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Nutrition & Mortality SMART Survey in Zabul Province (21 February 2018)

To determine the nutritional status of vulnerable population in Zabul province for future programming.
As the survey areas were large and the population was dispersed, the cluster sampling method was used. It was completed in two stages. Stage 1: Random selection of clusters/villages was chosen by using probability proportional to size (PPS) done by ENA for SMART software version 2011 of (9th July 2015). A list of all updated villages was entered into ENA for SMART software where PPS was applyied, so that the villages with a large population had a higher chance of being selected than villages with a small population and vice versa. Reserve Clusters (RCs) were also selected by ENA software version 2011(updated 9th July 2015), RCs were supposed to be selected only when 10% or more clusters would have been impossible to survey during data collection for any reason. RCs were not used as our non-response rate was at 0.9%, see Annex 3. 47 clusters have been covered and each survey team completed anthropometric measurements in 12 households in a day (566/12=47.1 clusters, rounded down to 47 Clusters). 566 HHs were planned to be surveyed according to ENA in the planning stage. In each selected village, one or more community members were asked to help the survey teams to conduct their work by providing information about the village with regard to the geographical organization and the number of households. In cases where there was large village in a cluster, the village was dividing into smaller segments and a segment was selected randomly to represent the cluster. This division was done based on existing administrative units e.g. neighbourhoods, streets or natural landmarks like a river, road or public places like market, schools, and mosques. Stage 2: Random selection of households from updated and complete list of households within a given village. The actual survey data collection incorporated 566 households randomly selected based on survey parameters calculation for anthropometric. Based on total sample size each team could cover effectively 12 households in a day. Six teams were engaged during the assessments, while data collection was expected to last for a maximum of 10 days. All households were enumerated and given numbers by the survey team. The 12 households were chosen randomly from these enumerated households, by systematic random sampling method to identify the households to be surveyed. The teams were trained in both methods of sampling (sample and systematic random sampling) and they were offered 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. If more than one eligible child was found in a household, both were included, even if there were twins. Eligible orphans living in the selected households were surveyed. All the selected HH included in the mortality survey, even if the targeted children were not present, were also surveyed for additional data related to WASH, FSL, HHs size, mortality, water storage and maternal health and nutrition status. Any empty households, absent households or HH with missing or absent children were revisited at the end of each day in each cluster; any missing or absent children that were not subsequently found were not included in the survey. A cluster control form was used to record all these cases, however the abandoned HH was excluded from the total HHs list at the beginning in the field. An elder of the villages provided this information to the teams. The household was our 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 has often defined and/or used synonymously with a compound – which potentially represents more than one household as defined here. In this case, a two-step process is 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 should be included in the study.
Key findings: 
The survey findings revealed that the Prevalence of Global Acute Malnutrition (GAM) and severe acute malnutrition (SAM) in children aged 6-59 months based on Weight for Height (WHZ) were at 11.2% (9.0-13.8 95% C.I.) while SAM prevalence is 3.2% (2.2.-4.7 95% CI.). This situation is “Serious” according to WHO classification of acute malnutrition. The prevalence of GAM based on MUAC cut-offs was 10.5% (8.5-13.0 95% C.I.) and SAM was at 3.5% (2.4-5.2 95% C.I.) respectively. The combine GAM and SAM prevalence based on MUAC and WHZ criteria was (n=160) 16.0% (13.7-18.3 95% CI) and (n=49) 4.9% (3.6-6.2 95% CI) respectively. The prevalence of stunting for children aged under 6-59 months was at 45.9% (42.3-49.6 95% CI), which is considered as very high public health problem according to WHO classification. It is important to consider the stunting situation in the province. Poor micronutrient supplementation and deworming, low maternal nutritional status as observed in Zabul province if not addressed can contribute to increasing the levels of chronic malnutrition. The fact that chronic malnutrition does not received appropriate attention in the health facilities could be a factor exacerbating the situation. Currently there is no clear guidance in Afghanistan on how to address chronic malnutrition. The prevalence of under nutrition of PLWs was 22.5% (19.0-26.0 95% CI) and low iron supplementation in the province. Crude Death Rate and Under-five Death rate were 0.48% (0.28-0.82 95% CI) with 1.95 design effect and under five mortality Rate was 1.15 (0.62-2.14) with a design effect of 1.25. The rates are both below SPHERE emergency thresholds. 37.7% of children reported to have been sick with fever, diarrhea and ARI, prior to the survey period.
Sample size: 
Assessment Report: 
Publicly Available
Assessment Questionnaire: 
Publicly Available
Assessment Data: 
Publicly Available
Assessment Date(s): 
03 Feb 2018 to 21 Feb 2018

Level of Representation

District / Province / Locality / County
Report completed
Unit(s) of Measurement: 
Collection Method(s): 
Field Interview
Population Type(s): 
Children under 5
Lactating women
Pregnant women
Leading/Coordinating Organization(s): 
Action against Hunger
Participating Organization(s): 
Organization for Research and Community Development (Afghanistan)
Government of Afghanistan - Ministry of Public Health