AFGHANISTAN. Nutrition & Mortality SMART survey preliminary report. Nangarhar province, Afghanistan. Date: December 2014

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1 AFGHANISTAN Nutrition & Mortality SMART survey preliminary report Nangarhar province, Afghanistan Date: December 2014 Authors: Hassan Ali Ahmed, Dr Baidar Bakht Funded by: Action Contre la Faim ACF is a non-governmental, non-political and non-religious organization 1

2 ACKNOWLEDGEMENT The authors would like to pass their sincere appreciation to the ACF team in Kabul and Paris and the logistics and Security department in Kabul. Special appreciation goes to the Save the Children team in Nangarhar and Kabul especially Dr. Akbar Sabawoon, Naqeebullah Khawareen, Dr. Sahibdzada, Dr. Shagiwali, and Dr.Lamar. Last but not least tremendous appreciation goes to the PNO Nangarhar for their support and authorisation of the survey and to the entire data collection team in Nangarhar for making the whole process smooth. This document has been produced with the financial assistance of the United Nations office for coordination and humanitarian affairs Common Humanitarian fund (UNOCHA- CHF). The views expressed herein should not be taken, in any way, to reflect the official opinion of the UNOCHA. ACRONYMS ACF BCG BPHS CHF CHW DEFF ENA SMART IYCF GAM HAZ HH MUAC UNOCHA WAZ WHO Action Contre la Faim Bacillus Calmette-Guérin Basic Package of Health Services Common Humanitarian Fund Community Health Worker Design Effect Emergency Nutrition Assessment Standardized Monitoring of Relief and Transition Infant and Young Child Feeding Global Acute Malnutrition Height for Age Z-score Household Mid Upper Arm Circumference United Nations Office for the Coordination of Humanitarian Affairs Weight for Age Z-Score World Health Organization Weight for Height Z- Score

3 TABLE OF CONTENT 1. INTRODUCTION OBJECTIVES METHODOLOGY PRIMARY RESULTS ANNEXES... 5 LIST OF TABLES Table Table Table

4 1. INTRODUCTION Nangarhar is one of the 34 provinces of Afghanistan, located in the eastern part of the country. It is divided into twenty-two districts and has a population of about 1,436,000. The city of Jalalabad is the capital of Nangarhar province. Nangarhar province borders Laghman, Kunar, Nuristan and Paktia provinces. Nangarhar is considered as the food basket of Afghanistan as most of the crops produced here are consumed in different parts of the country. The main summer crops grown in the province are rice, maize, cotton, sunflower, beans, potato whereas main winter crops are wheat, barley, sugarcane, potato and mustard. Although opium is still considered as the predominant crop in 12 southern districts of the province, farmers are increasingly engaging in vegetable crop production due to growing demand and relatively high benefit. The vegetables normally grown in summer are okra, tomato, eggplant, pepper, pumpkins, cucumbers, spinach, lettuce and others. The winter vegetables are onion, cauliflower, turnip, spinach, radish, carrot, cabbage etc. Rodat district is well known for potato and onion production. Most of the vegetables and crops produced are supplied to Kabul and other parts of Afghanistan. Some of the crops and vegetables are also sold locally. Only 5 districts out of 22 districts in Nangarhar province were surveyed due to security issues and inaccessibility of far areas. The population of these 5 districts represent 75% of the entire population of Nangarhar Province. According to SMART methodology, the results cannot be extrapolated to the whole province but only representative of the surveyed areas. This is a limitation with regards to having a complete picture of the nutritional status of children under five year s old and pregnant/lactating women in Nangarhar province. The justification of this SMART survey was to investigate and find up to date nutrition, mortality and IYCF data specific to these districts and to foster informed and evidence based programming for Save the Children s area of intervention. Save the Children was selected to participate in this survey because they are supporting the BPHS implementer in the proper implementation of nutrition program within the BPHS program. Therefore, this has been viewed as a great opportunity of build Save the Children s capacities. Indeed, Save the Children will then be in a position to better support the BPHS partner in Nangarhar with regard to nutrition. 1

5 2. OBJECTIVES 1. Broad objective - To estimate the prevalence of acute malnutrition of 0-59 months children in Nangarhar province. 2. Specific objective - To estimate crude death rate and under five death rate in 5 districts of Nangarhar province. - To determine prevalence of acute and chronic malnutrition of 0-59 months children. - To determine IYCF practice for children 0-23 months in 5 districts of Nangarhar province. - To determine the nutritional status of Pregnant and Lactating Women in 5 districts of Nangarhar Province. 3. METHODOLOGY Survey area: This survey covered 5 districts of Nangarhar Province (Jalalabad, Surkhrod, Kama, Behsud, and Kuzkunar Districts) Survey period: The survey was conducted from 17th December 2014 to 4th January 2015 Survey design: The survey was a cross sectional study with two-stages clusters samplings using Standardized Monitoring of Relief and Transition (SMART) methodology. Villages were considered as the smallest geographical unit (clusters). Survey population: 1,077,814 Sample size: Emergency Nutrition Assessment (ENA) for SMART software delta version 2011 updated November 2014, was used for sample size calculation (parameters used for sample size calculation are in Annex 1). 4. PRIMARY RESULTS For the sake of timely presentation of survey results, Table 1 summarizes preliminary findings with regards to nutrition and health indicators. The final report will contain the full analysis and will be completed within one month once completion of field data collection. A total of 697 children aged 0-59 months were assessed for their nutritional status through anthropometric measurements from 595 sampled households. The data quality analysis is presented in annex 2 (plausibility check on anthropometric results). 2

6 Table 1: Summary of Nutrition and Health indicator results, Nangarhar, December Results presented in brackets are expressed with 95.0% confidence interval (CI). Index Indicators Results Under nutrition Children 6-59 months (WHO 2006) Mortality - scores (n=697) HAZ- scores (n=645) WAZ-scores (n=693) MUAC (n=704) Maternal Malnutrition Measles vaccination Global Acute Malnutrition Weight for height< -2 z and/or oedema* 5.6% ( ) Severe Acute Malnutrition Weight for height < -3 z and/or oedema 0.6% ( ) Moderate acute malnutrition Weight for height <-2 z-score and >=-3 z-score 5.0% ( ) Stunting 51.5% Height for age <-2 z-score ( ) Underweight 24.2% Weight for age <-2 z-score ( ) Global Acute Malnutrition 4.1% MUAC <125 mm or oedema ( ) Severe Acute Malnutrition 0.4% MUAC <115 mm or oedema (<115mm) ( ) Crude Death rate 0.44% ( ) <5 Death rate 0.86% ( ) Pregnant and lactating mothers (MUAC<210 mm) 0.46% Pregnant and lactating mother (MUAC<230 mm) 6.66% 9-59 months; by card 63.14% 9-59 months; both by card and recall 81.26% BCG vaccination 6-59 months; by scar 89.91% Vitamin A supplementation 6-59 months; by recall 35.36% Morbidity Overall < 5morbidity in past 2 weeks 62.23% Fever 9.48% Cough/ARI 63.51% Under 5 Morbidity in the last 2 weeks prior to the Watery diarrhoea 5.24% survey Bloody diarrhoea 0.20% Therapeutic Zinc supplementation (Only diarrhoea cases) 23.08% *The prevalence of oedema was 0.0 % 3

7 Summary of Key Recommendations. Based on the results presented in the previous section some key recommendations can be already pointed out: Support women and their families to practice optimal breastfeeding and ensure timely and adequate complementary feeding through provision of IYCF programs at facility and community levels. Ensure that there are effective micronutrient strategies for pregnant women, to promote iron folate supplementation at community and facility levels. Support nutrition relevant aspects of availability, access, as well as the utilization of nutrition services through integrated programming. Community sensitization on importance of micronutrient supplementation and Vitamin A supplementation for children and pregnant women. Promote behaviour change communication strategies to increase community awareness and improve health seeking behaviour to combat childhood illness. Increase Zinc supplementation through facilities, campaigns, and CHW s to combat diarrhoea cases at facility and community levels. Promote proper hygiene practices at facility and community levels to reduce child morbidity. Final recommendations and detailed action plan will be presented in the final report of the survey. 4

8 5. ANNEXES Annex 1: Sample size calculation for nutrition status using ENA for SMART software (Version 2011 November 2014 update) Estimated GAM 1 Precision DEFF U5 Population 2 Av. HH size 3 Non response Sample size Children Sample size HHs Clusters (15HHs/ cluster) 8.2% % 7 6% Annex 2: Plausibility check summary CRITERIA Missing/ flagged data Overall sex ratio Overall age distribution Digit pref. score Weight Digit pref. score Height Digit pref. score MUAC Standard deviation Skewness Kurtosis Poisson distribution SCORE Interpretation Excellent Excellent Problematic Excellent Good Good Excellent Excellent Excellent Excellent Good Overall score 1 National nutrition survey 2013 GAM calculated with SD of 1 2 Afghanistan Mortality survey, National vulnerability assessment of Afghanistan