Afg-Sar E Pul Smart Final Report 2021.Pdf (English)

Integrated Nutrition and Mortality SMART Survey Final Report Sar e Pul Province, Afghanistan 6th to 15th April 2021

Survey Led by: Dr. Muhammad Khalid “Zakir”, SMART Program Manager Authors: NUT-Surveillance Department, Action Against Hunger Afghanistan

AFGHANISTAN Technically supported by: Global SMART team, AAH Canada and Technical Advisor, AAH France

Funded by:

Action Against Hunger | Action Contre La Faim A non-governmental, non-political, and non-religious organization Acknowledgments Action Against Hunger would like to thank all the stakeholders and partners who provided support to the SMART Assessment teams in all districts of Sar e Pul province:  This survey would not have been possible without the financial support provided by European Union Humanitarian Aid (ECHO).  Ministry of Public Health (MoPH), especially the M&EHIS Directorate, Public Nutrition Directorate (PND), AIM-Working Group, Afghanistan Nutrition Cluster, and the Nutrition Small Scale Surveys Steering Committee for their support, review, and validation of the survey protocol.  Sar e Pul Provincial Public Health Directorate (PPHD) for their support and authorization; special thanks go to Dr. Noor Ahmad Ishaqzi Sar e Pul public health director and Dr. Ghulam Habib Stanekzai SEHATMANDI Project Manager for all the facilitation and assistance they have provided for smoothly implementing of this assessment.  All community members for welcoming and supporting the survey teams during the data collection process.  Special appreciation to the survey teams for making the survey a reality.  Action Against Hunger team at Kabul and Paris for technical and operational Supports.  Bijoy Sarker, SMART Regional Advisor - Asia, and Action Against Hunger Canada for technical support, review and validation of the report.

Statement on Copyright © Action Against Hunger Action Against Hunger is a non-governmental, non-political, and non-religious organization. Unless otherwise indicated, reproduction is authorized on the condition that the source is credited. If reproduction or use of texts and visual materials (sound, images, software, etc.) is subject to prior authorization, such authorization was render null and void the above- mentioned general authorization and will clearly indicate any restrictions on use. The content of this document is the responsibility of the authors and does not necessarily reflect the views of Action Against Hunger and GAC.

Abbreviation

ACF/AAH Action Contre la Faim / Action Against Hunger AIM-TWG Assessment and Information Management Technical Working Group AOGs Armed Opposition Groups ARI Acute Respiratory Infection BHC Basic Health Centre BPHS Basic Package of Health Services BSU Basic Sampling Unit CBA Child-Bearing Age CDR Crude Death Rate CHC Comprehensive Health Centre CI Confidence Interval DEFF Design Effect DH District Hospital DP Desired precision ENA Emergency Nutrition Assessment EPHS Essential Public Health Services EPI Expanded Program on Immunization FHH Family Health House GAM Global Acute Malnutrition HAZ Height for Age Z-score HF Health Facilities HHs Households IDPs Internally Displaced People IEC Information Education and Communication IMNCH Integrated Maternal New born and Child Health IPC Integrated Food Insecurity Phase Classification IPC Infection Prevention and Control IPD-SAM Inpatient Department for Severe Acute Malnutrition IYCF Infant and young Child Feeding MCH Mother and Child Health M&EHIS Monitoring and Evaluation - Health Information System MHT Mobile Health Team MM Millimetres MoPH Ministry of Public Health MUAC Mid-Upper Arm Circumference MW Mean Weight NGO Non-Governmental Organization NSIA National Statistics and Information Authorities NSSSSC Nutrition Small Scale Surveys Steering Committee OPD-MAM Outpatient Department for Moderate Acute Malnutrition OPD-SAM Outpatient Department for Severe Acute Malnutrition OW Observed Weight PH Provincial Hospital PHC Prison Health Center PHC Primary Health Care

PLW Pregnant and Lactating Women PND Public Nutrition Directorate PNO Public Nutrition Officer PPHD Provincial Public Health Directorate PPS Probability Proportional to Size PSU Primary Sampling Unit RC Reserve Cluster RUSF Ready to Use Supplementary Food RUTF Ready to Use Therapeutic Food SAF Solidarity for Afghan Family SAM Severe Acute Malnutrition SD Standard Deviation SHC Sub Health Center SMART Standardized Monitoring and Assessment of Relief and Transitions U5DR Under-five Death Rate UNICEF United Nations Children’s Fund UN-OCHA United Nations Office for the Coordination of Humanitarian Assistance W/H Weight for Height WASH Water, Sanitation and Hygiene WAZ Weight for Age Z-Score WFP World Food Program WHO World Health Organization WHZ Weight for Height Z-score

Table of Contents Acknowledgments ...... 2 Abbreviation ...... 3 1. Executive summary ...... 8 2. Introduction ...... 10 2.1. Geographical area ...... 10 2.2. Health and Nutrition Services ...... 10 2.3. Food Security ...... 11 2.4. Description of the survey area ...... 11 2.5. COVID situation in Sar e Pul ...... 12 2.6. Survey Justification ...... 12 3. Survey objectives ...... 13 3.1. General objective ...... 13 3.2. Specific objectives ...... 13 4. Methodology ...... 13 4.1. Survey Design Considerations during Covid-19 pandemic ...... 13 4.2. Geographic target area and population group ...... 14

4.3. Survey period ...... 14 4.4. Survey design ...... 14 4.5. Sample Size ...... 15 4.6. Sampling Methodology ...... 17 4.6.1. First stage sampling (Selection of the clusters) ...... 17 4.6.2. Second Stage Sampling (Selection of Households) ...... 18 4.7. Field Procedures ...... 19 4.8. Household inclusion and exclusion criteria ...... 20 5. Health and Safety Measures During the Survey Implementation ...... 21 5. Indicators: Definition, Calculation, and Interpretation ...... 23 6.1. Overview of Indicators ...... 23 6.2. Anthropometric, Health, and Immunization Indicators ...... 24 6.3. Chronic and Acute Malnutrition ...... 25 6.4. Combined GAM ...... 26 6.5. Chronic malnutrition ...... 26 6.6. Underweight...... 26 6.7. The proportion of acutely malnourished children enrolled in or referred to a Program 27 6.8. Malnutrition prevalence among women 15-49 years based on MUAC criterion ..... 27 6.9. Measles Both Doses Coverage ...... 27 6.10. Morbidity ...... 28 6.11. Maternal Nutrition ...... 28 6.12. Retrospective mortality...... 28 7. Organization of the survey ...... 28 7.1. Survey Coordination and Collaboration ...... 28 7.2. Data Quality Control and Assurance ...... 28 7.3. Ethical considerations...... 29 7.4. Survey teams ...... 29 7.5. Training of the survey teams ...... 30 8. Data analysis ...... 31 9. SURVEY FINDINGS ...... 31 9.1. Survey Sample & demographics ...... 32 9.2. Data Quality ...... 34 9.3. Prevalence of Acute Malnutrition by WHZ ...... 34 9.4. Acute malnutrition by MUAC ...... 38 9.5. Acute Malnutrition by Oedema ...... 39 9.6. Combined Acute Malnutrition by WHZ and/or MUAC and/or Oedema ...... 39 9.7. Enrolment in nutrition program ...... 40

9.8. Prevalence of Chronic Malnutrition ...... 40 9.9. Prevalence of Underweight ...... 42 9.10. Prevalence of Overweight ...... 43 9.11. Malnutrition prevalence among Women 15-49 years old based on MUAC criterion 44 9.12. Retrospective Mortality ...... 44 9.13. Child health and Immunization Status ...... 45 9.14. Child health...... 46 10. Discussion ...... 46 10.1. Nutritional Status of children ...... 47 10.2. Maternal nutrition status ...... 48 10.3. Mortality rate ...... 48 10.4. Immunization ...... 48 11. Recommendations ...... 49 Annexes ...... 53 Annex1: Standardization test report ...... 53 Annex 2: Health Screening Checklist for Household Exclusion ...... 53 Annex 3: Daily Health Screening Checklist for Survey Team Members ...... 54 Annex 4: Standard Integrated SMART Survey Questionnaire (English) ...... 55 Annex 5: Geographical Units surveyed in Sar e Pul province...... 58 Annex 6: Plausibility check for Sar e Pul SMART 2021 ...... 60 Annex 7: Event Calendar Sar e Pul Province (April, 2021) ...... 71 12. References ...... 72

List of Tables Table 1: Summary of Findings ...... 8 Table 2: Estimated sample size for anthropometry ...... 15 Table 3: Sample size calculation for mortality survey...... 16 Table 4: Household selection per day time table ...... 17 Table 5: Standardized Integrated SMART Indicators...... 23 Table 6: Definition of Acute Malnutrition, Chronic Malnutrition, Underweight and Overweight according to WHO Reference 2006 ...... 25 Table 7: WHO Definition of Acute Malnutrition According to Cut-off Values for MUAC...... 26 Table 8: Classification for Severity of Malnutrition by Prevalence among Children Under-Five ...... 27 Table 9: list of PPE equipment used in the surveys ...... 31 Table 10: Proportion of household and child sample achieved ...... 32 Table 11: Demographic data summary ...... 32 Table 12: Household residential status by the proportion ...... 33 Table 13: Distribution of Age and Sex among Children 6-59 months ...... 33 Table 14: Mean Z-scores, Design Effects, Missing and Out-of-Range Data of Anthropometric Indicators among Children 6-59 Months ...... 34

Table 15: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 6-59 months, WHO 2006 Reference ...... 35 Table 16: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 6-23 months, WHO 2006 Reference ...... 35 Table 17: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 24-59 months, WHO 2006 Reference ...... 35 Table 18: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 0-59 months, WHO 2006 Reference ...... 36 Table 19: Prevalence of Acute Malnutrition per WHZ Severity and Age Group of 6-59 months ...... 36 Table 20: Prevalence of Acute Malnutrition by MUAC (and/or oedema) by Severity and Sex among children 6-59 months ...... 38 Table 21: Prevalence of Acute Malnutrition per MUAC and/or Oedema by Severity and Age Group...... 38 Table 22: Distribution of Severe Acute Malnutrition per Oedema among Children 6-59 Months ...... 39 Table 23: Prevalence of combining Acute Malnutrition by WHZ + MUAC by Severity and Sex among Children 6-59 months ...... 39 Table 24: Proportion of Acutely Malnourished Children 6-59 Months enrolled in a Treatment Program ...... 40 Table 25: Prevalence of Chronic Malnutrition by HAZ by Severity and Sex among Children 6-59 months, WHO 2006 Reference...... 41 Table 26: Prevalence of Chronic Malnutrition per HAZ by Severity and Age Group ...... 41 Table 27: Prevalence of Underweight by WAZ by Severity and Sex among Children 6-59 months, WHO 2006 Reference ...... 42 Table 28: Prevalence of Underweight per WAZ by Severity and Age Group ...... 42 Table 29: Prevalence of overweight based on weight for height cut-offs and by sex (no oedema) among children age 6- 59 months...... 43 Table 30: Prevalence of overweight by age, based on weight for height (no oedema) ...... 43 Table 31: Prevalence of Acute Malnutrition among Women per MUAC ...... 44 Table 32: Death Rate by Age and Sex with Reported Design Effect ...... 44 Table 33: Measles Immunization Coverages among Children 9-59 Months ...... 45 Table 34: Major illnesses reported among children 0-59 months ...... 46

Table of Figures Figure 1: Sar e Pul Province Map (District Level) ...... 10 Figure 2: Survey Team Composition ...... 30 Figure 3: Sar e Pul Province Population Pyramid...... 33 Figure 4: Distribution of cases (WHZ <-2) in clusters, Poisson distribution ...... 37 Figure 6: Distribution of WHZ Sample Compared to the WHO 2006 WHZ Reference Curve . 38 Figure 5: Means WHZ by age groups ...... 38 Figure 7: Mean HAZ by Age Group ...... 41 Figure 8: Distribution of HAZ Sample Compared to the WHO 2006 WHZ Reference Curve ... 41 Figure 9: Distribution of WAZ Sample Compared to the WHO 2006 with Reference Curve. ... 43 Figure 10: Mean WAZ by Age Group ...... 43 Figure 11: Percentages of causes of the deaths ...... 45 Figure 14: Among Stunted Children 6-59 Months, those Simultaneous Wasted (WHZ) ...... 47

Executive summary Sar-e-Pul is one of the 34 provinces of Afghanistan located in the north of the country. The province has borders with Jowzjan and Balkh to the west and north, Ghor Province to the south, and Samangan to the east. The province is divided into 7 districts (Sayyad, Kohistanat, Sozma Qala, Sancharak, Gosfandi, Balkhab, and Sar e Pul which serves as the capital of the province), The province’s population is around 6121,002 people. The survey design was a cross-sectional population-representative survey following the Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. The survey applied two-stage cluster sampling using the SMART methodology based on probability proportional to size (PPS) for cluster selection. Stage one sampling involved the sampling of the Villages/clusters to be included in the survey while the second stage sampling involved the random selection of the households within the sampled clusters. The smallest geographical unit in Sar e Pul defined as a cluster is a village. A total of 562 children aged 0-59 months were assessed, among them, 499 were 6-59 months old. The data collection took place from 6th to 17th April 2021, during the spring season in Afghanistan. Out of 430 households planned, 414 were successfully assessed. The survey results indicated a Global Acute Malnutrition (GAM) rate for children 6-59 months old based on WHZ is 7.5% (5.4-10.3 95% CI). The results also indicated a very high level of chronic malnutrition of 44.5% (39.3-49.8 95% CI) exceeding the 30% critical threshold2. The result for malnourished pregnant & lactating women based on MUAC (<230 mm) was at 16.9%. The final report presents the analysis and interpretation of the nutritional status of children under five, the nutritional status of women 15-49 years old, pregnant, and lactating women (PLW), measles immunization coverage, morbidity in the last 14 days, and retrospective mortality rates. The summary of the key findings is presented in table 1 below.

Table 1: Summary of Findings

Malnutrition prevalence – Children U5 Indicator Prevalence

GAM prevalence among children 6-59 months per WHZ <-2SD 7.5% ( 5.4-10.3 95% CI) SAM prevalence among children 6-59 months per WHZ <-3SD 0.8% ( 0.3- 2.1 95% CI) GAM prevalence among children 0-59 months per WHZ <-2SD 7.3% ( 5.4- 9.8 95% CI) SAM prevalence among children 0-59 months per WHZ <-3SD 0.5% (0.2- 1.7 95% CI)

1 National Statistics and Information Authority – NSIA_ Update Population 2020-21 2 Prevalence thresholds for wasting, overweight and stunting in children under 5 years, August 2018.

GAM prevalence among children 6-59 months per MUAC <125 mm 10.2% ( 6.9-14.9 95% CI) SAM prevalence among children 6-59 months per MUAC <115 mm 2.0% ( 0.9- 4.4 95% CI) Combined GAM prevalence among children 6-59 months per WHZ 12.6 % (9.1 - 17.3 95% C.I.) <-2SD and/or MUAC <125mm and/or Oedema Combined SAM prevalence among children 6-59 months per WHZ 2.8 % (1.5 - 5.2 95% C.I.) <-3SD and/or MUAC <115 mm and/or Oedema

Stunting among children 6-59 months per HAZ <-2SD 44.5% (39.3-49.8 95% CI) Severe Stunting among children 6-59 months per HAZ <-3SD 15.2% (11.8-19.5 95% CI) Underweight among children 6-59 months per WAZ <-2SD 24.4% (20.0-29.5 95% CI) 4.2% Severe Underweight among children 6-59 months per WAZ <-3SD ( 2.9- 6.2 95% CI) 2.0 % Overweight among children 6-59 months per WHZ >2SD (1.0 - 4.2 95% C.I.) *GAM and SAM prevalence by any indicator include cases of nutritional oedema

Nutritional status of Women 15-49 years old Women and PLW

Indicator Result Malnutrition among all (CBA) women 15-49 years including PLW and 15.7% Not PLW per MUAC <230mm (11.7-20.9 95% CI) Malnutrition among pregnant and lactating women (PLW) per MUAC 16.9% <230 mm (11.1-24.9 95% CI)

Crude and Under Five Death Rate (Death/10,000/Day)

Indicator Result

Crude Death Rate (CDR) 0.22 (0.09-0.49 95% CI) Under five Death Rate (U5DR) 0.44 (0.14-1.40 95% CI)

Child Immunization First Dose Second Dose Indicator (9-59 months) (18-59 months) Measles vaccination among children 57.3% 42.1% confirmed by vaccination card (48.8-65.3 95% CI) (33.1-51.7 95% CI)

Measles vaccination among children 29.0% 29.3% confirmed by caregiver recall (21.6-37.6 95% CI) (21.4-38.7 95% CI) Overall Measles vaccination among children confirmed by either vaccination 86.3% 71.5% (79.2-91.2 95% CI) (62.3-79.2 95% CI) card or caregiver recall

1. INTRODUCTION

2.1. Geographical area

Sar e Pul is one of the 34 provinces of Afghanistan located in the north of the country. The province has borders with Jowzjan and Balkh to the west and north, Ghor Province to the south, and Samangan to the east. The province is divided into 7 districts (Sayyad, Kohistanat, Sozma Qala, Sancharak, Gosfandi, Balkhab, and Sar e Pul which serves as the capital of the province, The province’s population was estimated around 621,002 people (NSIA3 2020-21). Sar-e Pol is a mountainous province, especially in its southern part. It covers an area of 16,360 km2. 75% of the province is mountainous or semi-mountainous terrain while 1/7 (14%) of the area is made up of flat land. The most important field crops grown in Sar-e-Pul province include Wheat, maize, alfalfa, barley, and flax. The most common crops grown in garden plots include; Grapes (75%), fruit and nut trees (16%), and vegetables (3%). 4

Sar e Pul is multi-ethnic, the main Figure 1: Sar e Pul Province Map (District Level) ethnic groups living in Sar-e-Pul province are Uzbek, Pashtoon, Hazara followed by Arab and Tajik, the major tribe is Uzbek in all districts. Dari is the most dominant language in the province.

2.2. Health and Nutrition Services

In terms of Public health, a national NGO Solidarity for Afghan Families “SAF” has been implementing the SEHATMANDI project in Sar e Pul province: A total of 72 health facilities providing health services (1 PH, 3 DHs, 1 CHCs+, 8 CHCs, 20 BHCs, 32 SHC, FHHs 5, 1 MHT,

3 National Statistics and Information Authority – NSIA_ Update Population 2020-21. 4 UNDSS Provincial Assessment provided by UNAMA- Sar e Pul province General Information.

10 and 1 Prison Health Center) delivering primary, and secondary health services to the entire population of the province. A total of 42 of the health facilities do provide OPD SAM and 18 HFs provide OPD MAM and 3 HFs provide IPD SAM services in the province. Out of these sites only 15 sites had nutrition counselors.

2.3. Food Security

In terms of food security, Sar-e-pul was projected in Phase 3 by IPC classification (nov-2020 to March 2021), an estimated 45% of people of the total population facing acute food insecurity. In response to the flash floods and natural disasters in which 163,000 people were affected among 11 provinces of Afghanistan, Sar-e Pul was one of the most affected provinces where agricultural land and public infrastructure impacted following flash floods on 20195. Due to the last years’ security collapse and ongoing conflicts, in the period of 1 March 2019 – 30 June 2020, 7,357 persons were displaced from the province of Sar-e Pul, of whom 79% were displaced within the province itself. In April 2019 and January 2020, Sar-e Pul province also hosted IDPs from Faryab and Jowzjan.6 To update data in nutrition area, AAH has implemented SMART survey in this province, the survey took place and conducted in spring season (starting from 06th to 17th April, 2021) by AAH in collaboration with Solidarity for Afghan Families “SAF” Sar-e-pul sub-office and Technically supporting by ACF HQ H&N technical advisor, France and SMART expert, ACF Canada, covering the whole province, with close coordination of Sar e Pul PPHD at the provincial level and at national level with AIM-TWG and Nutrition Cluster.

2.4. Description of the survey area

This SMART survey was conducted in all 7 districts of Sar e Pul province; the sampling frame was all the villages in the seven districts of the province, all the 6 districts were considered as rural areas (except the capital of the province) and were accessible for the survey teams, due to insecurity; out of the total of 748 villages 126 villages (16.8%) were excluded from sampling frame, it means the sampling frame was initialized from 622 (yellow & Green) villages of the province. Most of the inaccessible clusters/villages were mainly in Balkhab, Sancharak, Suzma Qala, and Kohistanat districts due to the recent peak of the insecurity and presence of Armed Opposition Groups (AOGs) with continued fighting in the areas. From the cultural, ethnic, and linguistic perspective, the inhabitants of the excluded villages were homogenous with the residence of the surveyed parts of the province.

5 OCHA Flash Floods Update, #8-Afghanistan. 6 Sar e pul province-COMMON ANALYSIS Last updated: December 2020

A full SMART Data collection was conducted in Sar e Pul province from 06th to 15th April 2021. [The 1st Month of year 1400 in Solar Calendar] at the beginning of the spring season. The survey covered the entire province, including partially secure and completely secure villages throughout the province.

2.5. COVID situation in Sar e Pul

The COVID-19 pandemic in Afghanistan is part of the worldwide pandemic of coronavirus disease 2019 (COVID-19) that causes a severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2). Based on Afghanistan MOPH confirmation and reporting the 1st case of COVID-19 was discovered on 24th February 2020 in Herat province. According to Sar e Pul PPHD, a total of 917 suspected cases were tested, out of which 235 cases were detected positive and 6 cases were died from 24th February 2020 up to 2nd February 2021.7 Based on the Sar e Pul province active surveillance and focal person report, no positive case of COVID- 19 was detected in the week, that preceded our initial assessment (28thJanuary 2021) therefore; we can assume, that the situation of COVID-19 was improving and that allowed us to implement this survey in the province, additionally all the preventive measures of COVID-19 were considered at training as well as during field data collection to reduce the spread of covid- 19. Through this activity to protect survey teams, interviewers/respondents, and caretakers of children during survey implementation, necessary technical and operational recommendations were followed as per interim guidelines 8to ensure adequate safety precautions for the beneficiaries as well as for the survey team.

2.6. Survey Justification As Sar e Pul was one of the provinces of Afghanistan where no any SMART assessment was implemented in the past, therefore this assessment took place in the province toward identifying nutritional status and mortality situation in the province, the paragraph bellow illustrates the core justifications of the survey:  Sar e Pul was one of the prioritized provinces for SMART assessment, where no any previous SMART or Rapid SMART was implemented in the province.  Sar e Pul province was categorized at critical/emergency level of acute malnutrition by nutrition cluster 2020 HNO 9severity ranking of Afghanistan.

7 Total Cases of COVID-19 date up to 2 february-2021- Surveillance MOPH 8 AAH/ACF AFGHANISTAN INTERIM GUIDANCE ON RESTARTING POPULATION LEVEL SURVEYS AND HOUSEHOLD LEVEL DATA COLLECTION DURING COVID-19 PANDEMIC- December, 2020. 9 Afghanistan Nutrition Cluster 2020 HNO

 This assessment was aiming to assess the nutritional status of people living in the Sar e Pul province. Because the province was faced with many conflicts in the last years as well as flash floods in 2019 which has resulted in internal displacements to central and secure areas as well as the province was hosted IDPs from Faryab and Jowzjan in 2020.  Sar e Pul province was classified in phase 3 of the IPC classification, which indicates that the population is living in crises in terms of food security (IPC_ November 2020).

2. SURVEY OBJECTIVES

3.1. General objective The overall objective of the survey was to assess the nutrition situation of under-five children and women of reproductive age, crude and under-five retrospective mortality rates in Sar e Pul province.

3.2. Specific objectives 1. To estimate the prevalence of undernutrition (Stunting, Wasting, and Underweight) and Overweight among children aged 0-59 months. 2. To estimate the retrospective Crude Death Rate (CDR) and Under-Five Death Rate (U5DR). 3. To estimate the first and second dose measles vaccination coverage among children 9- 59 months. 4. To estimate the morbidity prevalence (diarrhoea and ARI) among children age 0-59 months in the past 2 weeks recall period. 5. To determine the nutritional status of women (15-49 years) including PLW based on MUAC assessment. To note that, survey objectives have been limited in accordance with the interim guidance for conducting household survey during COVID 19 in order to limit the time of interaction with the household members. For the reason, some indicators usually collected in Afghanistan are not included in this survey, such as IYCF, WASH and FSL related indicators.

3. METHODOLOGY

4.1. Survey Design Considerations during Covid-19 pandemic

 This survey design was cross-sectional using the SMART methodology with two-stage clusters sampling.  The number of questions and indicators included in this survey have been kept to an absolute minimum. The design of the survey objectives and questionnaire have kept the total interview time as short as possible (ideally under 15 minutes).  This survey kept the sample size to a necessary minimum to ensure minimally acceptable precision as per the SMART guidelines. A relatively higher non-response rate was considered to account for household refusal as well as household exclusion that has given COVID-19 exposure or symptoms.  This survey has followed the usual methods for measuring MUAC, weight, height, and age using trained measurers as per the SMART guidelines.  Ideally, enumerators were <65 years of age and without comorbidities known to increase the risk of COVID-19 complications and the Organizations were also highly encouraged to recruit healthy and young surveyors with better mobility and endurance of hard physical work (day- long walking under difficult condition).  Before the interview, the team members were screening respondents and all measured subjects. If any relevant individual (e.g. children U5, survey respondent/mother/caregivers) if in the household met any of the following conditions, (See annex 6.1 health screening checklist), the household was excluded from the survey. If other member of the HH had high fever or other symptoms then that member was asked to stay away/isolated but that HH was included from the survey. NOTE: the survey teams were guided to clearly mark, if an HH was excluded because of this reason, but fortunately no one was observed in the above conditions to be excluded from the surveyed households.

4.2. Geographic target area and population group

A full SMART assessment targeted the whole Sar e Pul province. The household was the basic sampling unit (BSU). The surveyed population was children from the age of 0-59 months and Pregnant and Lactating Women (PLW) and Women from 15-49 years in addition to the household indicators, and for CDR, the general population (all household members) was integrated in the survey. 4.3. Survey period Six days of technical training was conducted from 30th, March to 05th April 2021 and the data collection took place from 06th to 15th April 2021 in all 7 districts of the Sar e Pul province.

4.4. Survey design

The survey design was cross-sectional using the SMART methodology, following two stages cluster sampling method.

4.5. Sample Size The anthropometry and mortality sample sizes were determined by using ENA for SMART software version 2020 (updated 11th Jan 2020) based on estimated prevalence rates of Global Acute Malnutrition (GAM) or estimated death rate, desired precision and design effect, average household size, percentage of <5’s in the population, And percentage of non-response rate. The parameters for the sample size calculation are outlined in Tables 2 and 3 below. Table 2: Estimated sample size for anthropometry Parameters for Value Assumptions Based on Context Anthropometry As there was no previous SMART/Rapid SMART survey conducted in the province, therefore, the

The estimated prevalence GAM prevalence of 7.3% from last Afghanistan 7.3% of GAM (%) Heath Survey “AHS”, 2018 10 report has been

considered here. And Confidence Interval (CI) was not available with the 2018 AHS Report. Based on SMART recommendation and consistent Desired precision ±3.0 with survey objectives to estimate the prevalence. According to SMART Manual.2- 2017 recommendations; as Sar e Pul province is one of the provinces where is no previous information about Design Effect 1.5 design effect Therefore; the DEFF of 1.5 was assumed for the planning of this survey in the province. The minimum sample size for children aged 6-59 Children to be included 472 months in the selected households that were surveyed Based on the Afghanistan Health Survey “AHS”, Average HH Size 7.4 2018 in Sar e Pul province. Based on the Estimated Population of Afghanistan % Children under five 18.01% 2020-2021 by National Statistics and Information Authority “NSIA”. 11

10 MOPH-Afghanistan- AHS 2018. 11 Estimated Population- NSIA 2020-2021- Afghanistan.

Due to COVID-19 pandemic, a great number of % Non-response Non-Response Rate (NRR) was taken into 7% Households consideration for sample size calculation in planning stage compared to usual NNR faced in Afghanistan. Minimum sample size-Households (BSUs) were Households to be included 423 planned to be surveyed.

Table 3: Sample size calculation for mortality survey Parameters for Mortality Value Assumptions based on context There was no any previous survey data for CDR Estimated Death Rate available in the province. Hence, based on SMART 0.5 /10,000/day Manual 2.0, a CDR rate of 0.5 was assumed in this survey. Based on SMART Manual. 2. - 2017, as there was no any Desired precision ±0.3 previous survey conducted in the province. According to SMART Manual.2- 2017 recommendations the DEFF of 1.5 was assumed for the

Design Effect 1.5 planning of this SMART survey, because as Sar e Pul province is one of the provinces where wasn’t previous information about design effect. The starting point of the recall period was 7th December and the (ص17th Qaws 1399) (Wafat Muhammad) 2020 Recall Period in days 125 mid-point of data collection was estimated on the 10th April 2021).

Population to be included 2,788 Population

12 Average HH Size 7.4 Based on Afghanistan Health Survey “AHS ”, 2018. Due to COVID-19 pandemic, a great number of Non % Non-response Response Rate (NRR) was taken into consideration for 7% Households sample size calculation in planning stage compared to usual NNR faced in Afghanistan. Number of households which were considered for the Households to be included 405 planning of sample size.

Based on the ENA for SMART (Jan 11th, 2020 version) calculations, the largest household sample

12 Afghanistan Health Survey “AHS”, 2018

16 size i.e. Anthropometry sample size (423) was used for both anthropometry and mortality survey. While the estimated 423 HH samples for anthropometry was sufficient for the rest of the pre- determined indicators (i.e. Health and Maternal Nutrition, mortality, etc.). The number of households to be surveyed in each day were determined according to the time the team spent in the field excluding transportation, other procedures, and break times. The details in table 4 below were taken into consideration when performing this calculation based on the given context: Table 4: Household selection per day time table 8:30 AM to 4:00 PM (7.5 Hours = 450 Total working time minutes) Time for transportation (round trip) – 120 min 450 - 120 = 330 minutes Coordination with village elder and preparation 330 – 30 = 300 minutes of HH list - 30 min Time for a break and pray – 50 Min 300 - 50 =250 minutes The average duration of the HH interview 15 minutes Distance from one HH to another HH 5 minutes Height board, weighing scales disinfection and 5 minutes other IPC measures Average HH per day per cluster by one team 250 ÷ 25 = 10 HHs

The above gives an average of 250 min of working time in each cluster. on average teams spent 15 min in each HH and 5.0 min traveling from one HH to another and 5 min for equipment disinfection and other IPC measures, each team can comfortably reach 10 HH per day, (250/25=10). The total number of households in the sample was divided by the number of households completed in one day to determine the number of clusters included in the survey. (423 HHs)/ (10HHs per cluster) =42.3 Clusters were rounded up to 43. 4.6. Sampling Methodology A two-stage cluster sampling methodology was adopted based on probability proportional to size (PPS); the villages with a large population had a higher chance of being selected than villages with a small population and vice versa. The village was the Primary Sampling Unit (PSU) while the household was the Basic Sampling Unit (BSU).

4.6.1. First stage sampling (Selection of the clusters) The first stage involved the selection of clusters/villages from a total list of villages. A list of all updated villages was uploaded into the ENA for SMART software where PPS was applied. The list of villages/cluster was gathered from the Basic Package of Health Services (BPHS) providers

17 in consultation with PPHD to finalize the sampling frame. Based on the latest EPI micro-plan, all insecure or inaccessible villages were identified and systematically excluded from the final sampling frame; the final list consisted of 622 out of 748 villages (126 inaccessible/insecure villages were excluded). The clusters generated using the ENA software version included 5 Reserve Clusters (RCs). Reserve clusters were planned to be surveyed only if 10% or more clusters were not possible to be surveyed, fortunately the achievement was greater and no any RC was used in this survey.

Based on the estimated time to travel to the survey area, select and surveying the households, it was estimated that each team could effectively survey 10 HHs per day. In each selected village, one or more community member(s) was asked to help the survey teams to survey by providing information about the village concerning the geographical organization or the number of households. In cases of large villages or semi-urban zones/small cities in a cluster, the village/zones were divided into smaller segments and a segment selected randomly (if similar in size) or using PPS to represent the cluster. This division was done based on existing administrative units e.g. neighborhoods, streets, or natural landmarks like a river, road, mountains, or public places like schools, and masjid.

4.6.2. Second Stage Sampling (Selection of Households) The second stage includes randomly selection of basic sampling units within the planned clusters, Based on the context and WFP household definition, a household was defined as a group of people living under the same roof and sharing food from the same cooking pot13. In polygamous households, those living and eating in different houses were considered as separate HHs. Wives living in different houses and eating from the same cooking pot were considered as one HH. Upon arrival at the villages, the survey team was introduced themselves and the objectives of the survey to the village leaders/chiefs at the respective villages, and in collaboration with the village leaders/chiefs, the team was preparing a list of all households in the village. Households to be sampled were selected using systematic random sampling as per the recommendation of the SMART methodology. This household selection method was preferred because it was objective, easy to monitor, and makes the process more transparent to the local community.

13 WFP household definition

Segmentation was done in villages with large numbers of households i.e. greater than 150 households, after which one segment was randomly selected to be sampled. The segmentation was done based on existing administrative units e.g. neighborhoods, streets, or natural landmarks like a river, road, mountains, or public places like schools, and mosques. The survey team was getting consent from the selected holds; if they agree, data collection was started from any convenient household of the 10 randomly selected households to carry out anthropometric14, morbidity, and mortality questionnaires. Household revisits was done to households in which eligible children (under five) or entire household members were found to be absent during the first attempt. No households was substituted. A cluster control form was used to record all these missed, refused and absent households.

4.7. Field Procedures The survey covered/achieved a total of 414 households from 42 total clusters surveyed, due to insecurity/inaccessibility one cluster was (out of a total of 43 planned) not possible in the Sar e Pul province. Each team was responsible for cover effectively 10 households per day. Households were chosen within each cluster using systematic random sampling as described below. A total of 6 teams were engaged during the assessments, while data collection was conducted in 10 days. On arrival at the Chief/Malik the survey team introduced themselves and the objective of the survey to the Chief/Malik leader.  In collaboration with the Chief/Malik leader, the team prepared a list of all households in the cluster. Abandoned absent households were excluded from the list.  The required number of households were selected using systematic random sampling.  The sampling interval was determined by:

Total number of sampling units in the population Sampling interval = Number of sampling units in the sample (10) Equation 1: Sampling Interval  Every household was asked for voluntary consent to take part in the survey process before any data was collected.  All children 0 to 59 months living in the selected house was included for anthropometric measurements, including twins and orphans or unrelated children living with the sampled household.

 If a child of a surveyed household was absent due to enrolment in an IPD treatment center at the time the household was surveyed, teams were not visited any treatment center to measure that child.  Households without children were still assessed for household-level questions (PLW nutritional status, and mortality).  Any absent households with missing or absent women or children were revisited at the end of the day before leaving the cluster.  The missing or absent child that was not found after multiple visits were not included in the survey.  A cluster control form was used to record all household visits and note any missed and absent households.

4.8. Household inclusion and exclusion criteria Before the interview, the team members were screening all the respondents and measured subjects. If any individual in the household meets any of the following conditions (annex 2 for household check), the household was excluded from the survey:  Measure temperature with a digital infrared thermometer for eligible children and their mothers/caregivers. The survey teams were guided to exclude, if the eligible child and/or mother has a temperature ≥100.4°F/ 38°C and/or other symptoms of COVID-19 (e.g. dry cough, sneezing, shortness of breath, chest pain, or pressure, loss of speech or movement, etc.). Other members of the HH were also asked if anyone has a fever or other COVID-like symptoms, then that member of the HH were suggested to be isolated and kept in distance but it was not considered as the HH exclusion criteria.  Inquire about prior diagnosis of COVID-19. Was excluded if anyone in the household had tested positive test for COVID-19 within the past 14 days,  It was asked if any household members have been in close contact with a confirmed COVID-19 patient within the last 14 days. Close contact is anyone who was within 2 meters of an infected person for at least 15 minutes. Reminded them that, an infected person can spread COVID-19 starting 48 hours (or 2 days) before the person has any symptoms or tests positive for COVID-19.  A suspect case for whom testing for the COVID-19 virus was inconclusive (Inconclusive being the result of the test reported by the laboratory) OR a suspect case for whom testing wasn’t performed for any reason.  The inquiry was done if any of the household’s members currently were in home quarantine or quarantine in health center for isolation.

NOTE: The survey teams were guided based on the interim guideline to clearly mark if the household/child become excluded due to the COVID specific reasons in the cluster control forms and the percentage of nonresponse due to COVID specific reasons outlined above should be included in the final report. There was no any Households with child’s and/or respondent having high fever (>100.4°F/38°C) confirmed by measuring body temperature or presence of any other sign/symptoms of COVID- 19 was found to be excluded from the survey. The same health screening checklist was employed again during revisit to ensure no sick children (with possible signs, symptoms of COVID) were measured. This approach of tracking each child and the corresponding household as well as revisiting other absent households was employed to minimize the non-response rate.

4. HEALTH AND SAFETY MEASURES DURING THE SURVEY IMPLEMENTATION Key technical and operational recommendations were followed to ensure all Infection Prevention Control (IPC), health and safety measures for the beneficiary as well as for the survey team as per below:

5.1. During the Training All survey team members received training on modules necessary for implementing a SMART survey (e.g. Objectives etc.) as well as a review of additional field safety procedures during COVID-19 as described above and below as well: The enumerators training was conducted in person preferably outdoors or in large rooms respecting social distancing guidelines. To limit training exposures, only interviewers were trained on the survey questionnaire module. All team members were screened before starting the training twice a day (morning and evening)

5.2. During the Field Data Collection  Introduction, consent, interviews, and measurement were done outside in a shaded area with enough space for proper physical distancing wherever feasible while still respecting a persons’ confidentiality, as this survey was taken place in the spring season, a suitable large place inside the house was utilized.  All survey team members were provided with face masks and gloves. Each team was carried out safety box/bag and safely dispose of used personal protective equipment at the end of data collection.

 Household members who were directly in contact with the survey team (survey respondent and measured children/adults above 2 years of age) were requested to wear a face mask during the entire household interview process. The survey teams ware offered a face mask to the key household members prior to the start of the interview.  During the interview, the interviewer and respondent kept a distance of at least 1-meter with having a mask.  All team members were sanitized their hands immediately before entering a household using soap and water or alcohol-based hand sanitizer with at least 60% alcohol.  The survey was followed the usual methods for measuring oedema, MUAC, weight, height and age using trained measurers as per the SMART guidelines. Anthropometric equipment (e.g. scales, height boards, MUAC tapes) were disinfected between households with a solution at 0.5% chlorine.  New MUAC tapes were used for each household and the previously used tapes were collected back by the survey team and were destroyed in a safe place at the end of the day.  The congregation of others (household or community members) around the place of interview was prevented, by asking to respect distance and privacy.  Well-functioning vehicles with enough space for sitting were hired for the survey teams and were disinfected regularly. All drivers were also provided a face mask and hand gloves. Note: Fortunately, we finally able to include all households because we had no household or children being found affected with or had symptoms of COVID-19.

Currently, the case definitions of COVID 19 in Afghanistan are:

Suspect case: A person who meets the clinical and epidemiological criteria has a high temperature (>100.4 °F/38 °C) with at least one symptom of COVID-19 (e.g. dry cough, sneezing, shortness of breath, chest pain or pressure, loss of speech or movement, etc.). Probable cause: A patient who meets clinical criteria above and is a contact of a probable or confirmed case, or epidemiologically linked to a cluster with at least one confirmed case. Confirmed case: A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms. (E.g. dry cough, sneezing, shortness of breath, chest pain or pressure, loss of speech or movement, etc.) It called a confirmed case of COVID-19

- All surveys were followed by the usual methods for measuring oedema, MUAC, weight, height and age using trained measurers as per the SMART guidelines. Anthropometric equipment (scales, height boards and MUAC tapes) was disinfected between households. - New MUAC tapes were used for each household and the previously used ones were left to the household after measurement.

5.3. Related to the survey methodology and human resources management

 Every team member had been monitored his/her symptoms twice a day and reported those to the team leader (morning before fieldwork and after return from the field). Self- assessment (ideally supervised by another team member) should include at least reporting of temperature check for fever (i.e. temperature ≥100.4 °F/38 °C) and reporting of new/worsening cough or other symptoms orientating to a potential COVID 19 infection.  Two survey teams (6 enumerators) were kept as a reserve and the necessary supplies for IPCs types of equipment were made available. But, fortunately, we didn’t had to use them because no team member was affected by COVID-19.

 All survey team members have received training on modules necessary for implementing a SMART survey (e.g. Logistics, Objectives, etc.) as well as a review of additional field safety procedures during COVID-19 as described above.

5. INDICATORS: DEFINITION, CALCULATION, AND INTERPRETATION 6.1. Overview of Indicators The anthropometric indicators assessed by this survey and the corresponding target population are presented in Table 5 below. Table 5: Standardized Integrated SMART Indicators Indicator Target Population

Anthropometry

Acute Malnutrition by WHZ

Acute Malnutrition by MUAC Chronic Malnutrition by HAZ Children 0-59 and 6-59 months Underweight by WAZ Overweight by WHZ Acute Malnutrition by Combined Criteria Children 6-59 months (WHZ and/or MUAC and/or Oedema)

Mortality

Crude Death Rate (CDR) Entire population Under Five Death Rate (U5DR) Children under five Morbidity Childhood Morbidities (Diarrhoea & ARI) Children under five within 14 days recall period

Health and immunization

Measles Vaccination (First and Second Children 9-59 months Doses)

Women of Reproductive Age & PLW

Nutrition status of women by MUAC Women 15-49 years and PLW

6.2. Anthropometric, Health, and Immunization Indicators Age Age was recorded among children 0-59 months as of the date of birth (Year/Month/Day) according to the Solar Calendar in the field, and later on, was converted to the Gregorian calendar for analysis. The exact date of birth was recorded only if the information was confirmed by supportive documents, such as a vaccination card or birth certificate. Where the above- mentioned documents were unavailable or questionable, age was estimated using a local calendar of events and recorded in months. In this assessment, the survey teams equally relied on the utilization of the event calendar and deriving the birth date from vaccination cards. Weight Weight was recorded among children 0-59 months in Kg to the nearest 0.1 kg using an electronic SECA scale with the 2-in-1 (mother/child) weighing function. Children who could easily stand up were weighed on their own. When children could not stand independently, the 2-in-1 weighing method was applied with the help of a caregiver. Two team members worked in unison to take the measurements of each child. Height Height was recorded among children 0-59 months in cm to the nearest 0.1 cm. A height board was used to measure bareheaded and barefoot children. Children less than two years old were measured lying down and those more than two years old were measured standing up. Two team members worked in unison to take the measurements of each child. MUAC MUAC was measured using three color-coded (red, yellow, green) for children flexible, non- elastic 26.5cm long tape and non-elastic 30cm long tape in white color for mother and caregivers , graduated with 1 mm precision. MUACs were measured at the mid-point of the left upper arm

24 of all children 6-59 months old and mother and caregivers 15-45 years. The reading of the measurement was recorded to the nearest 1mm. Oedema The presence of oedema among children 0-59 months was recorded as “yes” or “no”. All children were checked for the presence of oedema by applying pressure with thumbs for three continuous seconds on the tops of both feet. Any suspected cases required confirmation by multiple team members, a supervisor if present, and photo-documented when possible.

6.3. Chronic and Acute Malnutrition Acute malnutrition in children 6-59 months is expressed by using three indicators: Weight for Height (W/H) and MUAC as described below, nutritional oedema as the third indicator of severe acute malnutrition. Additionally, the prevalence of GAM amongst 0-59 was reported.

WHZ A child’s nutritional status is estimated by comparing it to the weight-for-height distribution curves of 2006 WHO growth standards reference population. The expression of the weight-for- height index as a Z-score (WHZ) compares the observed weight (OW) of the surveyed child to the mean weight (MW) of the reference population, for a child of the same height. The Z-score represents the number of standard deviations (SD) separating the observed weight from the mean weight of the reference population: WHZ = (OW - MW) / SD. During data collection, the weight-for-height index in Z-score was calculated in the field for each child to refer malnourished cases to the appropriate center if needed. Moreover, the results were presented in Z-score using WHO reference in the final report. The classification of acute malnutrition based on WHZ is well illustrated in Table 6.

Table 6: Definition of Acute Malnutrition, Chronic Malnutrition, Underweight and Overweight according to WHO Reference 2006 ACUTE CHRONIC Overweight UNDERWEIGHT Severity MALNUTRITION MALNUTRITION (WHZ) (WAZ) (WHZ) (HAZ) <-2 z-score GLOBAL <-2 z-score <-2 z-score >2 z-score and/or oedema <-2 z-score and ≥ <-2 z-score and ≥ - <-2 z-score and ≥ >2 z-score and MODERATE -3 z-score 3 z-score -3 z-score <3 z-score <-3 z-score SEVERE <-3 z-score <-3 z-score >3 z-score and/or oedema

MUAC The mid-upper arm circumference 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 greater or equal to 6 months. Table 7 provides the cut-off criteria for categorizing acute malnutrition cases. Table 7: WHO Definition of Acute Malnutrition According to Cut-off Values for MUAC

Severity MUAC (mm) GLOBAL <125 (and/or oedema) MODERATE ≥ 115 and < 125 SEVERE <115 (and/or oedema)

Oedema 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.

6.4. Combined GAM

In Afghanistan, but also at a worldwide level, it has been demonstrated that there is a large discrepancy between the prevalence of GAM by WHZ and GAM by MUAC. Therefore, Action Against Hunger routinely reports the prevalence of GAM by WHZ or MUAC as “Combined GAM” among children 6-59 months. Combined GAM considers the cut-offs of both WHZ<-2 SD score and/or MUAC<125 mm and/or Presence of bilateral pitting Oedema.

6.5. Chronic malnutrition

Chronic malnutrition is the physical manifestation of longer-term malnutrition which retards growth. Also known as stunting, it reflects the failure to achieve one’s optimal height. In children 6-59 months, chronic malnutrition is estimated using the Height-for-Age z-score (HAZ). HAZ is calculated using ENA Software for SMART by comparing the observed height of a selected child to the mean height of children from the reference population for a given age. When using HAZ, the distribution of the sample is compared against the 2006 WHO reference population. Global chronic malnutrition is the sum of moderate and severe chronic malnutrition.

6.6. Underweight

Underweight is the physical manifestation of both acute malnutrition and chronic malnutrition. In children 6-59 months, underweight is estimated using Weight-for-Age (WAZ) z-score. WAZ is calculated using ENA Software for SMART by comparing the observed weight of a selected child to the mean weight of children from the reference population for a given age. When using WAZ, the distribution of the sample is compared against the 2006 WHO reference population. Global underweight is the sum of moderate and severe underweight. WAZ cut-offs are presented in Table 8 below. The prevalence of malnutrition as identified by WHZ, HAZ and WAZ have also been classified by the WHO in terms of severity of public health significance. The thresholds are presented in table 8 below. Table 8: Classification for Severity of Malnutrition by Prevalence among Children Under-Five PREVALENCE THRESHOLDS (%) LABELS WASTING OVERWEIGHT STUNTING UNDERWEIGHT15

Very low <2.5 <2.5 <2.5 Low 2.5-<5 2.5-<5 2.5-<10 <10 Medium 5-<10 5-<10 10-<20 10-19.9 High 10-<15 10-<15 20-<30 20-29.9 Very high ≥15 ≥15 ≥30 ≥30

6.7. The proportion of acutely malnourished children enrolled in or referred to a Program

All children 6-59 months identified as severely acutely malnourished by MUAC and WHZ during the data collection were assessed for current enrolment status. All malnourished children not enrolled in a treatment program were referred to the nearest nutrition program if possible.

6.8. Malnutrition prevalence among women 15-49 years based on MUAC criterion

All women 15-49 years, including PLW, were assessed for nutritional status based on MUAC measurement. Low MUAC was defined as MUAC <230mm.

6.9. Measles Both Doses Coverage

Calculated as the proportion of children 9-59 months who received two doses of the measles vaccine. Assessed based on vaccination card or caregiver recall. As part of the Expanded Program on Immunization (EPI), the first dose of measles immunization is given to infants aged between 9 to 18 months, with the second given at 18 months. Second dose the last vaccination dose given to a child under five as per the recommended immunization schedule, the second dose measles

15 WHO threshold

27 coverage indicator can also be used as a proxy for overall immunization status and access to healthcare.

6.10. Morbidity

During the survey, all the children age 0-59 months were assessed for diarrhea and ARI in the pasts 2 weeks of the recall period.

6.11. Maternal Nutrition

Women of childbearing age were assessed for their nutritional status based on MUAC measurements. The nutritional status of pregnant and lactating mothers was derived using the MUAC cut-off of <230 mm. 6.12. Retrospective mortality

Demography and mortality were assessed for all households, regardless of the presence of children. All members of the household were counted according to the household definition. CDR refers to the number of persons in the total population that died over the mortality recall period (120 days). It is calculated by ENA Software for SMART using the following formula:

푵풃 풐풇 풅풆풂풕풉풔 ∗ ퟏퟎퟎퟎퟎ 풑풆풓풔풐풏풔 푪푫푹 = 풑풐풑풖풍풂풕풊풐풏 풂풕 풎풊풅 − 풊풏풕풆풓풗풂풍 ∗ 풕풊풎풆 풊풏풆풓풗풂풍 풊풏 풅풂풚풔 Equation 2: Crude Mortality Rate

U5DR refers to the number of children under five years that die over the same mortality recall period. 푵풃 풐풇 풅풆풂풕풉풔 풐풇 푼ퟓ풔 ∗ ퟏퟎퟎퟎퟎ 푼ퟓ풔 푼ퟓ푫푹 = 풑풐풑풖풍풂풕풊풐풏 풐풇 푼ퟓ풔 풂풕 풎풊풅 − 풊풏풕풆풓풗풂풍 ∗ 풕풊풎풆 풊풏풕풆풓풗풂풍 풊풏 풅풂풚풔

Equation 3: Under-five Death Rate

7. ORGANIZATION OF THE SURVEY

7.1. Survey Coordination and Collaboration Survey methodology was shared with the AIM-TWG, Research and Evaluation Directorate for validation and presented in the small-scale steering committee for their comments before deploying the SMART technical team to the province. Meetings were held with the respective administrative authorities on arrival by the survey team to brief them on the survey objective, methodology, procedures and Afghanistan interim guidance on restarting population level surveys and household level data collection during covid-19 pandemic as well as get relevant updated information on security, access, and village level population.

7.2. Data Quality Control and Assurance

Each questionnaire and data sheet was checked each night before the data entry if the team was arrived timely and was working in nearest areas. The data was entered daily and missing or flag data identified. Based on the results the supervisors were giving feedback to enumerators, and go back to the households with missing or dubious results. Different teams to clarify the reports was revisit clusters with unusual findings. Daily evening meetings were held to provide feedback to the teams on the day performance and address challenges. The public nutrition officer of PPHD, nutrition officer of BPHS, and SMART survey technical team had regular supervision from the teams during the data collection in some villages and provided on the job training to the teams as well as ensuring the availability of team in the planned villages.

7.3. Ethical considerations All relevant local authorities were informed of the study objectives, methodology and their roles and their permission sought. Verbal consent was sought from the caretakers of the children and household heads for voluntary participation in the survey. The identifying of the participants was kept anonymous. Those who do not wish to participate in the survey was respected for their self-determination/decisions. The interviewers were introduced themselves and establish rapport. All the information collected was treated as strictly confidential. All children diagnosed as severely or moderately malnourished were referred to a nearby health facility. Each team was provided with referral sheets.

7.4. Survey teams Six teams each comprising of four members collected data in all the selected clusters in the province. Each team was composed of one team leader, two measures, and one supervisor. Each team had one female surveyor to ensure acceptance of the team amongst the surveyed households, particularly for assessing maternal nutrition using MUAC. Each female member of the survey team was accompanied by a mahram to facilitate the work of the female data collectors at the community level. In each selected village, one or more community member (s) was asked to lead and guide the survey team within the village in locating the selected households.

Team Leader

Lead Measurer Assist Measurer Interviewer

Figure 2: Survey Team Composition 7.5. Training of the survey teams The survey teams were trained for six days in the capital of Sar e Pul province. The majority of the population was speaking and understood the Dari language; therefore, the survey manager was mostly used Dari to conduct training. One AAH technical staff has facilitated the training. The training was mainly focused on field procedures, sampling methods, how to fill the survey questionnaire/ tools, usage of the event calendar, and anthropometric measurements. The standardization test was done and useful to measure at least 10 children twice. However, the organization of the test was adjusted in a way where no more than 5 children were being measured at any one point. In addition; the survey manager was limited the number of survey teams participating at any point in time to a maximum of 5 teams (each team consisting of measurer and assistant measurer). Below is an example of a recommended structure: A. 1st half of the day: 5 children measured twice by a maximum of 5 teams (Group 1). The same 5 children were measured twice by the remaining teams (Group 2) maintaining the limit of 5 or fewer teams at a time. B. 2nd half of the day: 5 new children measured twice by Group1. The same 5 children were measured twice by Group 2.) To evaluate the accuracy and the precision of the team members in taking the anthropometric measurements. All survey team members received training on the module of field safety procedures in the context of COVID-19. All necessary steps were put in place to ensure the IPC measures during the training session. The teams conducted a one-day field test to evaluate their work in real field conditions. Feedbacks were provided to the team regarding the results of the field test; particularly with digit preferences and data collection. Refresher training on anthropometric measurements and the filling of the questionnaires and the household’s selection was organized on the last day of the training by Action Against Hunger technical team to ensure overall comprehension before going to the field.

A field guidelines document with instructions including household definition and selection were provided to each team member. All documents, such as local event calendar, questionnaires, or consent forms were translated in Dari (the local language), for better understanding and to avoid direct translation during the field data collection. The questionnaires were back-translated using a different translator and were pre-tested during the field test. Table 9: list of PPE equipment used in the surveys Final requirement (including Minimum IPC types of equipment as per new Guidelines 15% Unit requirement additional buffer) & rounded up Hand-held Infrared Thermometer (including 12 14 2 pcs per team buffer stock) 3pcs per Goggles for eye protection 30 35 person/per survey pcs Gloves for team members 7 box 8 box

Face Mask for team members 10 box 12 box pcs

Face Mask for household members 13 box 15 box pcs

Hand Sanitizer (60% alcohol) 12 14 Bottle (200 ml) Bottle- Disinfectant supplies for equipment (70% handgun 12 14 alcohol or 0.1% (1000ppm) chlorine solution) sprayer (500 ml) Supplies for safely dispose of used personal 12 14 Safety bag protective equipment

8. DATA ANALYSIS The anthropometric and mortality data was analyzed using update ENA for SMART software 2020 version (11th Jan 2020). Survey results were interpreted referencing to the WHO standards 2006; Analysis of other indicators including demographics was done using Epi-Info version 7. Contextual information in the field and from routine monitoring was used in complementing survey findings and strengthening the analysis. Interpretation of each result was done based on the existing thresholds for different indicators as well as comparing with other available data sources at the national and provincial levels.

9. SURVEY FINDINGS

9.1. Survey Sample & demographics Overall, the survey assessed 42 clusters out of 43 planned clusters, due to insecurtiy and ongiong conflicts in the area one cluster was inaccessible and missed. A total of 414 households, 2,651 individuals, 578 women 15-49 years old, 562 children under five (0-59m), and 499 children 6- 59 months were assessed in 42 clusters. Among the 414 households the survey teams surveyed, 6 household was absent and/or refused to participate in the survey and 10 HHs were missed due to inaccessibility of one cluster, resulting in a non-response rate of 3.7%. This rate is lower than the estimate done at the planning stage (7%) Overall, 96.2% of the planned households and 105.7% of children 6-59 months were assessed, which is presented in Table 10 below: Table 10: Proportion of household and child sample achieved No. of No. of No. of No. of % of No. of No. of children children % of Cluster Cluster cluster households households 6-59 6-59 children planned surveyed surveyed planned surveyed months months surveyed planned surveyed 43 42 97.6 430 414 472 499 105.7%

The mortality questionnaire was designed to gather demographic data and capture in- and out- migration. Household demographics and movement are presented in Table 11 below. The survey findings indicate that the average household size was 6.3 persons per household (compared to 7.4 used at the planning stage); 49.6% of the population were female, 50.4% were male; the percentage of children under five was 21.9%. The observed rate of in-migration (0.43) and the out-migration (1.20) during the recall period may have been influenced by the 125 recall period days. Table 11: Demographic data summary

Indicator Values

Total number of clusters 42 Total number of HHs 414 Total number of HHs with children under five 351 Average household size 6.3 Female % of the population 49.6% Male % of the population 50.4% Children under five % of the population 21.9% Birth Rate 0.77 In-migration Rate (Joined) 0.43 Out-migration Rate (Left) 1.20

Households were also assessed for residential status. Among the 414 surveyed households, 96.4% were residents of the area, 2.2% were internally displaced, 1.4% were refugees of the population and there were No nomadic (Kunchi16) residents found in the province.

Table 12: Household residential status by the proportion Resident 399 96.4% Residential Status of Households IDP 9 2.2% N= 414 Refugee 6 1.4% Nomad 0 0.0%

As the age and sex of all household members were assessed, it was possible to disaggregate the population by sex and five year age interval, as presented in Figure 3 below. The pyramid is wide at the base and narrows towards the apex, indicating a generally youthful population. The surveyed sample of children 6-59 months was 499. The distribution as disaggregated by age and sex are presented in Table 13 below. The overall sex ratio (male/female) 1.0, indicating a sample with almost equal representation of boys and girls with a slight excess of boys. The exact birth date was not possible to determine (through proper documents) for 21% of the children; only 79% of the surveyed children had documentation of evidence of their exact date of birth. This may have compromised the quality of the age determination to some extent, and therefore may have impacted the estimation of the stunting and underweight prevalence as well.

Figure 3: Sar e Pul Province Population Pyramid. Table 13: Distribution of Age and Sex among Children 6-59 months Boys Girls Total Ratio AGE (mo) no. % no. % no. % Boy: girl 6-17 62 50.0 62 50.0 124 24.8 1.0

16 Kuchi is a local term refers to Nomad

18-29 58 51.8 54 48.2 112 22.4 1.1

30-41 54 50.9 52 49.1 106 21.2 1.0

42-53 59 49.6 60 50.4 119 23.8 1.0

54-59 18 47.4 20 52.6 38 7.6 0.9

Total 251 50.3 248 49.7 499 100.0 1.0

9.2. Data Quality Seven children were excluded as outliers from WHZ analysis per SMART flags 17resulting in an overall percentage of flagged data of 1.4% and categorized as excellent by the ENA Plausibility Check. The standard deviation, design effect, missing values, and flagged values are listed for WHZ, HAZ, and WAZ in Table 14 below. The SD of WHZ was 1.13, the SD of HAZ was 1.12, and the SD of WAZ was 1.05. All WHZ, HAZ, and WAZ met the normal range (0.80 and 1.20) indicating an adequate distribution of data around the mean and data of good quality. The overall ENA Plausibility Check score was 7%, which is considered a survey of excellent quality. The ratio of children 6-29 months vs 30-59 months in the dataset was at 0.90 (p-value = 0.546) which is close to the standard expected ratio of 0.85 as per SMART methodology. Some digit preferences were also observed for children's age data, especially those whose exact date of birth was not available. A summary of the Sar e Pul ENA Plausibility Check report is presented in Annex-6. The full plausibility report which was generated from the ENA dataset. Table 14: Mean Z-scores, Design Effects, Missing and Out-of-Range Data of Anthropometric Indicators among Children 6-59 Months N Mean z-scores ± Design effect (z- Z-scores not Z-scores out Indicator SD score < -2) available* of range

Weight-for-Height* 492 -0.20±1.13 1.00 0 7

Weight-for-Age* 495 -1.18±1.05 1.50 0 4

Height-for-Age 492 -1.85±1.12 1.37 0 7

*No oedema case found in the survey

9.3. Prevalence of Acute Malnutrition by WHZ The prevalence of GAM per WHZ among children 6-59 months in Sar e Pul was 7.5% (5.4-10.3 95% CI) as presented in Table 15 below and was categorized as medium. This prevalence seems slightly higher in boys than girls but it is not statistically significant (P-value = 0.663).

17 ENA SMART software version 2020 (updated 11th Jan 2020)

The prevalence of SAM per WHZ among children 6-59 months was 0.8% (0.3- 2.1 95% CI) According to the national prioritization cut-off points, the prevalence was less than the threshold of 3%. Table 15: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 6-59 months, WHO 2006 Reference

All Boys Girls Indicators n = 492 n = 249 n = 243 Prevalence of global (37) 7.5 % (20) 8.0 % (17) 7.0 % acute malnutrition (<-2 z- (5.4 - 10.3 95% C.I.) (5.4 - 11.8 95% C.I.) (4.6 - 10.5 95% C.I.) score and/or oedema) Prevalence of moderate (33) 6.7 % (18) 7.2 % (15) 6.2 % acute malnutrition (<-2 to (4.7 - 9.5 95% C.I.) (4.6 - 11.1 95% C.I.) (3.8 - 9.8 95% C.I.) ≥-3 z-score) Prevalence of severe (4) 0.8 % (2) 0.8 % (2) 0.8 % acute malnutrition (<-3 z- (0.3 - 2.1 95% C.I.) (0.2 - 3.2 95% C.I.) (0.2 - 3.2 95% C.I.) score and/or oedema) *There were 0.0% oedema cases in the sample The prevalence of acute malnutrition by WHZ was also assessed among children 6-23 months and 24-59 months as well, as presented in tables’ bellow 16 & 17.

Table 16: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 6-23 months, WHO 2006 Reference All Boys Girls Indicators n = 179 n = 89 n = 90 (14) 15.6 % Prevalence of global (26) 14.5 % (12) 13.5 % acute malnutrition (<-2 (10.2 - 23.0 95% (10.5 - 19.7 95% C.I.) (7.7 - 22.4 95% C.I.) z-score and/or oedema) C.I.) Prevalence of moderate (20) 11.2 % (9) 10.1 % (11) 12.2 % acute malnutrition (<-2 (7.4 - 16.5 95% C.I.) (5.0 - 19.4 95% C.I.) (7.4 - 19.5 95% C.I.) to ≥-3 z-score) Prevalence of severe (6) 3.4 % (3) 3.4 % (3) 3.3 % acute malnutrition (<-3 (1.6 - 6.9 95% C.I.) (1.1 - 9.9 95% C.I.) (1.1 - 9.3 95% C.I.) z-score and/or oedema)

Table 17: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 24-59 months, WHO 2006 Reference All Boys Girls Indicators n = 315 n = 161 n = 154

Prevalence of global (13) 4.1 % (9) 5.6 % (4) 2.6 % acute malnutrition (<-2 (2.2 - 7.5 95% C.I.) (3.0 - 10.0 95% C.I.) (1.0 - 6.9 95% C.I.) z-score and/or oedema) Prevalence of moderate (13) 4.1 % (9) 5.6 % (4) 2.6 % acute malnutrition (<-2 (2.2 - 7.5 95% C.I.) (3.0 - 10.0 95% C.I.) (1.0 - 6.9 95% C.I.) to ≥-3 z-score) Prevalence of severe (0) 0.0 % (0) 0.0 % (0) 0.0 % acute malnutrition (<-3 (0.0 - 0.0 95% C.I.) (0.0 - 0.0 95% C.I.) (0.0 - 0.0 95% C.I.) z-score and/or oedema)

The prevalence of acute malnutrition by WHZ was also assessed among children 0-59 months. The GAM per WHZ was 7.3% (5.4- 9.8 95% CI), as presented in Table 18 below. The prevalence of SAM per WHZ among children 0-59 months was 0.5% (0.2- 1.7 95% CI). Table 18: Prevalence of Acute Malnutrition by WHZ (and/or oedema) by Severity and Sex among Children 0-59 months, WHO 2006 Reference All Boys Girls Indicators n = 549 n = 278 n = 271

Prevalence of global (40) 7.3 % (23) 8.3 % (17) 6.3 % acute malnutrition (<-2 (5.4 - 9.8 95% C.I.) (5.7 - 11.8 95% C.I.) (4.1 - 9.5 95% C.I.) z-score and/or oedema) Prevalence of moderate (37) 6.7 % (21) 7.6 % (16) 5.9 % acute malnutrition (<-2 (4.9 - 9.2 95% C.I.) (5.0 - 11.2 95% C.I.) (3.7 - 9.2 95% C.I.) to ≥-3 z-score) Prevalence of severe (3) 0.5 % (2) 0.7 % (1) 0.4 % acute malnutrition (<-3 (0.2 - 1.7 95% C.I.) (0.2 - 2.9 95% C.I.) (0.1 - 2.6 95% C.I.) z-score and/or oedema) When disaggregated by age group, the group with the highest MAM and SAM was 6-17 months, as presented in Table 19 below. The age group with the lowest MAM was 42-53 and 54-59 months and there was no SAM case in the age group of 30-41, 42-53 and 54-59 months. Results of this disaggregation suggest that the younger age groups (6-29) were more vulnerable to acute malnutrition than older groups (30-59) according to the WHZ criterion (p-value <0.05). Table 19: Prevalence of Acute Malnutrition per WHZ Severity and Age Group of 6-59 months

Severe wasting* Moderate wasting Normal Age Oedema N (WHZ <-3) (WHZ ≥-3 to <-2) (WHZ ≥-2) (months) N % N % N % n % 6-17 121 3 2.5 15 12.4 103 85.1 0 0.0 18-29 108 1 0.9 8 7.4 99 91.7 0 0.0 30-41 106 0 0.0 6 5.7 100 94.3 0 0.0 42-53 119 0 0.0 3 2.5 116 97.5 0 0.0

54-59 38 0 0.0 1 2.6 37 97.4 0 0.0 Total 492 4 0.8 33 6.7 455 92.5 0 0.0 *There were 0 oedema cases in the sample However, according to Poisson distribution, there were no pockets of malnutrition observed and the The Index of Dispersion (ID) indicates that the cases were uniformly distributed among the clusters for WHZ <-2 (ID=0.90; p=0.658) in which the ID was less than 1 and the P- Value was much greater than 0.05.

Figure 4: Distribution of cases (WHZ <-2) in clusters, Poisson distribution The WHZ distribution curve (in red) as compared to the WHO 2006 reference WHZ distribution curve (in green) and as presented in Figure 4 below demonstrates a shift to the left, suggesting a malnourished population. Figure 6 illustrates the mean WHZ for age categories and more affected children were 6-17 months.

Figure 5: Distribution of WHZ Sample Compared to the Figure 6: Means WHZ by age groups WHO 2006 WHZ Reference Curve

9.4. Acute malnutrition by MUAC

The prevalence of GAM per MUAC among children 6-59 months in Sar e Pul was 10.2% (6.9- 14.9 95% CI). The prevalence of SAM per MUAC among children 6-59 months was 2.0% (0.9- 4.4 95% CI). As presented in Table 20 below. Table 20: Prevalence of Acute Malnutrition by MUAC (and/or oedema) by Severity and Sex among children 6-59 months

All Boys Girls Indicators n = 499 n = 251 n = 248

Prevalence of global (51) 10.2 % (22) 8.8 % (29) 11.7 % malnutrition (6.9 - 14.9 95% C.I.) (5.8 - 13.0 95% C.I.) (6.9 - 19.2 95% C.I.) (<125 mm and/or Oedema)18

Prevalence of moderate (41) 8.2 % (19) 7.6 % (22) 8.9 % malnutrition (< 125 mm to (5.4 - 12.3 95% C.I.) (5.0 - 11.4 95% C.I.) (4.9 - 15.6 95% C.I.) ≥115 mm, no Oedema)

Prevalence of severe (10) 2.0 % (3) 1.2 % (7) 2.8 % malnutrition(< 115 mm (0.9 - 4.4 95% C.I.) (0.3 - 5.1 95% C.I.) (1.3 - 6.2 95% C.I.) and/or Oedema)

Table 21: Prevalence of Acute Malnutrition per MUAC and/or Oedema by Severity and Age Group.

Moderate wasting Age Severe wasting* Normal (MUAC ≥115 mm and Oedema N (MUAC<115 mm) (MUAC ≥125 mm) (months) <125 mm) N % N % N % n % 6-17 124 3 2.4 23 18.5 98 79.0 0 0.0 18-29 112 4 3.6 9 8.0 99 88.4 0 0.0 30-41 106 2 1.9 6 5.7 98 92.5 0 0.0 42-53 119 1 0.8 2 1.7 116 97.5 0 0.0 54-59 38 0 0.0 1 2.6 37 97.4 0 0.0 Total 499 10 2.0 41 8.2 448 89.8 0 0.0

9.5. Acute Malnutrition by Oedema No Oedema case was observed in the sample. Table 22 below illustrates data for the presence and absence of oedema cases.

Table 22: Distribution of Severe Acute Malnutrition per Oedema among Children 6-59 Months

WHZ <-3 WHZ>=-3 Marasmic kwashiorkor. 0 Kwashiorkor. 0 Presence of Oedema* (0.0 %) (0.0 %) Marasmic Not severely malnourished. Absence of Oedema No. 10 (2.0 %) 489 (98.0 %) *There were not oedema cases in the sample

9.6. Combined Acute Malnutrition by WHZ and/or MUAC and/or Oedema

The prevalence of Combined GAM & SMA among children 6-59 months in Sar e Pul was 12.6% and 2.8% respectively as there is not globally threshold established for Combined GAM, the GAM and SAM prevalence was slightly higher than for WHZ or MUAC separately, confirming that MUAC and WHZ are independent indicators for malnutrition see below table 23 for the Combine GAM results. Table 23: Prevalence of combining Acute Malnutrition by WHZ + MUAC by Severity and Sex among Children 6-59 months

All Boys Girls Indicators n = 499 n = 251 n = 248

Prevalence of Global Acute Malnutrition (MUAC<125 mm (63) 12.6 % (29) 11.6 % (34) 13.7 % and/or WHZ<-2SD and/or (9.1 - 17.3 95% C.I.) (8.2 - 16.0 95% C.I.) (8.6 - 21.2 95% C.I.) Oedema)

Prevalence of Severe Acute Malnutrition (MUAC<115 mm (14) 2.8 % (5) 2.0 % (9) 3.6 % and/or WHZ<-3SD and/or (1.5 - 5.2 95% C.I.) (0.7 - 5.5 95% C.I.) (1.8 - 7.4 95% C.I.) Oedema)

9.7. Enrolment in nutrition program

The proportion of children identified as acutely malnourished and their corresponding treatment enrolment status are presented in Table 24 below. Overall, out of 51 children 6-59 months old identified as acutely malnourished by MUAC and WHZ by the teams in the field, 41 were MAM cases and 10 were SAM cases. The proxy program coverage for all malnourished cases was 52.9%. A total of 24 children (47.1%) out of 51 children identified as malnourished were not in any program and were referred to the nearby appropriate program in the respective area. Table 24: Proportion of Acutely Malnourished Children 6-59 Months enrolled in a Treatment Program Enrolled Enrolled Enrolled in in an in an an IPD Not Sample OPD OPD SAM Enrolled/Referred SAM MAM Acutely malnourished children 6-59

months by MUAC and WHZ, or 5 22 0 24 oedema (N=51)

9.8. Prevalence of Chronic Malnutrition The prevalence of stunting per HAZ among children 6-59 months in Sar e pul province was 44.5%, as presented in Table 25 below. According to UNICEF-WHO prevalence thresholds 201819, this prevalence was categorized as “Very High”. This prevalence seems slightly higher in boys than girls but it is not statistically significant.

Indicators All Boys Girls n = 492 n = 248 n = 244 Prevalence of chronic (219) 44.5 % (116) 46.8 % (103) 42.2 % malnutrition (HAZ <-2 (39.3 - 49.8 95% (40.1 - 53.6 95% (34.7 - 50.1 95% SD) C.I.) C.I.) C.I.)

19 UNICEF-WHO thresholds 2018_ file:///C:/Users/ACF/Downloads/JME-2018-brochure-.pdf

Prevalence of moderate (144) 29.3 % (77) 31.0 % (67) 27.5 % chronic malnutrition (25.0 - 33.9 95% (25.5 - 37.1 95% (21.4 - 34.5 95% (HAZ <-2 to ≥-3 SD) C.I.) C.I.) C.I.) Prevalence of severe (75) 15.2 % (39) 15.7 % (36) 14.8 % chronic malnutrition (11.8 - 19.5 95% (11.1 - 21.7 95% (10.8 - 19.8 95% (HAZ <-3 SD) C.I.) C.I.) C.I.) Table 25: Prevalence of Chronic Malnutrition by HAZ by Severity and Sex among Children 6-59 months, WHO 2006 Reference.

Table 26: Prevalence of Chronic Malnutrition per HAZ by Severity and Age Group Severe stunting Moderate stunting Normal Age N (HAZ <-3) (HAZ >= -3 to <-2) (HAZ>= -2) (months) N % N % N % 6-17 121 8 6.6 21 17.4 92 76.0 18-29 110 20 18.2 28 25.5 62 56.4 30-41 105 22 21.0 38 36.2 45 42.9 42-53 118 21 17.8 44 37.3 53 44.9 54-59 38 4 10.5 13 34.2 21 55.3 Total 492 75 15.2 144 29.3 273 55.5

The HAZ distribution curve (in red) as compared to the WHO 2006 reference HAZ distribution curve (in green) as presented in Figure 9 below demonstrates a shift to the left, suggesting a very stunted population in comparison to the normal population. Further analysis suggests that linear severe growth retardation is at its highest in the group of children aged 18-29 months as shown.

Figure 8: Distribution of HAZ Sample Compared to the Figure 7: Mean HAZ by Age Group WHO 2006 WHZ Reference Curve

9.9. Prevalence of Underweight The prevalence of underweight per WAZ among children 6-59 months in Sar e Pul was 24.4%, as presented in Table 27 below, and the prevalence of severe underweight per WAZ among children 6-59months was 4.2%. Table 27: Prevalence of Underweight by WAZ by Severity and Sex among Children 6-59 months, WHO 2006 Reference

Indicators All Boys Girls n = 495 n = 250 n = 245 Prevalence of underweight (121) 24.4 % (52) 20.8 % (69) 28.2 % (WAZ <-2 SD) (20.0 - 29.5 95% (15.9 - 26.7 95% (22.2 - 34.9 C.I.) C.I.) 95% C.I.) Prevalence of moderate (100) 20.2 % (43) 17.2 % (57) 23.3 % underweight (WAZ <-2 and >=-3 (16.3 - 24.7 95% (12.9 - 22.5 95% (18.2 - 29.2 SD) C.I.) C.I.) 95% C.I.) Prevalence of severe underweight (21) 4.2 % (12) 4.9 % (9) 3.6 % (WAZ <-3SD) (2.9 - 6.2 95% (2.9 - 8.2 95% (2.0 - 6.5 95% C.I.) C.I.) C.I.)

When disaggregated by age group, the age group with the highest severe underweight was 18- 29 months, as presented in Table 28 below. The age groups with the lowest severe underweight were in 42-53 and 54-59 months. Table 28: Prevalence of Underweight per WAZ by Severity and Age Group Moderate Severe underweight Normal Age underweight N (WAZ <-3) (WHZ ≥-2) (months) (WAZ ≥-3 to <-2) N % N % N %

6-17 123 8 6.5 22 17.9 93 75.6 18-29 110 6 5.5 21 19.1 83 75.5 30-41 105 5 4.8 24 22.9 76 72.4 42-53 119 2 1.7 23 19.3 94 79.0 54-59 38 0 0.0 10 26.3 28 73.7 Total 495 21 4.2 100 20.2 374 75.6

The WAZ distribution curve (in red) as compared to the WHO 2006 reference WAZ distribution curve (in green) as presented in figure 10 below demonstrates a large shift to the left, suggesting a very underweighted population in comparison to the normal population. Further analysis suggests that linear underweight is at its highest in the group of children aged 30-41 months as shown in figure 10.

Figure 9: Distribution of WAZ Sample Compared to the Figure 10: Mean WAZ by Age Group WHO 2006 with Reference Curve.

9.10. Prevalence of Overweight The prevalence of overweight per W/H among children 6-59 months in Sar e Pul province was 2.0%, as presented in Table 25 below. According to UNICEF-WHO prevalence thresholds 2018, this prevalence was categorized as very low and higher in girls than boys. Table 29: Prevalence of overweight based on weight for height cut-offs and by sex (no oedema) among children age 6- 59 months. Indicators All Boys Girls n = 492 n = 249 n = 243 Prevalence of overweight (10) 2.0 % (4) 1.6 % (6) 2.5 % (1.0 - 4.2 95% C.I.) (0.6 - 4.0 95% C.I.) (0.9 - 6.8 95% C.I.) (WHZ > 2)

Prevalence of severe (0) 0.0 % (0) 0.0 % (0) 0.0 % (0.0 - 0.0 95% C.I.) (0.0 - 0.0 95% C.I.) (0.0 - 0.0 95% C.I.) overweight (WHZ > 3)

Table 30: Prevalence of overweight by age, based on weight for height (no oedema) Age N Overweight (WHZ > 2) Severe Overweight (WHZ > 3) (months) Age (mo) Total no. No. % No. % 6-17 121 2 1.7 0 0.0

18-29 108 2 1.9 0 0.0

30-41 106 3 2.8 0 0.0

42-53 119 2 1.7 0 0.0

54-59 38 1 2.6 0 0.0

Total 492 10 2.0 0 0.0

9.11. Malnutrition prevalence among Women 15-49 years old based on MUAC criterion All women of reproductive age (15-49 years) were included in the survey. A total of 578 women were assessed for nutrition status by MUAC. The analysis further disaggregating the sample by physiological status (pregnant, lactating, both); the prevalence of malnutrition by MUAC among all women was 15.7%; more details are presented in Table 31 below.

Table 31: Prevalence of Acute Malnutrition among Women per MUAC Indicators Not MUAC <230 mm N Malnourished Malnourished % All women 15-49 years 15.7% 578 487 91 with MUAC <230 mm (11.7-20.9 95% CI) Pregnant women <230 14.3% 49 42 7 mm (6.1-29.8 95% CI) Lactating women <230 16.0% 200 168 32 mm (10.4-23.7 95%CI) Both pregnant and 45.5% lactating women (at the 11 6 5 (18.4-75.5 95% CI) same time) <230 mm20 Non-pregnant and non- 14.8% 318 271 47 lactating women <230 mm (10.3-20.8 95% CI) 16.9% All PLWs <230 mm 260 216 44 (11.1-24.9 95% CI)

9.12. Retrospective Mortality

The overall death rate for the surveyed population was 0.22 (0.10-0.49 95% CI) which is below the WHO emergency thresholds of 1.0/10,000/day. The death rate was slightly higher for male compared to female in the population. The age group with the highest death rate was 65-120 years, followed by the age group 0-4 years. Deaths rate was 0.44 (0.14-1.40 95% CI) recorded during the 125 days recall period in Sar e Pul province. Table 32: Death Rate by Age and Sex with Reported Design Effect Population Death Rate (/10,000/Day) Design Effect

Overall 0.22 (0.09-0.49) 1.14

Male 0.30 (0.11-0.87) 1.35

20 *Women that were simultaneously pregnant and lactating

Female 0.06 (0.01-0.46) 1.00

'0-4 0.44 (0.14-1.40) 1.00 '5-11 0.00 (0.00-0.00) 1.00 '12-17 0.00 (0.00-0.00) 1.00 '18-49 0.08 (0.01-0.60) 1.01 '50-64 0.00 (0.00-0.00) 1.00 '65-120 4.32 (1.40-12.42) 1.00

Information collected about apparent causes of death showed most of the deaths attributed to UNKNOWN (42.9%) and followed by illness which is (28.6%). Figure 11 below summarizes the causes of deaths.

PERCENTAGES OF CAUSES OFTHE DEATHS

28.6

42.9

1] Unknown 2] Injury/Traumatic 3] Illness

Figure 11: Percentages of causes of the deaths

9.13. Child health and Immunization Status

In Sar e Pul province the survey results indicated that 86.3% of children age 9-59 months and 71.5% of children 18-59 months had received the first and second doses of measles respectively, immunization, as confirmed either by vaccination card or caregiver recall. Table 33 below illustrates the data on both doses of measles immunization coverage. Table 33: Measles Immunization Coverages among Children 9-59 Months First Dose 9-59m Second Dose 18-59m

Indicator Response (N=473) (N=375)

N % N %

Both Doses Yes by card 57.3% 42.1% 271 (48.8-65.3 95% CI) 158 (33.1-51.7 95% CI)

Measles Yes by recall 29.0% 29.3% 137 (21.6-37.6 95% CI) 110 (21.4-38.7 95% CI) Immunization Yes by card or 86.3% 71.5% (79.2-91.2 95% CI) (62.3-79.2 95% CI) recall 408 268 No 10.6% 24.3% 50 (6.6-16.6 95% CI) 91 (17.2-33.1 95% CI) Don’t know 3.2% 4.3% 15 (1.4-7.1 95% CI) 16 (1.9-9.2 95% CI) Total 473 100.0% 375 100.0%

9.14. Child health Retrospective morbidity data were collected among children 0-59 months with two weeks recall period to assess the prevalence of the main disease. The survey finding shows that 39.3 % of children had at least one episode of illness in the 2 weeks recall period to the survey. The major illnesses reported such as diarrhea and ARI as highlighted in table 34 below. Table 34: Major illnesses reported among children 0-59 months Parameter Response n = (562) Results 39.3% Yes 221 (28.4-51.5 95% CI) 60.7% No 341 Illness (N= 562) (48.5-71.6 95% CI) DK 0 0.0% Total 562 100.0% 28.5% Yes 160 (20.6-38.0 95% CI)

71.5% Acute Respiratory No infection (ARI) (N= 402 (62.0-79.4 95% CI) 562) DK 0 0.0%

Total 562 100.0% 19.2% 108 Yes (12.9-27.6 95% CI)

80.8% Diarrhea (N= 562) No 454 (72.4-87.1 95% CI)

DK 0 0.0% Total 562 100.0%

10. DISCUSSION

10.1. Nutritional Status of children As in other provinces of Afghanistan, Sar e Pul province has as main concern the security situation for several years, with active local armed groups. The results of this survey are giving an updated picture of the nutritional situation in this province and should be very different from the situation of other provinces. The results of this survey showed a GAM and SAM prevalence of 7.5% (5.4-10.3 95% CI) and a 0.8% (0.3- 2.1 95% CI) respectively by WHZ and/or MUAC; and based on MUAC, the prevalence is at 10.2% (6.9-14.9 95% CI) and 2.0% (0.9- 4.4 95% CI) GAM and SAM respectively. The prevalence falls under the medium category of emergency-threshold classification as per the latest update WHO/UNICEF 2018 threshold. The SAM rate by WHZ is however below the 3.0% threshold established by the MoPH, Nutrition Cluster, and the AIM-WG for the response prioritization in the Afghanistan context as contrary to the international emergency threshold of SAM above 2.0%. Currently, there are 42 OPD-SAM, 3 IPD-SAM, Total and 18 OPD MAM sites and 15 counselors Stunting were providing nutrition counselling around 44.5% (219) the above mentioned health facilities in the province. Global Wasting Estimation of the prevalence of malnutrition among Stunted based on Combined GAM continues to add (MUAC+ WHZ) impetus to the importance of the independent 16.0% diagnostic criteria of GAM by WHZ and MUAC (35) Severe in the identification of malnutrition hence Wasting among Stunted ensuring greater enrolment of malnourished (MUAC + WHZ) children and in need of treatment, as 3.2% (7) demonstrated by the 12.6 % (9.1 - 17.3 95% Figure 12: Among Stunted Children 6-59 Months, those C.I.) combined GAM rate as opposed to 7.5% Simultaneous Wasted (WHZ) (5.4-10.3 95% CI) based on WHZ alone. This translates to a significant difference in the caseload of acutely malnourished children. Chronic malnutrition in the province remains of public health concern. The prevalence of chronic malnutrition among children 6-59 months was 44.5% (39.3-49.8 95% CI), which is classified as very high according to the UNICEF-WHO 2018 thresholds. It means that, more than one in each three children in Sar e Pul province are not reaching optimal growth and development. Statistically, significant deterioration was observed in chronic malnutrition. The high prevalence is compounded further by the simultaneous presence of acute malnutrition resulting in a double burden of malnutrition. Recent research has concluded that children who

47 are both stunted and wasted are at a heightened risk of mortality21, further suggesting that this should be a priority group for treatment interventions. In Sar e Pul province, it was found that among the 219 stunted children, 35 of them (16.0 %) were also wasted by both criteria (WHZ<- 2SD + MUAC<125 mm) and 7 of them (3.2%) were severely wasted.

10.2. Maternal nutrition status Maternal undernutrition is one of the main contributory factors for low birth weight of babies. Babies who undernourished in the womb face the risk of dying during their early months and years. Hence it can strongly affect the nutrition situation of the children under five especially chronic malnutrition among the children, and those who survive have are likely to remain undernourished throughout their lives and to suffer a higher incidence of chronic disease. Children born underweight also tend to have cognitive disabilities and a lower IQ, affecting their performance in school and their job opportunities at adults, which eventually affects the province. Acute malnutrition among pregnant and lactating women in the province is always of concern; there is no globally defined cut-off for acute malnutrition among women. The results demonstrated that 15.7% of pregnant and lactating women were currently suffering from acutely malnourished. In other words, in one each six pregnant and lactating women are suffering from acute malnutrition based on MUAC (<230mm).

10.3. Mortality rate The CDR and U5DR were below the WHO emergency threshold with CDR of 0.22 death/10,000/Day and U5DR 0.44 death/10,000/Day. Most of the deaths were among the adults aged (65-120) was observed in Sar e Pul province.

10.4. Immunization Immunization is an important public health intervention that protects children from illness and disability. Based on this survey, 86.3% of children age 9-59 months, and 71.5% of the surveyed children between 18 to 59 months were immunized against measles first and second doses respectively. This coverage does not indicate satisfaction in both doses of measles and it is still poor (especially in second dose) and low than the national target of 90.0%, so the functioning of Expanded Program on Immunization “EPI” at the Sar e Pul province still needs to be improved and expand their activities among all areas of the province and especially outreach areas.

21 Myatt, M. et al (2018) Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries

11. RECOMMENDATIONS

Section Indicators Survey Findings Recommendation Actors Timeline - Increase of community awareness. Children Nutrition Prevalence of Prevalence of GAM (by To ensure nutrition messages are Status GAM (WHZ) WHZ) among children 6- included in health information 59 months is 7.5% which messages circulating by HFs and is categorized as health posts. “Medium” level of the - Improvements in the content and threshold. dissemination of the MAM= 6.7% information supplied to linking IEC DoPH BPHS- IP SAM= 0.8% materials. - The entire nutrition worker PND/MoPH assigned in the HFs should try to UNICEF use different tracking ways to WFP and And among children 0-59 other active File the gap as months GAM=7.3%, strength follow-up and referring soon as system between HFs and nutrition MAM= 6.7% & SAM= actors in the possible and 0.5%. community. regular - As the MCH handbooks have focus area - A high number of implementation, non-enrolled only on children <24 months, so follow-up and the screening part of children>24 cases 47.0% (24 (Nutrition, monitoring out of 51 cases) months should be added. - The capacity of nutrition worker EPI, CBHC, were observed in MCH and the community should be improved to use Z- Score among screening of children. Supply during the survey Departments) (this should not be - Expand Nutrition counseling included, unless if among all the eligible HFs. it is clear in the - To strengthen community nutrition objectives of the activities coverage in an integrated survey, otherwise, way to tackle the causes of it is not part of the undernutrition, to identify cases on key findings) a timely manner and refer them to HF for a proper management: Prevalence of Prevalence of GAM nutrition, WASH, FSL…sectors GAM (MUAC) (MUAC) working together among children 6-59 - To strengthen nutrition program to months is 10.2% manage cases: increase coverage in MAM= 8.2% hard to reach areas, capacity building of staff, strong supply SAM = 2.0% chain to ensure availability of - Out of 65 HFs just nutrition supplies… 15 HF had NCs - Out of 32 DH, CHC & BHC just 18 of them had OPD-MAM program - 2 BHC and 20 SHC also don’t had OPD-SAM service - Given the very high stunting rate Prevalence of Prevalence of Stunting observed in this survey, Stunting (HAZ) (HAZ) interventions are needed to focus DoPH among children 6-59 on the critical 1,000-day window BPHS- IP months is very high including antenatal care, MIYCN, PND/MoPH and IMNCI before a child turns two UNICEF years using community-based WFP and GAM= 44.5% service-delivery platforms. other active Continue MAM= 29.3% - Conducting regular health and nutrition nutrition education session at HFs actors in the SAM= 15.2% and community level. area - Strengthening GMP (growth monitoring promotion) at HFs and HPs.

- Strengthen nutrition community Prevalence of Prevalence of outreach activities. underweight underweight (WAZ) - Train and engage key informant in (WAZ) among children 6-59 the nutrition program to support months is in the Medium the nutrition program at BPHS Nut- level of the threshold. community. Supervisor, - Advocacy for the multi-sectorial PNO, projects. Nutrition GAM= 24.4 % extender, - Capacity building of the nutrition 3rd Q -2021 MAM= 20.2% staff through regular class room PND/MoPH and GCMU SAM= 2.7% and on the job training - Increase supportive supervision monitors Prevalence of Prevalence (MUAC<125 from the implementation nutrition Combined GAM mm and/or WHZ <-2) programs and SAM and/or oedema, of GAM - Conducting joint monitoring and (WHZ+MUAC) is 12.6 % and SAM is 2.8 supervision % - The health promotion at both HF Women Nutrition Prevalence of 15.7% Malnutrition in and community level should be Status CBA CBA (15-49 years) strengthen. HFs staff, Prevalence of 16.9% Malnutrition in - The supply of super serials should PNO, PLWs PLWs (15-49 years) be strengthen for all the HFs. Nutrition 3rd Quarter - To disseminate all the necessary Extender, 2021 message about family planning BPHS nut- about respecting spacing in Officer, WFP childbirths. and PND - Screening all women visiting HF for ANC and PNC visits - Comprehensive plan for the Immunization Coverage of 1st Dose coverage= community outreach EPI programs Coverage Measles Vaccine 86.2% PMT, BPHS, rd - Conducting regular EPI outreach 3 Quarter of (1st and 2nd DoPH 2nd Dose activities and covered the outreach 2021 Dose) coverage=71.4% and mobile areas

- Conducting measles campaign The immunization, based on need. coverage is very than - The active post monitoring should national EPI threshold for be done especially in outreach and Afghanistan. mobile areas. - To increase the capacity of the Mortality Crude Death CDR 0.22 (0.09-0.49) low public and private partners for PPHD Rate (CDR) then emergency threshold provision of health and nutrition BPHS for CDR 1.0/10,000/day. programs. And other Under Five U5DR 0.44 (0.14-1.40) - Advocacy for the multi-sectorial active Health 2021 Death Rate low then Emergency project partner (U5DR) Threshold for U5DR

1.0/10,000/day - Expend Health promotion program Morbidity Illness 39.3% among children 0- to community level. And the 59 months sessions should be increased. Acute 28.4% among children 0- - Strengthen community awareness BPHS, DoPH, MoPH Respiratory 59 months on personal hygiene. 2021 infection - Increase access to safe drinking water. Diarrhea 19.2% among children 0- - Expend the IMNCI service to 59 months community level.

ANNEXES

Annex1: Standardization test report Weight Height MUAC

Supervisor TEM acceptable TEM good TEM good

Enumerator 1 TEM acceptable TEM good TEM good

Enumerator 2 TEM poor TEM poor TEM good

Enumerator 3 TEM poor TEM acceptable TEM good

Enumerator 4 TEM poor TEM poor TEM good

Enumerator 5 TEM acceptable TEM acceptable TEM good

Enumerator 6 TEM acceptable TEM poor TEM good

Enumerator 7 TEM acceptable TEM poor TEM good

Enumerator 8 TEM poor TEM poor TEM good

Enumerator 9 TEM poor TEM acceptable TEM good

Enumerator 10 TEM poor TEM acceptable TEM good

Enumerator 11 TEM acceptable TEM poor TEM good

Enumerator 12 TEM acceptable TEM acceptable TEM good

Enumerator 13 TEM acceptable TEM acceptable TEM good

Enumerator 14 TEM poor TEM acceptable TEM good

Enumerator 15 TEM poor TEM acceptable TEM good

Enumerator 16 TEM poor TEM poor TEM acceptable

Enumerator 17 TEM poor TEM good TEM good

Enumerator 18 TEM poor TEM good TEM good

Annex 2: Health Screening Checklist for Household Exclusion

Observation checklist Response Remarks

1. Did respondent/mother and or any of eligible children have high temperature (≥100.4°F/ 38°C) Yes No

2. Did respondent/mother and or any of eligible children have high temperature (≥100.4°F/ 38°C) with at least Yes No

one symptom of COVID-19 (e.g. dry cough, sneezing, shortness of breath, chest pain or pressure, loss of speech or movement etc.) 3. Did anyone in this households has tested positive case for COVID-19 within the past 14 days? Yes No

4. Did any household member have been close contract with a confirmed COVID-19 positive patient within at Yes No

least 14-days?

5. Did any household member are currently in home quarantine or quarantine in centre for isolation? Yes No

Annex 3: Daily Health Screening Checklist for Survey Team Members Most common and mild symptoms Questions and observation Morning Evening Remarks 1. Did the staff and or any of the team member have high temperature (≥100.4°F/ Yes No Yes No 38°C) without dry cough, tiredness? 2. Did the staff and or any of the team member have high temperature (≥100.4°F/ Yes No Yes No

38°C) with dry cough, tiredness? Moderate and less common symptoms (treated from home) 3. Did the staff and or any of the team member have high temperature (≥100.4°F/ Yes No Yes No 38°C) without sore throat, diarrhoea, conjunctivitis, headache, loss of taste or smell, aches and pains? 4. Did the staff and or any of the team member have high temperature (≥100.4°F/ Yes No Yes No 38°C) with sore throat, diarrhoea, conjunctivitis, headache, loss of taste or smell, aches and pains? Serious symptoms (take immediate medical attention) 5. Did the staff and or any of the team member have running nose, sneezing, Yes No Yes No shortness of breath, chest pain or pressure, loss of speech or movement?

Annex 4: Standard Integrated SMART Survey Questionnaire (English) Date Cluster Name (dd/mm/year) Team Cluster Number HH Number Number Household Questionnaire Start date/event of recall period: 7th December 2020 (17th Qaws1399) (Wafat (Rehlat Nabi _صMuhammad 1 2 3 4 5 6 7 8 Sex Age Joined on Left on Born on Died on No. Name (m/f) (years) or after or after or after or after List all current household members* Head of 1 household 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 List all household members which left since the start of the recall period 1 Y 2 Y 3 Y 4 Y 5 Y

Cause of died: 1= unknown , 2= Trauma/ Injury 3= Illnesses , 4= Cause others code 1 Y 2 Y 3 Y 4 Y 5 Y

*Household defined as all people eating from the same pot and living together (WFP definition) Household Questionnaire Q1. What is the household resident status?

1=Resident of this area 2=Internally displaced 3=Refugee 4=Nomadic

Child Questionnaire 0-59 months 1 2 3 4 5 6 7 8 9 10 Chil Sex Birthday Age Weigh Heigh Measur Bilater MUA With d ID (f/m (dd/mm/yyy (month t t or e al C clothe ) y) s) (00.0 lengt (l/h)* edema (000 s kg) h mm) (y/n) (00.0 Left- cm) arm

8 *Note only if the length is measured for a child who is older than 2 years or height is measured for a child who is younger than 2 years, due to unavoidable circumstances in the field Child (6-59 months) ID Number For any child that is identified as acutely malnourished (WHZ, MUAC, or edema)

Q5. Is the child currently receiving any malnutrition treatment services?

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

1=OPD SAM 2=OPD MAM 3=IPD SAM 4=No treatment 98=Don’t know

If the child is not enrolled in a treatment program, refer to the nearest appropriate treatment center

Q6. Did you refer the child?

1=yes 0=no Child Questionnaire Child (9-59 months) CHILD ID NUMBER Q7. Has the child received the first dose of measles vaccination? (on the upper right arm)

Ask for a vaccination card to verify the first dose if available

0=Has did not receive one dose 1=Received one dose as confirmed by vaccination card 2=Received one dose as confirmed by caregiver recall 98=Don’t know Ask for a vaccination card to verify the second dose if available

0=Has did not receive two doses 1=Received two doses as confirmed by vaccination card 2=Received two doses as confirmed by caregiver recall 98=Don’t know

Child morbidity (0-59 months), CHILD ID NUMBER [Please use the same child ID used in the anthropometry section above] Q11: Has the child (name) ever been ill/sick in the past 14 days (last two weeks)? 0= No , 1= Yes , 98 Don’t know

Q1a: Acute Watery Diarrhea* [0= No , 1= Yes , 98 Don’t know] Q1b: ARI** [0= No , 1= Yes , 98 Don’t know] Q1d: Others [0= No , 1= Yes , 98 Don’t know] * Diarrhea defined as the passage of loose, watery/liquid stools three or more times a day or 24Hrs. **perceptions of a child who has a cough, is breathing faster than usual with short, quick breaths or is having difficulty breathing and a fever, excluding children that had only a blocked nose. ***Fever defined as mother checking child’s forehead and is warm accompanied my general malaise.

Woman (15-49 years) HH Member ID Number Q13. Status of woman

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

General comments (optional)

Annex 5: Geographical Units surveyed in Sar e Pul province.

Selected Area For Sar e Pul SMART

Province Population Organization HFs Name Geographical unit Cluster Name size 1 1400 قریه حبیب Sar e Pul SAF Chaman Ali Jan SHC 2 840 سیدآباد مرکز Sar e Pul SAF Sayed Abad CHC 3 560 نواباد خانقا Sar e Pul SAF Sayed Abad CHC 4 1050 غجرقدوق Sar e Pul SAF Sayed Abad CHC 5 2100 نوی حا ج Sar e Pul SAF Adam Sang BHC

6 1400 چپ قون سا ی Sar e Pul SAF Adam Sang BHC 7 420 قوش قوتن Sar e Pul SAF Pestalai BHC

8 700 انگوت ازبکیه Sar e Pul SAF Bughawi BHC 9 140 رساسیاب Sar e Pul SAF Bughawi Olia SHC 10 2100 لغمان Sar e Pul SAF Laghman SHC 11 420 نواباد Sar e Pul SAF Lati BHC 12 14000 صیاد Sar e Pul SAF Sayad CHC 13 1750 کوترمه Sar e Pul SAF Sayad CHC 14 2800 قفالطون Sar e Pul SAF Sayad CHC 15 2100 قورق Sar e Pul SAF Qara khawal BHC 16 595 خالر Sar e Pul SAF Tarkhoj DH 17 910 گرو Sar e Pul SAF Tarkhoj DH 18 2450 قشالق کالن Sar e Pul SAF Pirghola BHC 19 4900 باچگاه Sar e Pul SAF Bajgah SHC 20 700 دوشاخ Sar e Pul SAF Je SHC 21 1470 پشته Sar e Pul SAF Tarpach CHC 22 2800 سوزمه قلعه Sar e Pul SAF Suzma Qala CHC 23 700 کاریز افغانیه Sar e Pul SAF Chahrak BHC 24 1050 رسدره Sar e Pul SAF Jurghan BHC 25 1750 رس ده Sar e Pul SAF Bidastan SHC 26 2520 ده رسخ پای ی Sar e Pul SAF Kohistanat DH 27 672 قرغیتو پایان Sar e Pul SAF Qarghaito SHC 28 1750 دره گرزیوان Sar e Pul SAF Qala e Shar BHC 29 2100 اختیار Sar e Pul SAF Dehmian BHC 30 3500 دهمیانه پای ی Sar e Pul SAF Dehmian BHC 31 5600 فرشقان Sar e Pul SAF Tukzar DH 32 1260 چهلمرد Sar e Pul SAF Tukzar DH 33 2100 بهارک Sar e Pul SAF Tukzar DH 34 4550 ت ب قبله Sar e Pul SAF Tiber CHC 35 560 عرب قلعه Sar e Pul SAF Tiber CHC 36 560 ررسق توپخانه Sar e Pul SAF Masjid Sabz BHC

37 6650 دو درگ Sar e Pul SAF Awqaf SHC 38 4200 دره زم چ Sar e Pul SAF Dar e Zamchi SHC 39 2810 قورق قا ض Sar e Pul SAF Ab e Kalan SHC 40 3500 ملکان Sar e Pul SAF Gosfandi CHC 41 2450 پاله Sar e Pul SAF Pala SHC

42 420 قریه کالن Sar e Pul SAF Khasar BHC 43 280 مسجدعبدالویل قریه دار Sar e Pul SAF Aq Gumbad BHC

Annex 6: Plausibility check for Sar e Pul SMART 2021 Plausibility check for: ENA file_ for Sar e Pul province. As a 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

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of out of range subjects) 0 5 10 20 0 (1.4 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.893)

Age ratio (6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.546)

Dig pref score – weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (5)

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

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

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . And and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 5 (1.13)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.19)

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

Poisson dist. WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.658)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 7 %

The overall score of this survey is 7 %, this is excellent.

There were no duplicate entries detected.

Percentage of children with no exact birthday: 21 %

Anthropometric Indices likely to be in error (-3 to 3 for WHZ, -3 to 3 for HAZ, -3 to 3 for WAZ, from observed mean - chosen in Options panel - these values will be flagged and should be excluded from analysis for a nutrition survey in emergencies. For other surveys this might not be the best procedure e.g. when the percentage of overweight children has to be calculated):

Line=20/ID=1: WHZ (-5.527), WAZ (-4.591), Weight may be incorrect Line=32/ID=2: WHZ (-3.998), HAZ (5.736), Height may be incorrect

Line=63/ID=1: HAZ (2.664), Age may be incorrect Line=70/ID=1: HAZ (1.637), Age may be incorrect Line=96/ID=2: WHZ (-3.793), Weight may be incorrect Line=103/ID=1: WAZ (1.975), Weight may be incorrect Line=110/ID=1: WAZ (1.857), Weight may be incorrect Line=185/ID=3: WHZ (-3.275), Weight may be incorrect Line=260/ID=2: HAZ (1.625), Age may be incorrect Line=348/ID=1: HAZ (2.032), Age may be incorrect Line=371/ID=1: WHZ (-3.721), WAZ (-4.637), Weight may be incorrect Line=394/ID=1: HAZ (1.406), Age may be incorrect Line=406/ID=1: HAZ (1.658), Age may be incorrect Line=458/ID=2: WHZ (-3.425), Weight may be incorrect Line=517/ID=2: WHZ (2.833), Weight may be incorrect

Percentage of values flagged with SMART flags:WHZ: 1.4 %, HAZ: 1.4 %, WAZ: 0.8 %

Age distribution:

Month 6 : ####### Month 7 : ####### Month 8 : ######### Month 9 : ######### Month 10 : ########## Month 11 : ############ Month 12 : ############### Month 13 : ########## Month 14 : ############ Month 15 : ############ Month 16 : ######### Month 17 : ######## Month 18 : ########## Month 19 : ######## Month 20 : ############# Month 21 : ######## Month 22 : ########## Month 23 : ########## Month 24 : ########## Month 25 : ################ Month 26 : ######## Month 27 : ######## Month 28 : ######## Month 29 : ###### Month 30 : ###### Month 31 : ########## Month 32 : ######## Month 33 : ####### Month 34 : ##### Month 35 : ##### Month 36 : ######################## Month 37 : ##### Month 38 : #######

Month 39 : ######### Month 40 : ######## Month 41 : ########### Month 42 : ############# Month 43 : ########## Month 44 : ###### Month 45 : ###### Month 46 : ##### Month 47 : ####### Month 48 : #################### Month 49 : ############ Month 50 : ############### Month 51 : ######### Month 52 : ####### Month 53 : ########## Month 54 : ##### Month 55 : #### Month 56 : ######## Month 57 : ######## Month 58 : ########## Month 59 : ### Month 60 : #

Age ratio of 6-29 months to 30-59 months: 0.90 (The value should be around 0.85).: p-value = 0.546 (as expected)

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

Age cat. Mo. Boys’ girls total ratio boys/girls ------6 to 17 12 62/58.4 (1.1) 62/57.7 (1.1) 124/116.0 (1.1) 1.00 18 to 29 12 58/56.3 (1.0) 54/55.7 (1.0) 112/112.0 (1.0) 1.07 30 to 41 12 54/55.2 (1.0) 52/54.5 (1.0) 106/109.7 (1.0) 1.04 42 to 53 12 59/54.3 (1.1) 60/53.6 (1.1) 119/107.9 (1.1) 0.98 54 to 59 6 18/26.9 (0.7) 20/26.5 (0.8) 38/53.4 (0.7) 0.90 ------6 to 59 54 251/249.5 (1.0) 248/249.5 (1.0) 1.01

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

Overall sex ratio: p-value = 0.893 (boys and girls equally represented) Overall age distribution: p-value = 0.182 (as expected) Overall age distribution for boys: p-value = 0.459 (as expected) Overall age distribution for girls: p-value = 0.583 (as expected) Overall sex/age distribution: p-value = 0.165 (as expected)

Distribution of month of birth

Jan: ####################################### Feb: ###################################### Mar:##################################################### Apr: ############################################################# May: ########################################## Jun: ######################################

Jul: ####################################### Aug: ############################################ Sep: ####################################### Oct: ######################################## Nov: ###################################### Dec: ############################

Digit preference Weight:

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

Digit preference score: 5 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.218

Digit preference Height:

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

Digit preference score: 8 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.000 (significant difference)

Digit preference MUAC:

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

Digit preference score: 7 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.009 (significant difference)

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

. No exclusion exclusion from exclusion from . Reference mean observed mean . (WHO flags) (SMART flags) WHZ Standard Deviation SD: 1.20 1.18 1.13 (The SD should be between 0.8 and 1.2) Prevalence (< -2) Observed: 8.6% 8.4% 7.5% Calculated with current SD: 7.1% 6.6% 5.5% Calculated with a SD of 1: 3.9% 3.8% 3.6%

HAZ Standard Deviation SD: 1.23 1.23 1.12 (The SD should be between 0.8 and 1.2) Prevalence (< -2) Observed: 43.9% 43.9% 44.5% Calculated with current SD: 43.3% 43.3% 44.7% Calculated with a SD of 1: 41.7% 41.7% 44.1%

WAZ Standard Deviation SD: 1.09 1.09 1.05 (The SD should be between 0.8 and 1.2) Prevalence (< -2) Observed: 24.6% 24.6% 24.4% Calculated with current SD: 22.5% 22.5% 21.7% Calculated with a SD of 1: 20.6% 20.6% 20.6%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.005 p= 0.028 HAZ p= 0.000 p= 0.000 p= 0.258 WAZ p= 0.745 p= 0.745 p= 0.217 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)

Skewness WHZ -0.44 -0.31 -0.19 HAZ 0.63 0.63 -0.05 WAZ -0.03 -0.03 0.00 If the value is: -below minus 0.4 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 0.4 and minus 0.2, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 0.2 and plus 0.2, the distribution can be considered as symmetrical. -between 0.2 and 0.4, there may be an excess of obese/tall/overweight subjects in the sample. -above 0.4, there is an excess of obese/tall/overweight subjects in the sample

Kurtosis WHZ 0.74 0.23 -0.07 HAZ 2.76 2.76 -0.19 WAZ -0.12 -0.12 -0.45 Kurtosis characterizes the relative size of the body versus the tails of the distribution. Positive kurtosis indicates relatively large tails and small body. Negative kurtosis indicates relatively large body and small tails. If the absolute value is: -above 0.4 it indicates a problem. There might have been a problem with data collection or sampling. -between 0.2 and 0.4, the data may be affected with a problem. -less than an absolute value of 0.2 the distribution can be considered as normal.

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

WHZ < -2: ID=0.90 (p=0.658) WHZ < -3: ID=0.93 (p=0.605)

GAM: ID=0.90 (p=0.658) SAM: ID=0.93 (p=0.605) HAZ < -2: ID=1.05 (p=0.379) HAZ < -3: ID=1.27 (p=0.114) WAZ < -2: ID=1.26 (p=0.126) WAZ < -3: ID=0.80 (p=0.809)

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 > 0.95 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p value is between 0.05 and 0.95 the cases appear to be randomly distributed among the clusters, if ID is higher than 1 and 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 likely due to inclusion of oedematous cases in GAM and SAM estimates.

Are the data of the same quality at the beginning and the end of the clusters? Evaluation of the SD for WHZ depending upon the order the cases are measured within each cluster (if one cluster per day is measured then this will be related to the time of the day the measurement is made).

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.02 (n=42, f=0) ######### 02: 1.15 (n=41, f=0) ############### 03: 1.11 (n=38, f=0) ############# 04: 1.11 (n=41, f=0) ############# 05: 1.34 (n=39, f=0) ####################### 06: 1.36 (n=37, f=1) ######################## 07: 1.12 (n=38, f=0) ############## 08: 1.24 (n=36, f=0) ################### 09: 1.25 (n=36, f=0) ################### 10: 1.47 (n=31, f=3) ############################ 11: 1.28 (n=25, f=1) #################### 12: 1.41 (n=19, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOO 13: 1.02 (n=20, f=0) ######### 14: 0.86 (n=14, f=0) OOO 15: 1.16 (n=12, f=1) OOOOOOOOOOOOOOO 16: 1.09 (n=11, f=0) OOOOOOOOOOOO 17: 1.02 (n=10, f=0) OOOOOOOOO 18: 0.41 (n=06, f=0) 19: 1.42 (n=02, f=1) ~~~~~~~~~~~~~~~~~~~~~~~~~~

(When n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)

Analysis by Team

Team 1 2 3 4 5 6 n = 111 69 92 73 67 87 Percentage of values flagged with SMART flags: WHZ: 0.9 2.9 2.2 1.4 0.0 1.1 HAZ: 0.9 4.3 0.0 0.0 4.5 0.0 WAZ: 1.8 1.4 0.0 0.0 0.0 1.1 Age ratio of 6-29 months to 30-59 months: 0.82 0.82 1.42 0.82 1.03 0.64 Sex ratio (male/female): 0.85 1.16 1.04 0.82 1.09 1.23 Digit preference Weight (%):

.0 : 9 9 16 7 6 2 .1 : 14 6 15 21 12 16 .2 : 14 7 8 10 13 9 .3 : 10 10 9 5 7 11 .4 : 9 14 5 10 13 11 .5 : 12 13 9 7 10 10 .6 : 9 10 9 12 7 13 .7 : 9 12 10 11 9 8 .8 : 9 12 7 10 10 10 .9 : 5 7 13 8 10 8 DPS: 8 9 12 13 8 11 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference Height (%): .0 : 10 14 4 15 4 7 .1 : 10 12 21 5 12 7 .2 : 11 7 13 11 15 24 .3 : 12 16 17 16 9 17 .4 : 8 13 9 11 9 7 .5 : 12 12 8 4 7 7 .6 : 14 4 8 11 15 10 .7 : 6 9 10 16 15 5 .8 : 5 9 2 7 4 10 .9 : 14 4 9 3 9 6 DPS: 9 13 18 16 13 19 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference MUAC (%): .0 : 21 4 2 8 0 2 .1 : 12 7 9 5 15 9 .2 : 8 9 11 11 6 14 .3 : 14 17 7 14 15 7 .4 : 5 7 17 10 13 14 .5 : 18 14 16 18 6 10 .6 : 8 9 14 11 15 14 .7 : 5 7 12 7 10 10 .8 : 4 16 4 7 7 9 .9 : 5 9 8 10 12 10 DPS: 19 14 16 12 16 11 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Standard deviation of WHZ: SD 1.16 1.28 1.24 1.07 1.16 1.25 Prevalence (< -2) observed: % 6.3 10.1 7.6 6.8 11.9 10.3 Prevalence (< -2) calculated with current SD: % 4.8 10.2 7.9 3.3 9.6 9.0 Prevalence (< -2) calculated with a SD of 1: % 2.6 5.1 4.0 2.4 6.4 4.7 Standard deviation of HAZ: SD 1.04 1.62 1.11 1.11 1.40 1.12 observed: % 37.8 46.4 43.5 56.2 37.3 44.8 calculated with current SD:

% 37.5 43.1 45.5 51.8 35.4 48.1 calculated with a SD of 1: % 37.0 38.9 45.0 52.0 30.0 47.8

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

Team 1:

Age cat. Mo. Boys’ girls total ratio boys/girls ------6 to 17 12 15/11.9 (1.3) 11/14.0 (0.8) 26/25.8 (1.0) 1.36 18 to 29 12 10/11.4 (0.9) 14/13.5 (1.0) 24/24.9 (1.0) 0.71 30 to 41 12 11/11.2 (1.0) 14/13.2 (1.1) 25/24.4 (1.0) 0.79 42 to 53 12 9/11.0 (0.8) 12/13.0 (0.9) 21/24.0 (0.9) 0.75 54 to 59 6 6/5.5 (1.1) 9/6.4 (1.4) 15/11.9 (1.3) 0.67 ------6 to 59 54 51/55.5 (0.9) 60/55.5 (1.1) 0.85

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

Overall sex ratio: p-value = 0.393 (boys and girls equally represented) Overall age distribution: p-value = 0.870 (as expected) Overall age distribution for boys: p-value = 0.836 (as expected) Overall age distribution for girls: p-value = 0.771 (as expected) Overall sex/age distribution: p-value = 0.404 (as expected)

Team 2:

Age cat. Mo. boys girls total ratio boys/girls ------6 to 17 12 10/8.6 (1.2) 9/7.4 (1.2) 19/16.0 (1.2) 1.11 18 to 29 12 9/8.3 (1.1) 3/7.2 (0.4) 12/15.5 (0.8) 3.00 30 to 41 12 9/8.1 (1.1) 8/7.0 (1.1) 17/15.2 (1.1) 1.13 42 to 53 12 6/8.0 (0.7) 9/6.9 (1.3) 15/14.9 (1.0) 0.67 54 to 59 6 3/4.0 (0.8) 3/3.4 (0.9) 6/7.4 (0.8) 1.00 ------6 to 59 54 37/34.5 (1.1) 32/34.5 (0.9) 1.16

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

Overall sex ratio: p-value = 0.547 (boys and girls equally represented) Overall age distribution: p-value = 0.771 (as expected) Overall age distribution for boys: p-value = 0.893 (as expected) Overall age distribution for girls: p-value = 0.467 (as expected) Overall sex/age distribution: p-value = 0.301 (as expected)

Team 3:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 13/10.9 (1.2) 10/10.5 (1.0) 23/21.4 (1.1) 1.30 18 to 29 12 15/10.5 (1.4) 16/10.1 (1.6) 31/20.6 (1.5) 0.94 30 to 41 12 9/10.3 (0.9) 8/9.9 (0.8) 17/20.2 (0.8) 1.13 42 to 53 12 9/10.2 (0.9) 11/9.7 (1.1) 20/19.9 (1.0) 0.82 54 to 59 6 1/5.0 (0.2) 0/4.8 (0.0) 1/9.8 (0.1) ------6 to 59 54 47/46.0 (1.0) 45/46.0 (1.0) 1.04

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

Overall sex ratio: p-value = 0.835 (boys and girls equally represented) Overall age distribution: p-value = 0.008 (significant difference) Overall age distribution for boys: p-value = 0.214 (as expected) Overall age distribution for girls: p-value = 0.066 (as expected) Overall sex/age distribution: p-value = 0.006 (significant difference)

Team 4:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 5/7.7 (0.7) 15/9.3 (1.6) 20/17.0 (1.2) 0.33 18 to 29 12 8/7.4 (1.1) 5/9.0 (0.6) 13/16.4 (0.8) 1.60 30 to 41 12 7/7.3 (1.0) 6/8.8 (0.7) 13/16.0 (0.8) 1.17 42 to 53 12 10/7.1 (1.4) 9/8.7 (1.0) 19/15.8 (1.2) 1.11 54 to 59 6 3/3.5 (0.8) 5/4.3 (1.2) 8/7.8 (1.0) 0.60 ------6 to 59 54 33/36.5 (0.9) 40/36.5 (1.1) 0.82

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

Overall sex ratio: p-value = 0.413 (boys and girls equally represented) Overall age distribution: p-value = 0.650 (as expected) Overall age distribution for boys: p-value = 0.696 (as expected) Overall age distribution for girls: p-value = 0.180 (as expected) Overall sex/age distribution: p-value = 0.049 (significant difference)

Team 5:

Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 6/8.1 (0.7) 8/7.4 (1.1) 14/15.6 (0.9) 0.75 18 to 29 12 8/7.9 (1.0) 12/7.2 (1.7) 20/15.0 (1.3) 0.67 30 to 41 12 7/7.7 (0.9) 5/7.0 (0.7) 12/14.7 (0.8) 1.40 42 to 53 12 12/7.6 (1.6) 6/6.9 (0.9) 18/14.5 (1.2) 2.00 54 to 59 6 2/3.7 (0.5) 1/3.4 (0.3) 3/7.2 (0.4) 2.00 ------6 to 59 54 35/33.5 (1.0) 32/33.5 (1.0) 1.09

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

Overall sex ratio: p-value = 0.714 (boys and girls equally represented) Overall age distribution: p-value = 0.233 (as expected) Overall age distribution for boys: p-value = 0.402 (as expected) Overall age distribution for girls: p-value = 0.223 (as expected) Overall sex/age distribution: p-value = 0.044 (significant difference)

Team 6:

Age cat. Mo. Boys girls total ratio boys/girls ------6 to 17 12 13/11.2 (1.2) 9/9.1 (1.0) 22/20.2 (1.1) 1.44 18 to 29 12 8/10.8 (0.7) 4/8.8 (0.5) 12/19.5 (0.6) 2.00 30 to 41 12 11/10.5 (1.0) 11/8.6 (1.3) 22/19.1 (1.2) 1.00 42 to 53 12 13/10.4 (1.3) 13/8.4 (1.5) 26/18.8 (1.4) 1.00 54 to 59 6 3/5.1 (0.6) 2/4.2 (0.5) 5/9.3 (0.5) 1.50 ------6 to 59 54 48/43.5 (1.1) 39/43.5 (0.9) 1.23

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

Overall sex ratio: p-value = 0.335 (boys and girls equally represented) Overall age distribution: p-value = 0.084 (as expected) Overall age distribution for boys: p-value = 0.630 (as expected) Overall age distribution for girls: p-value = 0.143 (as expected) Overall sex/age distribution: p-value = 0.041 (significant difference)

Evaluation of the SD for WHZ depending upon the order the cases are measured within each cluster (if one cluster per day is measured then this will be related to the time of the day the measurement is made).

Team: 1

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.01 (n=07, f=0) ######### 02: 1.81 (n=07, f=0) ########################################### 03: 0.86 (n=06, f=0) ### 04: 1.05 (n=07, f=0) ########### 05: 1.04 (n=06, f=0) ########## 06: 1.11 (n=06, f=0) ############# 07: 1.30 (n=07, f=0) ##################### 08: 1.50 (n=07, f=0) ############################# 09: 1.39 (n=07, f=0) ######################### 10: 0.69 (n=06, f=0) 11: 0.85 (n=06, f=0) ## 12: 1.32 (n=07, f=0) ###################### 13: 0.65 (n=06, f=0) 14: 0.52 (n=05, f=0) 15: 1.00 (n=04, f=0) OOOOOOOO 16: 1.20 (n=06, f=0) ################# 17: 1.03 (n=05, f=0) ########## 18: 0.37 (n=04, f=0)

(When n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; the numbers marked "f" are the numbers of SMART flags found in the different time points)

Team: 2

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.63 (n=07, f=0) 02: 0.83 (n=07, f=0) # 03: 0.38 (n=06, f=0) 04: 0.89 (n=07, f=0) #### 05: 1.14 (n=07, f=0) ############## 06: 2.37 (n=05, f=1) ################################################################ 07: 0.96 (n=05, f=0) ####### 08: 1.21 (n=05, f=0) ################# 09: 1.00 (n=05, f=0) ######### 10: 1.72 (n=05, f=1) ###################################### 11: 1.41 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOO 12: 0.34 (n=02, f=0) 13: 0.15 (n=02, f=0) 14: 0.05 (n=02, f=0)

Team: 3

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.18 (n=07, f=0) ################ 02: 1.15 (n=07, f=0) ############### 03: 1.30 (n=07, f=0) ##################### 04: 1.16 (n=06, f=0) ############### 05: 1.12 (n=07, f=0) ############# 06: 0.81 (n=06, f=0)

07: 0.88 (n=07, f=0) ### 08: 1.28 (n=07, f=0) #################### 09: 1.39 (n=06, f=0) ######################### 10: 1.06 (n=05, f=0) ########### 11: 1.84 (n=06, f=1) ############################################ 12: 1.29 (n=04, f=0) ##################### 13: 1.16 (n=05, f=0) ############### 14: 1.69 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 15: 1.70 (n=03, f=1) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 16: 0.44 (n=02, f=0) 17: 1.39 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOO 18: 0.63 (n=02, f=0)

Team: 4

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.78 (n=07, f=0) 02: 0.71 (n=06, f=0) 03: 1.32 (n=07, f=0) ###################### 04: 1.20 (n=07, f=0) ################# 05: 0.78 (n=07, f=0) 06: 1.50 (n=06, f=0) ############################## 07: 1.17 (n=07, f=0) ################ 08: 0.74 (n=04, f=0) 09: 1.01 (n=05, f=0) ######### 10: 1.83 (n=05, f=1) ########################################### 11: 0.75 (n=02, f=0) 12: 0.85 (n=02, f=0) OO 13: 0.81 (n=02, f=0) 14: 0.53 (n=02, f=0) 15: 1.12 (n=02, f=0) OOOOOOOOOOOOO

Team: 5

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.52 (n=07, f=0) ############################## 02: 0.72 (n=07, f=0) 03: 1.69 (n=05, f=0) ##################################### 04: 0.89 (n=07, f=0) #### 05: 1.64 (n=05, f=0) ################################### 06: 0.64 (n=07, f=0) 07: 0.85 (n=07, f=0) ## 08: 1.11 (n=05, f=0) ############# 09: 1.42 (n=06, f=0) ########################## 10: 0.63 (n=03, f=0) 11: 1.26 (n=04, f=0) ###################

Team: 6

Time SD for WHZ Point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.86 (n=08, f=0) ### 02: 1.33 (n=07, f=0) ###################### 03: 1.01 (n=07, f=0) ######### 04: 1.39 (n=07, f=0) ######################### 05: 1.58 (n=07, f=0) ################################# 06: 1.29 (n=07, f=0) #################### 07: 1.63 (n=05, f=0) ################################### 08: 0.63 (n=07, f=0) 09: 0.97 (n=07, f=0) ####### 10: 1.88 (n=07, f=1) #############################################

11: 1.11 (n=04, f=0) OOOOOOOOOOOOO 12: 1.98 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 13: 1.50 (n=04, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOO 14: 0.65 (n=03, f=0) 15: 0.58 (n=02, f=0)

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

Annex 7: Event Calendar Sar e Pul Province (April, 2021)

1400 ماه 1399 ماه 1398 ماه 1397 ماه 1396 ماه 1395 ماه ماه

زخصنی نوروز ، جشن د هقان ، زخصنی نوروز ، جشن د هقان ، زخصنی نوروز ، جشن د هقان ، زخصنی نوروز ، جشن د هقان ، زخصنی نوروز ، جشن د هقان ، زخصنی نوروز ، جشن د هقان ، ،غرس نمودن نیال ها ،وقت شگوفه ،غرس نمودن نیال ها ،وقت شگوفه ،غرس نمودن نیال ها ،وقت شگوفه ،غرس نمودن نیال ها ،وقت شگوفه ،غرس نمودن نیال ها ،وقت شگوفه ،غرس نمودن نیال ها ،وقت شگوفه

م درختان، میش چینی گوسفندان 1 درختان، میش چینی گوسفندان 12 درختان، میش چینی گوسفندان 24 درختان، میش چینی گوسفندان 36 درختان، میش چینی گوسفندان 47 درختان، میش چینی گوسفندان 59 ح نیش تریاک، بارندگی شروع میشود نیش تریاک، بارندگی شروع میشود نیش تریاک، بارندگی شروع میشود نیش تریاک، بارندگی شروع میشود نیش تریاک، بارندگی شروع میشود نیش تریاک، بارندگی شروع میشود اب رود خانها جاری میشود اب رود خانها جاری میشود اب رود خانها جاری میشود اب رود خانها جاری میشود اب رود خانها جاری میشود اب رود خانها جاری میشود جشن روخصتی هشت ثور ، برګ جشن روخصتی هشت ثور ، برګ جشن روخصتی هشت ثور ، برګ جشن روخصتی هشت ثور ، برګ جشن روخصتی هشت ثور ، برګ جشن روخصتی هشت ثور ، برګ

و درختان، ،ماه مبارک رمضان درختان، ،ماه مبارک رمضان 22 درختان، ،ماه مبارک رمضان 23 درختان، ،ماه مبارک رمضان 35 درختان، ،ماه مبارک رمضان 58 درختان، ،ماه مبارک رمضان 58 ث زیات شده ماهی به سطحه اب زیات شده ماهی به سطحه اب زیات شده ماهی به سطحه اب زیات شده ماهی به سطحه اب زیات شده ماهی به سطحه اب زیات شده ماهی به سطحه اب شروع امتحانات مکاتب، شروع امتحانات مکاتب، شروع امتحانات مکاتب، شروع امتحانات مکاتب، شروع امتحانات مکاتب، شروع امتحانات مکاتب،

و عید سعید فطر ،بادهای ۱۲۰ روزه عید سعید فطر ،بادهای ۱۲۰ روزه 11 عید سعید فطر ،بادهای ۱۲۰ روزه 22 عید سعید فطر ،بادهای ۱۲۰ روزه 34 عید سعید فطر ،بادهای ۱۲۰ روزه 46 عید سعید فطر ،بادهای ۱۲۰ روزه 57 ج کندم درو ، رخصتی مکاتب کندم درو ، رخصتی مکاتب کندم درو ، رخصتی مکاتب کندم درو ، رخصتی مکاتب کندم درو ، رخصتی مکاتب کندم درو ، رخصتی مکاتب

شورع تابستان ، پخته شدن انګور ، شورع تابستان ، پخته شدن انګور ، شورع تابستان ، پخته شدن انګور ، شورع تابستان ، پخته شدن انګور ، شورع تابستان ، پخته شدن انګور ، شورع تابستان ، پخته شدن انګور ، ا

ر تربوز و خربوزه ، وخت خرمن کوبی تربوز و خربوزه ، وخت خرمن کوبی 10 تربوز و خربوزه ، وخت خرمن 21 تربوز و خربوزه ، وخت خرمن کوبی 33 تربوز و خربوزه ، وخت خرمن کوبی 45 تربوز و خربوزه ، وخت خرمن کوبی 56 س ګرما سوزان ګرما سوزان کوبی ګرما سوزان ګرما سوزان ګرما سوزان ګرما سوزان وخت کشت جواری ، روزی استقالل ، وخت کشت جواری ، روزی استقالل ، وخت کشت جواری ، روزی استقالل وخت کشت جواری ، روزی استقالل ، وخت کشت جواری ، روزی استقالل ، وخت کشت جواری ، روزی استقالل ،

ماه دوهم ګرمی ، څله سیاه ، وخت رفتن ماه دوهم ګرمی ، څله سیاه ، وخت ، ماه دوهم ګرمی ، څله سیاه ، وخت ماه دوهم ګرمی ، څله سیاه ، وخت رفتن ماه دوهم ګرمی ، څله سیاه ، وخت ماه دوهم ګرمی ، څله سیاه ، وخت رفتن س حاجیان رفتن حاجیان 9 رفتن حاجیان 20 حاجیان 32 رفتن حاجیان 44 حاجیان 55 ا ، زیات شدن ماهی ، زیات شدن ماهی ، زیات شدن ماهی ، زیات شدن ماهی ، زیات شدن ماهی ، زیات شدن ماهی

عید قربان، شروع مکاتب ، وخت عید قربان، شروع مکاتب ، وخت عید قربان، شروع مکاتب ، وخت عید قربان، شروع مکاتب ، وخت عید قربان، شروع مکاتب ، وخت عید قربان، شروع مکاتب ، وخت ه

ن سبزیجات ، وخت امدن حاجیان، سبزیجات ، وخت امدن حاجیان، 8 سبزیجات ، وخت امدن حاجیان، 19 سبزیجات ، وخت امدن حاجیان، 31 سبزیجات ، وخت امدن حاجیان، 43 سبزیجات ، وخت امدن حاجیان، 54 س ۱۰محرم ۱۰محرم ۱۰محرم ۱۰محرم ۱۰محرم ۱۰محرم

برګ ریزی درخاتها، متوقف شدن برګ ریزی درخاتها، متوقف شدن برګ ریزی درخاتها، متوقف شدن برګ ریزی درخاتها، متوقف شدن برګ ریزی درخاتها، متوقف شدن برګ ریزی درخاتها، متوقف شدن ی 7 18 30 42 53 م بادهای ۱۲۰ روزه ، بادهای ۱۲۰ روزه ، بادهای ۱۲۰ روزه ، بادهای ۱۲۰ روزه ، بادهای ۱۲۰ روزه ، بادهای ۱۲۰ روزه ،

امادګی ګرفتن برای زمیستان ، ب

امادګی ګرفتن برای زمیستان ، هموار امادګی ګرفتن برای زمیستان ، هموار امادګی ګرفتن برای زمیستان ، هموار امادګی ګرفتن برای زمیستان ، هموار امادګی ګرفتن برای زمیستان ، هموار ق 6 هموار کردان زمین برای کشت ، غلو 17 29 41 52 ع کردان زمین برای کشت ، غلو تروش کردان زمین برای کشت ، غلو تروش کردان زمین برای کشت ، غلو تروش کردان زمین برای کشت ، غلو تروش کردان زمین برای کشت ، غلو تروش تروش شروع زمستان ، تهیه نمودن هزوم ، شروع زمستان ، تهیه نمودن هزوم ، شروع زمستان ، تهیه نمودن هزوم شروع زمستان ، تهیه نمودن هزوم ، شروع زمستان ، تهیه نمودن هزوم ، شروع زمستان ، تهیه نمودن هزوم ،

وخت الندی ، شب یالدا ، جمعه اوری وخت الندی ، شب یالدا ، جمعه اوری ، وخت الندی ، شب یالدا ، جمعه وخت الندی ، شب یالدا ، جمعه اوری وخت الندی ، شب یالدا ، جمعه اوری وخت الندی ، شب یالدا ، جمعه اوری س

و مسکه ، دوغ، شیر، مسکه ، دوغ، شیر، 5 اوری مسکه ، دوغ، شیر، 16 مسکه ، دوغ، شیر، 28 مسکه ، دوغ، شیر، 40 مسکه ، دوغ، شیر، 51 ق پخته شدن خرما پخته شدن خرما پخته شدن خرما پخته شدن خرما پخته شدن خرما پخته شدن خرما

توره سیله ، سیله، خوشک ،پخته شدن توره سیله ، سیله، خوشک ،پخته توره سیله ، سیله، خوشک ،پخته توره سیله ، سیله، خوشک ،پخته شدن توره سیله ، سیله، خوشک ،پخته توره سیله ، سیله، خوشک ،پخته شدن ی

د مالته، سیب ، شلغم ، زردک ، کشت شدن مالته، سیب ، شلغم ، زردک ، 4 شدن مالته، سیب ، شلغم ، زردک ، 15 مالته، سیب ، شلغم ، زردک ، کشت کندم 27 شدن مالته، سیب ، شلغم ، زردک ، 39 مالته، سیب ، شلغم ، زردک ، کشت کندم 50 ج کندم ، امتحانات چهارنیمه ، کشت کندم ، امتحانات چهارنیمه ، کشت کندم ، امتحانات چهارنیمه ، ، امتحانات چهارنیمه ، کشت کندم ، امتحانات چهارنیمه ، ، امتحانات چهارنیمه ،

باران ها زیات میشود، سره سیله باران ها زیات میشود، سره باران ها زیات میشود، سره باران ها زیات میشود، سره سیله باران ها زیات میشود، سره باران ها زیات میشود، سره سیله ، ل 3 14 26 38 49 د ، پوجی کوکنار، ۲۲ بهمن سیله ، پوجی کوکنار، ۲۲ بهمن سیله ، پوجی کوکنار، ۲۲ بهمن ، پوجی کوکنار، ۲۲ بهمن سیله ، پوجی کوکنار، ۲۲ بهمن پوجی کوکنار، ۲۲ بهمن

کشت پخته ، کشت کردن خربوزه ، کشت پخته ، کشت کردن خربوزه ، کشت پخته ، کشت کردن خربوزه ، کشت پخته ، کشت کردن خربوزه ، کشت پخته ، کشت کردن خربوزه ، کشت پخته ، کشت کردن خربوزه ، و 48 ح تربوز ، سبز شدن درختان تربوز ، سبز شدن درختان 2 تربوز ، سبز شدن درختان 13 تربوز ، سبز شدن درختان 25 تربوز ، سبز شدن درختان 37 تربوز ، سبز شدن درختان

12. REFERENCES

 ENA software 2020 updated 11th Jan 2020.  Afghanistan Health Survey 2018.  WHO Child Growth Standard 2006.  Myatt, M. et al (2018) Children who are both wasted and stunted are also underweight and have a high risk of death: descriptive epidemiology of multiple anthropometric deficits using data from 51 countries.  WHO mortality emergency threshold.  WHO Emergency Severity classification for underweight.  NSIA updated population 1399 (2020)