not transitory but chronic. Therefore, this refers to a chronic problem; stunting, which primarily results, among others, from lack of access to food over a long period of time, is at the highest level in Afghanistan. According to NRVA 2005, 25% of the population in the province is estimated to receive less than the minimum daily caloric intake necessary to maintain good health. In the whole province more than three quarters of the population (77%) has low dietary diversity and poor or very poor food consumption as shown below. 23 http://www.fews.net/ml/en/info/Pages/fmwkfactors.aspx?gb=af&loc=2&l=en 49 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Food consumption classification for all households Low dietary diversity Better dietary diversity Households Very poor food Poor food Slightly better food Better food (%) consumption consumption consumption consumption Rural 69 22 7 3 Total 53 24 5 5 Moreover, few job opportunities are available in Bamyan province. It has been reported that daily construction labor, which is a major source of income, is not available due to the lack of investment in that area. At the time of this report writing, the on going drought which affects especially the northern regions of Afghanistan was not declared in Bamyan province. Nevertheless, 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 Bamyan province, in August 2011. The main results of this assessment state that Bamyan province may suffer from drought impacts in the coming months. Bamyan is considered as one food insecure province related to many factors, such as poor food consumption, inappropriate coping mechanisms (mainly loans) and poor household access to food commodities. In addition and according to the ‘estimated food security conditions, 4 th quarter 2011 (October- December 2011) released by FEWS Net, the harvest for 2011 is expected to be decreased by 34% in comparison to the average 2002-2010 (See map – Annex 12). In addition to the drought, the affected provinces are among the poorest in the country. Bamyan is among the second group of 6 provinces considered poor. Indeed, the poverty level out of the total population is estimated at 42-48% in Bamyan province according to NRVA 2007/2008. Inappropriate IYCF practices: The IYCF study provides significant information to have a view on the infant feeding practices among the targeted population in Saighan, Yakawlang and Panjab districts, Bamyan province. Inappropriate IYCF practices are one of the main causes of malnutrition. o Late initiation of breastfeeding: Only 80.4% of the infants 0-23 months old were put on the breast within 1 hour after birth; o Prevalence of exclusive breastfeeding among children 0-5 months can be improved: Only 80.6% of the infants were exclusively given breast-milk; o Abrupt cessation of breastfeeding without progressive introduction of other liquids/foods: 50% of the caretakers of children who were no longer breastfed said that they stopped breastfeeding their children abruptly. Moreover, most of the interviewed lactating women who stopped breastfeeding their children took this decision due to a new pregnancy or because of presumed low milk production; o Inappropriate early initiation of foods or liquids: 19% of the infants were fed with other liquids/foods than breastmilk during the 3 first days of life. This is particularly concerning since such young infants cannot tolerate other sources of nutrients well. Whereas only 66.7% of the infants 6-8 months were given other foods/liquids while they are in needs to receive weaning food. 50 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 .Nevertheless, some appropriate practices have to be highlighted: o 98.8% of the children were ever breastfed; o Colostrum was given to 93.2% of the surveyed breastfed infants. This shows a good administration of the colostrum to infants after birth even if all children should have received this to provide them with protection and ensure favourable breastfeeding later on; o Only 1 child under 6 months was never breastfed and 100% of the ever breastfed infants 0-5 were currently still receiving breastmilk; o Breastfeeding was continued up to 2 years old for 70.2%. Nevertheless, breastfeeding was progressively stopped when children get older while it could have been continued up to 2 years and above for all. Breastfeeding counselling by peers or by professional workers and IYCF education could help the caretakers to better provide appropriate care to their infants. Topics such as breastmilk production, the importance of the colostrum or the necessity to exclusively breastfed infants up to 6 months should be emphasized while implementing IYCF project or any other projects targeting pregnant-lactating women. By ensuring adequate care to infants, risk of infections, malnutrition or even death can be mitigated. The child’s health, development and survival could be better ensured. Poor food consumption for children 6-23 months: Despite that quantities given were not evaluated, it can be assumed that the food intake of infants is not satisfactory. o Few micronutrient-rich foods were given to the children over the 24hr food recall period. o Only 2 children received iron-rich foods including 1 child below 6 months old who should not have been given such kind of food items. o The high consumption of carbohydrates is concerning, especially with regards to other food items more appropriate but not given to children. Promotion on weaning food through cooking demonstrations and nutrition education should be one of the key priorities while intervening toward children below 2 years. 51 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 6. CONCLUSION The anthropometric nutrition survey and the IYCF study conducted in Bamyan province have limitations. Causes of malnutrition could not be assessed and only assumptions can be made with regards to highlighted results. Acute malnutrition levels are not indicating an alarming or at risk situation, but still the nutrition situation trends needs to be followed closely on a regular basis. The population in this province is categorized as chronically food insecure and hence is considerably vulnerable to changes of the socio-economic environment. The alarming rate of chronic malnutrition reflects the nutritional deficiency affecting the population on a long term process. More than half of the surveyed children were found to be stunted and almost one quarter was severely stunted. By intervening at an early stage through a multi- sectorial approach, chronic malnutrition can be prevented. Despite the mentioned limitations of this study, the prevalence of acute malnutrition among women is concerning. According to State of the World Mothers report - Save the Children published in 2011, Afghanistan has been ranked the worst place in the world to be a mother. Performance on most of the other indicators places Afghanistan among the lowest-ranking countries in the world. Afghanistan has the highest lifetime risk of maternal mortality and the lowest female life expectancy in the world. It also places second to last on skilled attendance at birth, under-5 mortality and gender disparity in primary education. In addition, daily stressors (as poverty, unemployment, limited services...) and series of traumatic situations (conflict, insecurity, loss…) have a clear impact on the mental health conditions of people. This fragile psychosocial condition has a clear influence on child nutritional and health status, through care practices deterioration. Hence, special attention should be paid to women with the goal to improve the wellbeing of the mothers and through them the development of their children. Special attention should be paid to infants below 6 months old. Recent anthropometric data are almost not available at country level for this target group. Learnt from the ACF expertise over many years in Afghanistan, childcare practices appear to be especially involved in the etiology of malnutrition and child’s survival and hence should be incorporated in the management of infants. It is important to acknowledge that, given the inclusion of 3 districts out of 7 in the province, the results of this survey are not representative for the whole province. The malnutrition situation in the excluded places should be assessed when feasible to provide a better view on the whole province. The drought affecting most of the northern regions in Afghanistan has not yet been reported to affect Bamyan province. Nevertheless, the situation may deteriorate in the coming months and for this reason the nutrition trends should be closely followed. The survey was conducted in July 2011, corresponding to the period of the main harvest, 2 months after the hunger gap, and when people are considered as being in the most food secure period of the year. Bamyan benefits from its stable security context with more opportunities and feasibilities to implement humanitarian projects. Numerous organizations are operating in this area in different fields of intervention. In the nutrition sector alone, 3 NGOs and 2 UN agencies are providing services to the population. This context allows expanding intervention to un-covered areas without facing the challenges that may impact interventions in other less stable provinces. 52 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 7. RECOMMENDATIONS According to the 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. For a GAM rate greater than 15%: SAM treatment services should be expanded if required and blanket SFPs should be established for children six to 24 months of age. According to the GAM rate raised by this survey and in respect to the national public nutrition policy, no nutrition programs are required. Nevertheless, in respect to the ‘Scaling up CMAM’ efforts set up in Afghanistan, the full CMAM components (TFP, SFP and Community mobilization) should be implemented within health facilities at provincial level. Moreover, 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 line with the national nutrition policy, the following recommendations are submitted: To advocate to the Ministry of Public Health and the other health agencies operating in the studied area, to maintain the satisfactory Vitamin A supplementation coverage and to improve the measles vaccination coverage; out reach activities should be emphasized to cover population living in remote areas as well as people not seeking cares in health facilities; To scale up CMAM project within the BPHS framework in the whole province in accordance with the national nutrition policy and in collaboration between the several health-nutrition actors present in the area; o In patient units should be implemented in all districts. 4 TFU are currently functional whereas not covering the 7 districts in Bamyan province; o Out patient Therapeutic Program (OTP) component should be implemented in each district. OTP distribution sites are only located in 1 district in the whole province; o SFP component should be extended to all districts. SFP distribution sites are only located in 4 districts; o Community mobilization program should be extended to remote areas as much as possible according to feasibilities; To monitor the nutrition situation on regular basis. o To improve the regular collection of data through the HMIS to enable the monitoring of nutrition trends on a regular basis; o To conduct further nutrition surveys. According to the nutrition national policy, surveys should be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in nutritional situation; Areas excluded from this survey should be considered while conducting further surveys; o To conduct nutrition surveys in the coming months to evaluate the drought impact if the situation is worsening according to the humanitarian community; o To use follow-up surveys to compare the nutritional situation between 2 periods; o To evaluate the nutritional status of infants below 6 months in a separate survey; To improve IYCF education, counselling by health professionals and peer support groups, so as to improve IYCF practices and through them the children’s health; 53 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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 ACF-CAF Anthropometric nutrition survey, Chal and Rustaq, Takhar province, June 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), Bamyan province, Afghanistan 2006 CSO Afghanistan Statistical Yearbook 2010-2011 Emergency Food Security Assessment (EFSA), World Food Program, August 2011 EPI 5 Stat Calc Software EPI Info Software – Version 2008 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, Bamyan provincial profile, Ministry of Rural Rehabilitation and Development (MRRD) 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 State Of the World, Save the Children UK, 2011 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) 54 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9. ANNEXES 9.1 Annex 1: Map of Bamyan province, Afghanistan (Source: MoPH) 9.2 Annex 2: 3 Ws (Who is doing What and Where), Bamyan province, April 2011 (Source: OCHA) Protection (Human Emergency Shelter Food Security & Rights, Child Water, Sanitation & Districts Education Health Nutrition & Non-Food Iems Agricultural Protection, GBV, Hygiene (WASH) Mine Action, HLP) Kahmard UNICEF, Helvetas IOM, ARCS, FAO, AKF, IRD, WHO,UNICEF, UNICEF IOM, UNHCR, NRC, UNICEF, Helvetas, UNICEF, SC, Helvetas, Helvetas ICRC AIHRC, ICRC Solidarites Solidarites WFP,SCA, ICRC (orthopedic), AADA International (through ARCS), Bamyan AKF,GP,SCA,Habita ICRC,CCA, IOM, SolidaritesAKF,GP,SCA,FAO, IMC,DHSA,,WHO,U UNICEF, SC, IOM, UNHCR, ICRC, Save the Children, t,UNESCO/Japan,U ARCS, UNICEF, SC, IRD, Root of Peace, NICEF,AKF, ICRC NRC, AAA, AIHRC, UNICEF, AKF, SCA, NESCO/LIFE,UNICE CRS, Solidarites Solidarites,WFP,AK (orthopedic), AADA AAA F, ARZU, AAA International F,SCA, AAA Sayghan IOM, ARCS, FAO, AKF, WHO,UNICEF, UNICEF, AADA IOM, UNHCR, ICRC, UNICEF, Solidarites UNICEF, SC, Solidarities, AAA, AADA ICRC NRC, AIHRC, Solidarites IRD, Helvetas, WFP, (orthopedic), AADA Shibar IOM,International ARCS, FAO,Solidarites AKF, IRD, WHO,UNICEF, UNICEF, IOM, UNHCR, ICRC, UNICEF UNICEF, SC, WFP ICRC (orthopedic), NRC, AIHRC, Yakawlang AAA, IOM, ARCS, FAO, AKF, AAA, WHO,UNICEF, UNICEF, SC, AADA IOM, UNHCR, ICRC, UNICEF, AAA UNICEF, SC, CRS, IRD,WFP< AAA, AADA, ICRC NRC, AAA, AIHRC, Solidarites Solidarites (orthopedic) Panjab AKF, AAA IOM, ARCS, FAO, AKF, AAA, WHO,UNICEF, UNICEF, AADA, SC IOM, UNHCR, ICRC, UNICEF, AAA UNICEF, SC, IRD, WFP, Madair AADA, ICRC NRC, AAA, AIHRC, Waras AKF IOM, ARCS, FAO, AKF, IRD, WHO,UNICEF, UNICEF IOM, UNHCR, ICRC, UNICEF, MadAir UNICEF, SC, WFP, AADA, ICRC NRC, AIHRC, 56 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.3 Annex 3: Cluster selection, Saygan, Yakawlang and Panjab districts, Bamyan province, Afghanistan, July 2011 Total Cluster Number District Name Village Name Population selection HH Sayghan MOSSA DARA 193 1 33 Sayghan DEMAN 919 2 149 Sayghan NOW ABAD 972 3 165 Sayghan KAFSH KHAIL 626 4 87 Sayghan BAYANI 723 5 139 Sayghan QALA CHA 236 6 39 Yakawlang GANDA JOWI 100 7 22 Yakawlang DAHANA 244 8 53 Yakawlang DAHAN ZOLEAJ 427 9 65 Yakawlang BALENA 131 RC 24 Yakawlang SOM SAFID 260 10 48 Yakawlang SHAHRASTAN 327 RC 37 Yakawlang DAHANA GAZAK 612 11 101 Yakawlang GALALAK 361 12 51 Yakawlang SHARFAK 466 RC 76 Yakawlang DAHI DASHT 322 13 47 Yakawlang MARSI 257 14 36 Yakawlang LORCHA 236 15 42 Yakawlang WATA POOR 96 16 17 Yakawlang GHARAK 330 17 53 Yakawlang SORKH KOCHA 62 18 8 Yakawlang M.SHARAF 405 19 63 Yakawlang ZAMOCH 174 20 31 Panjab RASHK 153 21 20 Panjab JANG JAY 429 22 81 Panjab WATPOOR 54 23 8 Panjab GHAR GHARI 33 24 6 Panjab SHAGRA 166 25 25 Panjab KAZIM MOURDA 129 26 21 Panjab SHABAR SUFLA 102 RC 18 Panjab SAR JEE 140 27 28 Panjab MARKAZ PANJAB 224 28 38 Panjab PASTA LAK 64 29 10 Panjab KODAK 94 30 20 Panjab DAHAN TAHER 393 31 70 TOTAL 10,460 1,731 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.6 Annex 6: Anthropometric survey – children 6-59 months old and if age not know 65-110 cm, Bamyan province, Afghanistan, July 2011 ANTHROPOMETRIC SURVEY - CHILDREN 6-59 MONTHS AND 65-110 CM - PREGNANT WOMEN BAMYAN PROVINCE - JULY 2011 DATE: N° CLUSTER: N° TEAM: VILLAGE: MUAC Measles Vitamin MUAC Weight in Height in N° Sex Age in W/H Oedema for Vaccination A 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.7 Annex 7: Local event calendar, Bamyan province, Afghanistan, July 2011 2006 2007 2008 2009 2010 2011 Mths Mths Mths Mths Mths Mths وا ت ه 1385 solar 1386 solar 1387 solar 1388 solar 1389 solar 1389 solar 20 of Dalwa 20 of Dalwa 20 of Dalwa 20 of Dalwa 20 of Dalwa 20 of Dalwa start of start of Chella 54 start of Chella 42 start of Chella 30 start of 18 start of 6 66 داو Jan Chella khord khord khord khord Chella khord Chella khord To blow the To blow the To blow the wind of To blow the To blow the To blow the wind of 17 wind of 5 29 41 53 65 ت Feb HOOT wind of HOOT wind of HOOT wind of HOOT HOOT HOOT 1 of Hamal 1 of Hamal 1 of Hamal 1 of Hamal 1 of Hamal Now 1 of Hamal Now rouz, Now rouz, Now rouz, Now rouz, Now rouz, (1390) rouz, raining and raining and Planting 64 52 raining and 40 raining and 28 raining and 16 raining and 4 March Planting of of young tree Planting of Planting of Planting of Planting of young tree young tree young tree young tree young tree Cultivation of Cultivation of Cultivation Cultivation Cultivation of wheet Cultivation of ر 63 51 wheet and 39 wheet and 27 of wheet 15 of wheet 3 Apr and potato wheet and potato potato potato and potato and potato 13 of JAWZA flood, Cultivation of Cultivation of Cultivation Cultivation Cultivation of cultivation of barley 62 50 barley and 38 barley and 26 of barley 14 of barley 2 زا May barley and beens and beens beens beens and beens and beens Irrigation of Irrigation of Irrigation of Irrigation of Irrigation of Irrigation of 1 13 25 37 49 61 ن June agriculture agriculture agriculture agriculture agriculture agriculture 1 of Assad 1 of Assad melon 1 of Assad 1 of Assad 1 of Assad 20 of Assad melon 12 0 24 36 48 60 ا July season melon season melon season melon season Ramazan season 1 of 10 of 21 of 20 of SUNBOLA SUNBOLA SUNBOLA Aug 59 47 SUNBOLA first 35 23 11 first of first of Eid of of Ramazan Ramazan Ramazan Ramazan 1 of MIZAN 1 of MIZAN 1 of MIZAN 1 of MIZAN Eid of 1 of MIZAN Eid Eid of Eid of Eid of Season crop Ramazan and of Ramazan and Ramazan and 34 Ramazan and 22 Ramazan 10 of Potato 46 58 م? زان Sept season crop of weath season crop of season crop of season crop and season and weath and potato weath and potato weath and of weath and crop of 1 of AQRAB Eid 1 of AQRAB Eid Crop of Crop of Ramazan Crop of 57 Ramazan Crop 45 Crop of weath 33 Crop of weath 21 9 ب Oct weath weath weath of weath cold cold weather cold weather without cold weather cold weather cold weather weather without 8 20 32 44 56 س Nov raining without raining without raining without raining without raining raining 1 of Jadi 1 of Jadi 1 of Jadi Chella 1 of Jadi 1 of Jadi ? 1 of Jadi Chella Chella Chella 55 Calan and 43 Chella Calan 31 Chella Calan 19 7 Dec Calan and snowing Calan and Calan and snowing and snowing and snowing snowing snowing 62 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.8 Annex 8: IYCF study – children 0-23 months old, Bamyan, Afghanistan, July 2011 IYCF SURVEY FOR ALL CHILDREN 0 -23 MONTHS BAMYAN PROVINCE, JULY 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.9 Annex 9: Skip patterns - IYCF study – children 0-23 months old, Bamyan province, Afghanistan, July 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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.10 Annex 10: Plausibility check – AFG_201107_BAY_VF.as, Afghanistan, July 2011 Plausibility check for: AFG_201107_BAY_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 (2.5 %) Overall Sex ratio Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 0 (p=0.834) Overall Age distrib Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 4 (p=0.022) Dig pref score - weight Incl # 0-5 5-10 10-20 > 20 0 2 4 10 2 (6) Dig pref score - height Incl # 0-5 5-10 10-20 > 20 0 2 4 10 4 (12) Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >1.20 0 2 6 20 0 (0.98) Skewness WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (-0.13) Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (0.07) Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <0.000 0 1 3 5 0 (p=0.367) Timing Excl Not determined yet 0 1 3 5 OVERALL SCORE WHZ = 0-5 5-10 10-15 >15 10 % At the moment the overall score of this survey is 10 %, this is good. There were no duplicate entries detected. Percentage of children with no exact birthday: 100 % Percentage of values flagged with SMART flags:WHZ: 2.5 %, HAZ: 3.2 %, WAZ: 0.7 % Age ratio of 6-29 months to 30-59 months: 0.68 (The value should be around 1.0). Statistical evaluation of sex and age ratios (using Chi squared statistic): Age cat. mo. boys girls total ratio boys/girls ------6 to 11 6 25/32.9 (0.8) 16/33.5 (0.5) 41/66.4 (0.6) 1.56 12 to 23 12 64/64.2 (1.0) 70/65.3 (1.1) 134/129.5 (1.0) 0.91 24 to 35 12 66/62.2 (1.1) 61/63.3 (1.0) 127/125.5 (1.0) 1.08 36 to 47 12 62/61.2 (1.0) 71/62.3 (1.1) 133/123.5 (1.1) 0.87 48 to 59 12 64/60.5 (1.1) 68/61.6 (1.1) 132/122.2 (1.1) 0.94 ------6 to 59 54 281/283.5 (1.0) 286/283.5 (1.0) 0.98 The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.834 (boys and girls equally represented) Overall age distribution: p = 0.022 (significant difference) Overall age distribution for boys: p = 0.673 (as expected) Overall age distribution for girls: p = 0.022 (significant difference) 66 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 Overall sex/age distribution: p = 0.008 (significant difference) Digit Preference Score Weight: 6 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable) Digit Preference Score Height: 12 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable) Digit Preference Score MUAC: 11 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable) Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures . no exclusion exclusion from exclusion from . reference mean observed mean . (WHO flags) (SMART flags) WHZ Standard Deviation SD: 1.15 1.13 0.98 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 6.7% 6.5% calculated with current SD: 7.8% 7.4% calculated with a SD of 1: 5.2% 5.1% HAZ Standard Deviation SD: 1.34 1.34 1.15 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 59.4% 59.4% 60.5% calculated with current SD: 53.9% 53.9% 56.8% calculated with a SD of 1: 55.2% 55.2% 57.8% WAZ Standard Deviation SD: 1.05 1.05 1.00 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 29.8% 29.8% 29.7% calculated with current SD: 30.6% 30.6% 29.8% calculated with a SD of 1: 29.7% 29.7% 29.8% Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.462 HAZ p= 0.000 p= 0.000 p= 0.015 WAZ p= 0.012 p= 0.012 p= 0.205 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed) Skewness WHZ -0.33 -0.22 -0.13 HAZ 0.70 0.70 0.20 WAZ -0.03 -0.03 -0.13 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 2.41 2.11 0.07 HAZ 2.08 2.08 -0.05 WAZ 0.87 0.87 0.04 (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 Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 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=1.07 (p=0.367) WHZ < -3: ID=0.86 (p=0.682) GAM: ID=1.07 (p=0.367) SAM: ID=0.86 (p=0.682) HAZ < -2: ID=1.49 (p=0.045) HAZ < -3: ID=1.48 (p=0.049) WAZ < -2: ID=1.15 (p=0.267) WAZ < -3: ID=1.15 (p=0.266) 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. 68 Anthropometric nutrition survey and Infant and Young Child Feeding Practices study Saighan, Yakawlang and Panjab districts, Bamyan province – Afghanistan – July 2011 9.11 Annex 11: Estimated percentage of population consuming a diet with very poor food group diversity, NRVA, Afghanistan, September 2005 9.12 Annex 12: Estimation food security conditions, 4 th quarter 2011 (October – December 2011) - FEWS Net