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Nutrition & Mortality SMART Survey in Uruzgan Province (26 February 2018)


To determine the nutritional status of vulnerable population mainly under five, pregnant and lactating women living in the province.


As the survey area is large and the population is dispersed, a two-stage cluster methodology was applied as follows.
The first stage involved a random selection of clusters/villages from a list of villages using probability proportion to size (PPS) method. The sample size of household’s survey was determined using ENA for SMART software version 2011 (up dated 9th July 2015). This was done before starting the data collection at the office by the team. “Village” was the primary sampling unit for the proposed survey.
The second stage of methodology, involved systematic random selection of households (13 households) from an updated list of households. This was conducted at the field level. “Household” was the basic sampling unit for the proposed survey in the selected villages/Clusters.

The surveyed province has a scattered population, therefore a two-stage cluster sampling methodology was chosen. With the above assumptions, the number of children was 753, converted into 717 households to survey.
Stage 1: random selection of clusters/villages was chosen using probability proportion to size (PPS) using ENA for SMART software version 2011 of (9th July, 2015). A list of all updated villages was amounted into the ENA for SMART software where PPS was applied. The villages with a large population had a higher chance of being selected than villages with small population and vice versa. Reserve Clusters (RCs) were also selected by ENA software version 2011 (updated 9 July 2015). 717 /13 =55.15 round dawn to 55 clusters were supposed to be surveyed, each team could complete anthropometric measurements in 13 HHs in a day. Finally a total of 52 Clusters were surveyed out of 55 clusters: three clusters were missed due to ongoing fighting. As the nonresponse cluster was less than 10 % we did not used the reserve clusters as the reserve clusters was supposed to be used if 10% or more clusters were impossible to reach during the survey as per SMART methodology. The selected clusters are highlighted in Annex 2. In each selected cluster/village, one or more community member(s) was asked to help the survey teams to conduct their work by providing information about the village with regard to the geographical organization or the number of households. For large villages, the village was divided into smaller segments and a segment was selected randomly to represent the cluster. This division was done based on existing administrative units e.g. neighborhoods, or streets or natural landmarks like river, road, or public places like market, schools, and masjid.
Stage 2: households to survey were randomly selected in each cluster/village using the systematic random sampling method. Based on the total sample size, each team could effectively cover 13 households in a day. In this assessment, 6 teams were engaged during the assessments, while data collection was reached to 11 days. The survey team were enumerated and given numbers to all households. The 13 households were randomly selected from these enumerated households, by systematic random sampling to identify the households to survey. The teams were trained on both methods of sampling (simple and systematic random sampling) and they were provided with materials to assist in determining the households during the data collection exercise.
All the children living in the selected house, aged 0 to 59 months old, were included for anthropometric measurements. Children aged <24 months were included for IYCF measurements. To ensure that every child had the same chance to be surveyed, if more than one eligible child was found in a household, all children were included, even if there were twins. Eligible orphans living in the selected Households were also surveyed. All the selected HH were included in the mortality survey as well as to answer to questions concerning the HH as a whole (ex. water storage, WASH and FSL).
Any empty households, or households with missing or absent children were revisited at the end of the sampling day in each cluster; any missing or absent child that was not subsequently found was not included in the survey. A cluster control form was used to record all the temporary empty households. The abandoned ones were excluded from the total HHs list at the beginning of the field work. This information was provided to the teams by the village elders. The household was the basic sampling unit. The term household was defined as all people eating from the same pot and living together (WFP definition). In Afghanistan, the term household often defined and/or used in synonymous with a compound – which potentially represents more than one household as defined here. In this case, a two-step process was ensured with the village leaders/community elders and then identifying compound together with the use of the list of households within the community, asking if there are multiple cooking areas to determine what members of the household/compound.

Six teams of four members conducted the field data collection. Each team was composed of one supervisor, one team leader and two data collectors. Each team had at least one female data collector to ensure acceptance of the team amongst the surveyed households, particularly for IYCF questionnaires. Each female member of the survey team was accompanied with a mahram3 to facilitate the work of the female data collectors at the community level. The teams were supervised by ACF, Partner and PPHD staffs.
The entire teams received a 6-days training on the survey methodology and all its practical aspects; the training was facilitated by two ACF technical staffs. A standardization test was conducted over the course of 1day, measuring 8 children, in order to evaluate the accuracy and the precision of the team members in taking the anthropometrics measurements. The teams conducted a one-day field test in order to evaluate their work in real field conditions. Feedback was provided to the team in regard to the results of the field test; particularly in relation to digit preferences and data collection. Refresher training on the anthropometric measurement and on the filling of the questionnaires and the household’s selection was organized on the last day of the training by ACF to ensure overall comprehension before going to the field.
One field guidelines document with instructions and household definition and selection document was provided to each team member. All documents, such as local event calendar, questionnaires or consent forms were translated in Pashtu, local language, for better understanding and to avoiding direct translation during the data field collection. The questionnaires were back translated using a different translator and were pre-tested during the field test. Alterations were made as necessary.
Daily data entry and analysis were done using ENA for anthropometric data, plausibility check, and feedback were provided to the data collection teams. Anthropometric data was directly entered into ENA while IYCF and other data was completed through an excel spreadsheet.

Key findings: 

Results may not reflect the national nutrition situation and are representative of only for the entire Province of Uruzgan.
The results of the survey showed a level of Global Acute Malnutrition of 15.0% (12.3-18.2 95% CI) and Severe acute malnutrition (SAM) of 4.3% ( 3.0- 6.0 95% CI) based on weight for height, that according to the WHO classification is considered as above the emergency threshold. The GAM and SAM prevalence were respectively 21.6% (17.9 - 25.78 95 % CI), and 11.2 % (7.47 - 16.5 95%CI), in the last 2013 NNS
The GAM prevalence based on MUAC is 17.8% (14.7-21.3 95% CI) and SAM based on MUAC was of 4.4% (3.0- 6.2 95% CI) was slightly higher than WHZ based GAM, but insignificantly.
GAM and SAM prevalence based on MUAC and W/H combined revealed a percentage of 26.5 % (23.6 -29.5, 95 % CI) and 7.8 % (5.7-9.3, 95 % CI) respectively. The combined rate informs on estimated GAM and SAM caseload in the province for better programing. Only children in the sample were detected as acutely malnourished according to both criteria. To detect all acute malnourished children eligible for treatment, the MUAC only detection is not enough according criteria specified in Afghanistan IMAM Guidelines.
Further investigation of prevalence according to age, showed that both GAM WHZ and MUAC was higher in children under 2 years (WHZ based =19.0% within (15.0-23.7 95% CI) and MUAC based=34.9% with 28.3-42.1 95% CI) than to children over 2 years ( WHZ based =12.7% with 9.8-16.3 95% CI and MUAC based=6.8% with 5.0- 9.3 95% CI). This suggests higher vulnerability of younger children to wasting.
Chronic malnutrition in the province continue to be worrying. The results of the present survey showed that, based on WHO classification of severity of malnutrition, the overall prevalence of stunting was very high 49.0% (43.7-54.5 95% CI). One in every two children included in the survey were found to be stunted, while one in every three children was underweight.
Maternal nutritional status
There are no commonly accepted standards for maternal nutrition status. In surveys, the MUAC cutoff of 230 mm is used to approximately identify their status. This survey shows that 14.0% (11.0-17.2 95%CI) of the mothers suffered from malnutrition based on MUAC<230mm.
The main concern was iron supplementation among pregnant women, which the survey found to be low (57.6%). The Iron supplementation prevent anemia during pregnancy and eventual life-threatening complications during pregnancy and delivery. Therefore, it decreases maternal mortality, prenatal and perinatal infant loss and prematurity (that can be directly related to child stunting in the first 2 years of life).
Child health and immunization
The UNICEF conceptual framework of malnutrition can be used to explain the probable causes of under-nutrition in this area. Diseases weaken the individual immune system, increase nutritional needs and in the same time might be a reason of reduced food intake and absorption (diarrhea), engaging the body in a vicious circle with malnutrition. In the Uruzgan province, half of the sampled children (50.1 %) had suffered from one or another form of illness symptoms such as diarrhea (16.2%), fever (39.5%) or acute respiratory (27.7%) signs in the last 2 weeks prior the survey, suggesting quite high illness of basic treatable diseases.
It important to note that low child immunity system also contributes to increase the malnutrition, morbidity and mortality. The survey shows a BCG vaccination coverage of 66.2%, a measles vaccination coverage both by recall and by card confirmation of 65.5%, polio vaccination coverage of 81.9% and 62.5% for PENTA 3 vaccination that compared to national target 90 % is considered as low. Low immunization coverages contribute to increase morbidity and mortality rates.
Worm infection in children caused mal- absorption, which can aggravate malnutrition and anemia rates and contribute to retarded growth, child morbidity and mortality. Deworming is recommended for children from 24 to 59 months of age as children in this age group are considered as a potential risk of acquiring the disease. As deworming also helps to enhance the iron status of children which eventually helps children to exercise their intellectual ability to the completest. The proportion of all children aged 24-59 months who had received deworming in the last 6 month prior to the survey was low ( 57.9 %),
Improving the Vitamin A status of deficient children through supplementation enhances their resistance to disease and can significantly reduce mortality and morbidity, therefore it can be considered as a central element of the child survival program. The proportion of all children aged 6-59 months who had received vitamin A in the last 6 months prior to the survey was 56.5 %, which is lower than the SPHERE recommendation and WHO target of 80%.

Sample size: 
Assessment Report: 
Assessment Questionnaire: 
Publicly Available
Assessment Data: 
Publicly Available
Assessment Date(s): 
07 Feb 2018 to 26 Mar 2018
Report completed
Unit(s) of Measurement: 
Population Type(s): 
Children under 5
Lactating women
Pregnant women
Leading/Coordinating Organization(s): 
Action against Hunger
Participating Organization(s): 
Government of Afghanistan - Ministry of Public Health
Afghan Health & Development Services