Nutrition and Health Survey

Badghis Province, Afghanistan

 

February – March 2002

 

 

 

A collaborative survey by:

 

UNICEF

and

U.S. Centers for Disease Control and Prevention (CDC)

 

 

The following persons authored this report and are responsible for its content:

 

Bradley A. Woodruff

Meredith Reynolds

U.S. Centers for Disease Control and Prevention

Atlanta, Georgia USA

 

Felicite Tchibindat

Cyridion Ahimana

UNICEF – Afghanistan Country Office


ACKNOWLEDGMENTS

 

Although this survey was funded by UNICEF, it was the work of many people from many organizations.  The authors thank those attended the workshop in Mazar-i-Sharif where many valuable suggestions were discussed (see appendix 1 for list of participants). 

            Many other UNICEF staff contributed to various aspects of this survey, including Peter Salama, Head of the Health and Nutrition Section of the UNICEF – Afghanistan Country Office. Dr. Simon Azariah of UNICEF and Dr. Mesfin Teklu of World Vision assisted with much of the preparatory work.  In addition, many UNICEF national staff did translations and backtranslations, provided the information necessary to construct the local calendar, and offered invaluable advice on all aspects of the survey. 

            The Ministry of Public Health of Herat Province provided the personnel who acted as survey team supervisors.  The Office of the Governor of Badghis Province, especially Mr. Zaudin, provided advice on logistic matters, including identification of the location of selected villages. 

            The Norwegian Project Office/ Rural Rehabilitation Association for Afghanistan (NPO/RRAA), the Danish Committee for Aid to Afghan Refugees (DACAAR), Ockenden International (OI), and Oxfam-UK provided lists of villages in Badghis Province.  These lists were essential to carrying out the survey sampling.

            Major partners of UNICEF provided general advice and overall coordination: the World Food Programme (WFP), the World Health Organization (WHO), and the United Nations Office for Coordination of Humanitarian Affairs (UNOCHA). 

The authors offer special thanks to the survey workers (listed in appendix 1) whose intelligence, dedication, and overall competence in the face of extreme logistical difficulties made this survey possible.


TABLES OF CONTENTS

                                                                                                                                                  Page

List of tables, figures, and appendices .....................................................................................     4

Executive summary...................................................................................................................     5

Introduction ................................................................................................................................     6

Goals and Objectives ................................................................................................................     6

Methods

      I.      Sample size and sampling ..........................................................................................     7

      II.     Data collection .............................................................................................................     8

      III..   Definitions  ...................................................................................................................     9

      IV.    Data analysis  ..............................................................................................................   10

Results

      I.      Description of survey population .................................................................................   10

      II.     Child nutrition ...............................................................................................................   11

      III.     Child health and vaccination ........................................................................................   12

      IV.    Women of reproductive age ........................................................................................   13

      V.    Morality .........................................................................................................................   13

Conclusions and Discussion

      I.      Household characteristics ...........................................................................................   14

      II.     Child nutrition ...............................................................................................................   14

      III.    Child health and vaccination ........................................................................................   16 

      IV.    Women of reproductive age ........................................................................................   16

      V.    Mortality ........................................................................................................................   17

Recommendations

      I.      Children ........................................................................................................................   17

      II.     Women ........................................................................................................................   18

      III.    General ........................................................................................................................   18

References ................................................................................................................................   19

Tables                                                                                                                                          ......................................................................................................................................   20

Figures                                                                                                                                          29

Appendix 1

Appendix 2

Appendix 3

Appendix 4


LIST OF TABLES, FIGURES, AND APPENDICES

                                                                                                                                                  Page

 

Table 1.     Description of households included in survey ........................................................   20

Table 2.     Description of children and women of reproductive age included in survey ..........   21

Table 3.     Prevalence of acute and chronic malnutrition and underweight

                  (as defined by z-score) in children less than 5 years of age, by age .....................   22

Table 4.     Prevalence of acute and chronic malnutrition and underweight

                  (as defined by % of median) in children less than 5 years of age, by age .............   22

Table 5.     Potential risk factors for acute and chronic malnutrition in children < 5 years

                  of age .......................................................................................................................   23

Table 6.     Possible signs of micronutrient deficiencies in children less than 5 years of age,

                  by age ......................................................................................................................   24

Table 7.     WHO breastfeeding indicators ................................................................................   25

Table 8.     Cumulative prevalence of diarrhea and pneumonia in previous 2 weeks in

                  children less than 5 years of age, by age ...............................................................   25

Table 9.     Reproductive outcomes among women of reproductive age .................................   25

Table 10.   Prevalence of various categories of malnutrition (as defined by BMI) in

                  non-pregnant women of reproductive age ..............................................................   26

Table 11.   Distribution of MUAC measurements in all women of reproductive age ................   26

Table 12.   Prevalence of various categories of malnutrition using the combination of

                  BMI and MUAC, non-pregnant women of reproductive age ....................................   27

Table 13.   Age- and sex-specific death rates since Eid Qurban 1379 (13-16 February 2001)   27

Table 14.   Distribution of causes of death, for deaths with cause determined,

                  by age group ............................................................................................................   28

 

Figure 1.    Population pyramid of survey sample

Figure 2.    Distribution of weight-for-height z-scores, children < 5 years of age

Figure 3.    Distribution of height-for-age z-scores, children < 5 years of age

Figure 4.    Distribution of weight-for-age z-scores, children < 5 years of age

Figure 5.    Percent (3-month moving average) of children eating solid food, by age

Figure 6.    Percent (3-month moving average) of children breastfeeding, by age

Figure 7.    Distribution of BMI values in non-pregnant women of reproductive age

Figure 8.    Number of deaths, by month

 

Appendix 1.     Persons who attended the Mazar workshop and members of survey teams

Appendix 2.     List of villages included in survey

Appendix 3.     Data collection form in English

Appendix 4.     Questions used for verbal autopsy

 


EXECUTIVE SUMMARY

 

            This 30 cluster survey of Badghis province, the first province-level assessment of nutrition and health since the change of government in Afghanistan, was designed to establish baseline data on the nutritional status of children and women and the level and causes of mortality.  Data were collected 17 - 31 March 2002 on 507 households with 545 children less than 5 years of age and 555 women 15 – 49 years of age.  Major findings are summarized below:

 

Indicator

Value

Household characteristics

           

Percent of households using safe water source

5.2%

Percent of households using iodated salt

2.4%

Child Nutrition and Health (< 5 years of age)

 

Prevalence of acute malnutrition                                       0 – 11 months
                                                                                         12 – 23 months
                                                                                         24 – 59 months

                                                                                                      All ages

4.6%

16.0%

3.3%

6.5%

Prevalence of chronic malnutrition                                    0 – 11 months
                                                                                         12 – 23 months
                                                                                         24 – 59 months

                                                                                                      All ages

26.7%

59.5%

64.9%

57.5%

Prevalence of at least one sign of vitamin deficiencies             Vitamin A
                                                                                                   Vitamin C
                                                                                                   Vitamin D

                                                                                                   Riboflavin

2.6%

3.1%

3.9%

8.5%

WHO breastfeeding indicators:                          Exclusive breastfeeding
                                                                       Predominant breastfeeding
                                                                 Timely complementary feeding
                                                             Continued breastfeeding – 1 year
                                                           Continued breastfeeding – 2 years
                                                                                            Bottle feeding

95%

100%

21%

96%

52%

7%

Cumulative prevalence of diarrhea in prior 2 weeks

29.8%

Cumulative prevalence of acute respiratory infection in the prior 2 weeks

33.8%

% recently vaccinated against measles

59.4%

% ever vaccinated against TB

13.5%

Women’s Nutrition (15 – 49 years of age)

 

BMI                                                                                                  < 16.0                                                                                                16.0 – 16.9

                                                                                                17.0 – 18.4

                                                                                                        > 18.5

3.2%

2.3%

13.1%

81.5%

MUAC                                                                                              < 22.0

17.1%

Mortality

 

Mortality Rate (deaths / 10,000 / day)                                             Crude                                                                                     Children < 5 years

0.72

2.51

Causes of death in children < 5 years of age                        Pneumonia

                                                                                        Watery diarrhea

                                                                                         Bloody diarrhea

                                                                                                     Measles

                                                                                                  Meningitis

                                                                                                       Malaria

                                                                                                     Tetanus

                                                                                                          Injury

                                                                                                         Other

19%

6%

21%

6%

9%

8%

6%

2%

25%


INTRODUCTION

 

            For decades, Afghanistan has been one of the world’s poorest countries with the worst health statistics.  Health problems in the country’s population, already significantly exacerbated by more than 20 years of civil conflict, have recently been further worsened by 3 years of severe drought and the military conflict following the events of September 11, 2001.  An estimated six million people have little or no access to health care [1], while an estimated seven million rely on food aid to survive.  Many available health statistics, such as the estimate of infant mortality rate of 220 per 1000 live births and maternal mortality rate of 1700 per 100,000 live births [2], are outdated and were originally based on local data collections or estimates.  Several local surveys, conducted in various parts of Afghanistan, have demonstrated acute malnutrition and high crude mortality rates [3, 4]

Based on these surveys, it is estimated that an average of 10% of children less than five years of age are acutely malnourished, of which 2% are severely malnourished.  Reports of declining nutritional status of children and women are increasingly common, particularly from the western and northern regions of the country, and many humanitarian aid organizations have implemented feeding programs and intensified food distributions in these regions. UNICEF, along with participating partners, including WFP and national and international non-governmental organizations, have developed a Concept Paper proposing a framework for nutritional surveillance composed of 1) monthly nutritional status information from health centers, 2) cross-sectional quantitative surveys, and 3) community-based sentinel site nutritional surveillance.  This survey of Badghis province represents one of the first population-based surveys and can serve as a model for subsequent province-level surveys.

 

 

GOALS AND OBJECTIVES

 

            The overall goal of this survey is to assess the health and nutritional status of children less than 5 years of age and women of reproductive age (15 – 49 years of age).  This assessment will be used to establish baseline data for a nutritional surveillance system and to provide recommendations to national and international organizations providing health and nutrition services.

 

The specific objectives of this survey are to estimate:

·         The prevalence of salt iodation

·         The prevalence of acute and chronic malnutrition in children less than 5 years of age

·         The prevalence of clinically apparent anemia and vitamin deficiencies (riboflavin and vitamins A, C, and D) in children less than 5 years of age

·         WHO breastfeeding indicators

·         The two-week cumulative prevalence of diarrhea and acute respiratory infection in children less than 5 years of age

·         The prevalence of malnutrition in women of reproductive age (15-49 years of age)

·         The prevalence of iodine vitamin A deficiency in women of reproductive age

·         The reproductive history of women of reproductive age

·         Crude mortality rate and causes of death

·         Age-specific mortality rates, including the mortality rate among children less than 5 years of age

·         The coverage of recent measles vaccination campaigns among children 9 months to 5 years of age

 

METHODS

 

I.  Sample size and sampling

 

Sample size calculations used the following assumptions: 1) the limit of statistical significance (alpha) is 0.05 (that is, 95% confidence interval will be used), and 2) the power (beta) equals 0.8.  The UNICEF Multi-Indicator Cluster Survey (MICS) [5] completed in 2000 in six provinces in Eastern Afghanistan provided estimates of prevalence and demographic data which we used to formulate assumptions for sample size calculations.  We assumed an average of 1.3 children less than 5 years of age and one woman 15-49 years of age per household.  Because the sample size required to achieve a given statistical precision increases as the estimated prevalence approaches 50%, the assumed prevalence rates for this survey were assumed to be closer to 50% than those found in the MICS. 

 

Assumptions and estimated sample size for nutrition outcomes, Badghis Nutrition and Health Survey, March 2001. 

 


Target group and indicator

Assumed current value

DEFF* assumed


Precision

Sample size

Children 0-59 months

Acute malnutrition (< -2 SD)

Anemia (<11.0 g/dl)

 

 

20%

50%

 

 

2

2

 

 

±5

±6

 

492

534

Women of reproductive age

Malnutrition (BMI <17 or MUAC < 22.0)

Anemia (<12.0 g/dl)

 

20%

50%

 

2

2

 

±5

±6

 

492

534

    *    DEFF = Design effect

  

Because the primary objective of this survey was to measure nutritional status of young children, the final sample size used was based on nutrition outcomes in young children.  The largest sample size (n=534) is needed to obtain an estimate of the prevalence of anemia.  Because emigration from Badghis Province has been extensive in recent years, we assumed that 25% of households would be unreachable.  With an average of 1.3 children less than 5 years of age per household and household absenteeism or non-response of 25%, a total of 534 households are needed to find 534 children.  These households were to be grouped into 30 clusters of 18 households each.   This would result in a precision of ±4 percentage points for acute malnutrition in children assuming an estimated prevalence of 20%.  Approaching 18 households per cluster should result in a total of 684 women of reproductive age included in the survey.  This would result in a precision of ±5 percentage points for anemia, assuming a prevalence of 50%.  Assuming a cumulative incidence of death of 5.7% (crude mortality rate equivalent to 1.5 deaths per 10,000 population per day), a sample of 534 households with an average of 6 persons per household would yield 1,217,520 person-days of experience and 183 deaths.  If the design effect for mortality were 2, the precision around a point estimate of 1.5 deaths per 10,000 per day would be ±0.3.  Although the sample size was based on anemia prevalence, because the equipment and supplies for measuring hemoglobin concentration were unavailable at the time data collection began, this survey did not collect these data.

Lists of all villages in each district in Badghis Province were obtained from organizations responsible for relief food distribution.  These organizations had recently registered every village in Badghis Province and the number of households contained therein.  In the first sampling stage, 30 clusters were selected after constructing a single list of all villages in Badghis Province, the number of households in each, and a column of cumulative sums.   Sampling probability proportional to size was done by calculating a sampling fraction (the total number of households in Badghis Province divided by the number of clusters [30]), and adding this sampling fraction repeatedly to an initial random number.  Each village in which the resulting number fell became the site for one cluster.  No village contained more than one cluster.  Because population estimates were not available for Qala-e-Nau town at the time of sampling, it was not included in the sampling frame.  However, its 2000 households do not constitute a large proportion of the estimated 114,000 households in Badghis Province.  Appendix 2 shows a list of the villages selected for clusters.  Two villages in Ghormach District were felt to be inaccessible due to security risk.  Two other nearby villages were substituted for them.  

For the second sampling stage, a mullah, abob, or other village leader was asked to provide a preexisting list of all households in each village or to help create one.  The households on the list were then numbered, and 18 households were selected using a random number table.  In each village, it was confirmed that all households currently residing in the village were included on the list of households.  Any missing households, such as recent returnees, were added to a preexisting list.  In villages containing more than 200-300 households, village leaders helped create a list of mosques with the number of subscribing households in each.  Similar to the first stage sampling, one mosque was then chosen probability proportional to size.  All households subscribing to this mosque were then listed, and 18 selected as described above.

A household was defined as any group of persons occupying the same structure and sharing household resources, such as food and bedding.  Members of a household were not necessarily relatives by blood or marriage.  If no one was at home at a selected house, a neighbor was consulted concerning the whereabouts of members of the household.  If the members had departed permanently or were not expected to return before the survey team had to leave the village, the household was skipped and not replaced.  If household members were expected to return, the survey team revisited the house at least twice more before declaring the household missing.

 

II.  Data collection

 

            A data collection tool was created after consultation with national and international organizations providing nutrition and health services to the population of western Afghanistan.  The types of data collected conform to the recommendations of the February meeting in Kabul of organizations working in nutrition and food.  The entire form was translated from English into Dari, the major language of Badghis province, and then back-translated into English by a second translator (see appendix 3 for the English form).  The survey instrument was pretested in 9 households in a village near Herat City which were not included in the survey, and revisions were made based on this experience. 

Data were collected by 5 teams of 4 persons each.  Each team included a supervisor, a logistics coordinator, and two interviewers (one female and one male).  All supervisors were medical doctors.  All survey workers received 4 days of classroom training and 1 day of field practice training under close supervision.  During data collection for the first cluster done by each team, an expatriate supervisor or consultant from UNICEF monitored each team.

At each household, interviewers asked questions about displacement and water source for the household.  In addition, a household census was taken as of Eid Qurban of the previous year (1379 in the Afghan calendar; 13-16 February 2001 in the Gregorian calendar). Births and deaths occurring in each household between Eid Qurban and the date of the survey were recorded along with month of occurrence. A local calendar of events was used to determine ages of household members and dates of death.  The cause of each death was classified into 1 of 11 categories (war related injury, non-war related injury, measles, tetanus, watery diarrhea, dysentery, meningitis, pneumonia, malaria, scurvy, or other) using a hierarchical series of questions adapted from a WHO recommended protocol for verbal autopsies (see appendix 4 for the questions used). [6]  A sample of salt from each selected household was tested for iodine content.

            Survey workers asked questions of each woman of reproductive age in each household regarding nightblindness, number of pregnancies, number of births, date of last delivery, and tetanus vaccination history.  In addition, an examination for goiter was performed and each woman had mid-upper arm circumference (MUAC), height, and weight measurements taken.

Information was gathered from an adult household member, preferably the mother, on each child less than 5 years of age regarding nightblindness, breastfeeding history, vitamin A supplementation and vaccination history, and recent diarrhea and acute respiratory infection.  Because vaccination cards have not been issued during recent mass immunization campaigns, mothers' reports were taken as evidence of vaccination against measles and receipt of vitamin A supplementation.  BCG vaccination was confirmed by examination for a characteristic scar on the child’s left arm. 

The physician supervisor performed a physical examination targeted to signs of micronutrient deficiency.  Survey workers then measured the child’s weight and height.   Children less than 5 years of age and women of reproductive age were weighed to the nearest 100 grams with UNICEF Uniscale.  For children less 24 months of age, length was measured to the nearest millimeter in the recumbent position using a standard height board.  Children 24 months of age or older were measured in a standing position.  Women’s height was measured using a portable stadiometer while the woman was standing against a vertical surface or support.  MUAC in women was measured using a standard measuring tape. 

 

III.  Definitions

 

Z-scores were used in most analyses of anthropometric data on children in this survey. However, percent of median is used in many situations where a simpler calculation is needed, such as screening for admission to feeding programs.  Therefore, for purposes of comparing the results of this survey to other data, the prevalence rates of acute and chronic malnutrition and underweight are also presented percent of median.  The relevant definitions are as follows:

 

Type of malnutrition

Anthropometric index

Degree of malnutrition

Definition using z-score

Definition using percent of median

 

 

None

> -2.0

> 80%

Acute

Weight-for-height

Moderate

> -3.0 but < -2.0

> 70% but < 80%

 

 

Severe

< -3.0 or edema

< 70% or edema

 

 

None

> -2.0

> 90%

Chronic

Height-for-age

Moderate

> -3.0 but < -2.0

> 80% but < 90%

 

 

Severe

< -3.0

< 80%

 

 

None

> -2.0

> 80%

Underweight

Weight-for-age

Moderate

> -3.0 but < -2.0

> 70% but < 80%

 

 

Severe

< -3.0

< 70%

 

Z-scores and percent of median were derived from comparison of children in the survey sample to the NCHS/CDC/WHO reference population.[7] 

            Malnutrition among non-pregnant women of reproductive age was assessed using BMI WHO-recommendationed categories.[7]  Body mass index (BMI) was calculated as weight in kilograms divided by the square of the height in meters.

 

BMI                              Category of malnutrition

               < 16.0                                   Severe thinness

               16.0 – 16.9                           Moderate thinness

17.0 - 18.4                            Mild thinness

                                    18.5 - 24.9                            Normal

                      25.0 - 29.9                            Overweight

                      > 30                                      Obese

 

            This report presents the proportion of non-pregnant and pregnant women who have MUAC measurements less than 22.0 cms; however, because no consensus exists regarding the cut-off points for MUAC for adults, the distribution of MUAC results is also presented.

Malnutrition in non-pregnant women of reproductive age was also defined using a combination of BMI and MUAC [8], as follows :

 

Categories of nutritional status using a combination of BMI and MUAC

 

BMI

 

MUAC

Normal

>18.5

At risk

17.0 - 18.4

Moderate

16.0 - 16.9

Severe

<16.0

< 22.0

Normal

Normal?

Mild

(Category I)

Moderate (Category II)

> 22.0

Normal?

Mild

(Category I)

Moderate

(Category II)

Severe

(Category III)

 

Although not considered normal nutritional status, the health consequences among persons in the category “Normal?” have not been determined. 

 

V.  Data analysis

 

            Data were keypunched and analyzed using EpiInfo version 6.04b. The calculation and analysis of anthropometric indices was carried out using the Epinut module.  Indicators of the precision of prevalence estimates, such as confidence intervals, for major health outcomes accounted for the cluster sampling and implicit stratification used in selecting the sample for this survey.  Stratification was achieved because the list of villages was first ordered by district before selecting the first stage sample.  A p value <0.05 was considered to be statistically significant.  The strength of association between potential risk factors and various outcomes was estimated using relative risks, and 95% confidence intervals (CI) were used to judge the statistical precision of point estimates for relative risks.

 

 

RESULTS

 

I. Description of survey sample

 

Households

            The survey sample included 507 households.  Interviews were done by female survey workers in 359 (70.8%) households and by male survey workers in the remaining households.  Few households were displaced from their homes at the time of the survey (table 1).  The most common primary source of water for the majority of households was rivers and streams.  Overall, only 26 (5.1%) of households obtained water from a safe source (borehole, truck, or piped system).  The current source of water was the same as in the previous years for most households.  The mean average time required to bring water to the household was 94 minutes.  Although the majority of households had water within a 1 hour round trip, more than one-quarter required more 2 hours. About one-half of all households had received some form of food aid since the change in government that occurred in October 2001.  Iodine was present in the salt of very few households.

 

Individuals

Overall, the survey collected data on 3075 members of selected households; these household members included 1529 (49.8%) males, 1542 (50.2%) females, and 4 for whom sex was not recorded.  A population pyramid for these household members is shown in figure 1.  

The survey collected more detailed data on 545 children less than 5 years of age.  For 528 (97.1%) of these children, interviews were conducted with the mother.  For 10 (1.8%) children, the mother was not alive at the time of the survey.  The age distribution of children is shown in table 2.  Among these children, 240 (44.1%) were boys, 304 (55.9%) were girls, and 1 did not have sex recorded; 59 (10.8%) children were 0 – 6 months of age.   The survey sample also included 565 women of reproductive age.  The distributions of age and literacy of these women are shown in table 2.  The large majority of women were not literate. 

 

II.  Child nutrition

 

Acute malnutrition

Acute malnutrition was not common in children less than 5 years of age (table 3).   Of those children with acute malnutrition, 6 (17%) had edema.  Among children without edema, the mean weight-for-height z-score is -0.28 and the standard deviation is 1.1.  The prevalence of acute malnutrition is greatest among children 12 – 23 months of age.  In other age groups, the prevalence of acute malnutrition is not statistically significantly greater than that found in the reference population (2.3%).  Among all children less than 5 years of age, the prevalence is not statistically higher among the 301 girls (7.0% with acute malnutrition) than among the 238 boys (5.9%).  The distribution of weight-for-height z-scores is shown in figure 2.  The entire curve for the survey sample is slightly shifted to the left when compared to that of the reference population. 

 

Chronic malnutrition

Chronic malnutrition was much more common that acute malnutrition (table 3).   A greater proportion of children had severe chronic malnutrition than moderate chronic malnutrition.  The mean height-for-age z-score in the survey sample is –2.19 and the standard deviation is 1.59.  This elevated standard deviation demonstrates that either height or age may not be determined with precision.  The prevalence of chronic malnutrition increases with age.  Chronic malnutrition was somewhat more common in boys that in girls (147 [61.8%] vs. 162 [54.2%], respectively (relative risk = 1.1, 95% confidence interval = 0.99, 1.3).  The distribution of height-for-age z-scores is shown in figure 3.  The entire curve for the survey sample is substantially shifted to the left when compared to that of the reference population, demonstrating that virtually all the children in the survey sample have some degree of chronic malnutrition. 

 

Underweight

Underweight is also very common in the survey sample (table 3).   The mean average weight-for-age z-score in the survey sample is –1.57 and the standard deviation is 1.34.  The distribution of weight-for-age z-scores is shown in figure 4.  The entire curve for the survey sample is substantially shifted to the left when compared to that of the NCHS/CDC/WHO reference population, demonstrating that virtually all the children in the survey sample have some degree of low weight. 

 

Percent of median

            The prevalence rates of acute and chronic malnutrition and underweight as expressed in percent of median are presented in table 4. 

 

Risk factors for acute and chronic malnutrition

            The association between potential risk factors and acute and chronic malnutrition is shown in table 5.  Few of the potential risk factors analyzed demonstrate an association with either acute or chronic malnutrition.  Nevertheless, none of the eight children of literate mothers were acutely malnourished, and a smaller proportion of children of literate mothers than children of illiterate mothers had chronic malnutrition, albeit without statistical significance.  Mother's who were malnourished, as measured by BMI, were more likely to have acutely malnourished children.  Receipt of relief food was inversely associated with acute malnutrition and not at all associated with chronic malnutrition. 

 

Micronutrient deficiencies and supplementation

      Vitamin A.  The prevalence of night blindness and Bitots spots is shown in table 6.  Mothers of 145 (26.6%) children could not answer the question regarding night blindness, usually because these children were too young to determine if night blindness existed.  Among all children less than 5 years of age, 295 (55.6%) had received vitamin A supplementation at any time in their lives. 

      Vitamin C.  The prevalence of signs of vitamin C deficiency is shown in table 6.  Signs of scurvy were more common in children 12 months of age or older than in infants less than 12 months of age.

      Vitamin D.  The prevalence of major signs compatible with vitamin D deficiency is shown in table 6.  As with vitamin C, signs of vitamin D deficiency were more common in children 12 months of age and older than in infants. 

      Riboflavin.  The prevalence of angular stomatitis, one sign of riboflavin deficiency, is shown in table 6. 

      Anemia.  The prevalence of pallor is shown in table 6.  Despite the fact that this sign is only consistently found in children with more severe anemia, it was found relatively commonly in the survey sample. 

 

Infant feeding 

The breastfeeding indicators recommended by WHO are shown in table 7.  Exclusive and predominant breastfeeding are very common.  In contrast, timely complementary feeding is not common.  Breastfeeding at 1 year of age is nearly universal, and at 2 years of age, about one-half of children are still breastfeeding.  Few children less than 12 months of age have received feeding from a bottle with a nipple.  The mothers of only 3 (0.6%) children report giving formula or dried milk to their children. 

The mean and median time betweeen birth and first breastfeeding was 13.1 and 3.0 hours, respectively.  Overall, 175 (79%) of 222 breastfeeding children had initiated breastfeeding by 24 hours after birth.  Figures 5 shows the proportion of children, by age, who eat solid or semi-solid food.  Figure 6 shows the proportion who are still breastfeeding.  From these figures, the median age of introduction of complementary food is 10-11 months, and the median age of weaning is 20-23 months.

 

III.  Child health and vaccination

 

Childhood morbidity  

Overall, a large proportion of children less than 5 years of age had had diarrheal disease or acute respiratory infection in the 2 weeks prior to the survey (table 8).  However, relatively few children with these illnesses were taken to a health facility.   

 

Vaccination 

Measles.  The mothers of only 277 (59.4%) children 9-59 months of age reported that the children had been vaccinated since October 2001.  The mass vaccination campaign recently completed in Badghis Province targeted children 9 months to 14 years of age. 

BCG.  Only 73 (13.5%) children had a scar indicating BCG vaccination at some time in their lives.

 

IV. Women of Reproductive Age

 

Reproductive history

            Overall, 78 (14.0%) women of reproductive age were pregnant at the time of the survey (table 9).  The highest prevalence of pregnancy is found in the age groups 25-29 and 30-34 years.  Pregnancy is less common in women 40 years of age and older.  As expected, the average number of pregnancies and births increases with age; it reaches a plateau in women 40-44 years of age.  For women less than 35 years of age, the prior delivery was an average of less than 2 years prior to the survey. 

 

Nutritional status

            BMI.  The prevalence of various degrees of malnutrition, as defined by BMI, among non-pregnant women of reproductive age is shown in table 10.  The overall prevalence of undernutrition in non-pregnant women of reproductive age was not greatly elevated; however, a much larger proportion are at nutritional risk.  The distribution of BMI values in this group is shown in figure 7.  Among non-pregnant women of reproductive age, the mean and median BMI were 21.1 and 20.6, respectively, and the range of BMI values was 14.0 - 33.4. 

MUAC.  The distribution of MUAC in all women of reproductive age is shown in table 11.  Overall, 95 (17.1%) women had a MUAC < 22.0 cms.  Among all women of reproductive age, the mean and median MUAC values were 23.9 cms and 23.8 cms, respectively, and the range was 15.0 - 34.6 cms. 

BMI/MUAC.  The proportion of non-pregnant women of reproductive ages who fall into various categories using the combined BMI and MUAC criteria is shown in table 12. 

Micronutrient deficiencies.  Among women of reproductive ages, 62 (11.5%) had detectable goiter, indicating substantial iodine deficiency and a risk of having iodine-deficient children at birth.  Additionally, 26 (4.7%) women reported having nightblindness, a symptom of vitamin A deficiency. 

 

V. Mortality

 

            The crude mortality rate in the survey sample between Eid Qurban 1379 (13-16 February 2001 in the Gregorian calendar) and the time of the survey was 0.72 deaths per 10,000 population per day.  This crude mortality rate corresponds to rates of 2.2 deaths per 1000 per month and 26.3 deaths per 1000 per year.  Age- and sex-specific mortality rates are shown in table 13.  The age-specific mortality rate for children less than 5 years of age (2.51 per 10,000 per day) is substantially higher than the rates in other age groups.  The mortality rate for children < 5 years of age corresponds to rates of 7.6 deaths per 1000 children < 5 years of age per month or 91.6 deaths per 1000 children < 5 years of age per year.  The distribution of deaths over time is shown in figure 8.  With the exception of March 2001, deaths are not markedly clustered over time. 

For all deaths, including those for which cause was not determined, 55 (65%) occurred in children less than 5 years of age, and 8 (9%) occurred in person 50 years of age and older.  Shown in table 14 is the distribution of causes of those deaths for which a cause was determined by verbal autopsy.  For all ages combined and for children less than 5 years of age, bloody diarrhea and pneumonia were the most common causes of death identified by verbal autopsy. 

Information on nutritional status was collected for 67 (79%) of the 85 deaths identified in the survey.  Malnutrition was reported to be an aggravating factor among 38 (57%) of these 67 deaths and in 25 (58%) deaths in children less than 5 years of age.  Among the seven deaths of women of reproductive age for whom pregnancy or delivery status is known, 2 (22%) were, at the time of death, pregnant or within 40 days of giving birth

 

 

CONCLUSIONS AND DISCUSSION

 

I.            Household characteristics

 

Water supply

        Overall, the accessibility and quality of water is poor for households in Badghis Province.  Most households depend on unsafe sources for their water supply.  Moreover, the members of many households spend substantial time obtaining this water. 

 

Food

        Food aid has not been universally received by households in Badghis Province.  Iodine is virtually absent from salt consumed in Badghis households. 

 

II.     Child nutrition

 

Acute malnutrition

            Acute protein-energy malnutrition, although not uncommon, is not currently an overwhelming public health problem among children less than 5 years of age in Badghis Province.  Among these children, only children 12-23 months of age appear to be at elevated risk of acute malnutrition.  Infants less than 12 months are not at disproportionate risk. 

            The shape of the distribution curve of weight-for-height z-scores and the relatively low standard deviation imply that the anthropometric measurements taken during the survey are relatively precise.  Moreover, these measurements are probably accurate given that Uniscales were used to measure weight and survey supervisors carefully checked the accuracy of the height boards used to measure height and length.

            In some severe emergency situations elsewhere, high mortality among children less than 5 years of age has decreased the apparent prevalence of acute malnutrition.  Malnourished children had died, leaving only those with better nutritional status to be measured in a survey.  However, this is probably not the situation in Badghis Province given the mortality rate measured in children less than 5 years of age.  Although this rate is elevated above baseline, it is not nearly as high as the age-specific mortality rates measured in the extreme situations mentioned above.

            The level of acute malnutrition among children in Badghis Province may not, in and of itself, justify extensive feeding programs.  Nonetheless, communicable diseases, especially dysentery, can, even in the absence of severe food shortage, have an important affect on nutrition status.  The level of morbidity and mortality due to pneumonia and diarrhea in Badghis Province, in combination with the somewhat elevated prevalence of acute malnutrition, may justify enrollment of malnourished children in targeted supplementary feeding programs.  Moreover, a small hospital-based therapeutic feeding program may be necessary for the relatively few children with severe acute malnutrition.  Nonetheless, there is little justification for blanket supplementary feeding or implementation of specialized therapeutic feeding centers.

 

Chronic malnutrition

            In contrast to acute malnutrition, chronic malnutrition is a very common problem affecting all age groups of children less than 5 years of age.  The prevalence of severe chronic malnutrition among children 12 months of age and older is of special concern.  Nonetheless, the wide standard deviation of height-for-age z-scores and their skewed distribution indicate that this index was not measured with adequate precision.  Most mothers could not produce documentation of their children's dates of birth nor state a specific date of birth. Moreover, reported ages showed a strong preference for certain ages.  More than 3% of the 545 children were 14, 24, 26, 35, or 48 months of age.  If the number of births were constant over time for this age cohort, only 1.7% of the sample should be of any specific age.  As a result, the results of this survey should not be used as a specific baseline against which to evaluate current or future interventions targeted toward chronic malnutrition.          Regardless of these limitations, the very low height-for-age z-scores found in this survey, as well as data from other sources, indicate a long-standing chronic nutrition problem among children less than 5 years of age in Afghanistan in general. 

 

Risk factors for malnutrition

            The lack of association between receipt of food aid and either acute or chronic malnutrition in children may indicate that one-time or sporadic food distributions, as carried out in Badghis Province this past winter, have had no effect on children's nutritional status. 

            There is a clear association between mothers' nutritional status and the presence of acute malnutrition in their children less than 5 years of age.  Unfortunately, a cross-sectional survey cannot determine if this is a cause-effect relationship.  It may be true that in households with insufficient food, all members become malnourished.  On the other hand, there may be mechanisms by which maternal nutritional status may directly influence child nutrition status.  Regardless, provision of food to households with malnourished members may assist in the recovery of all malnourished household members.

 

Micronutrient deficiencies

            Signs and symptoms of several micronutrient deficiencies are not uncommon among children less than 5 years of age in Badghis Province.  The prevalence of Bitots spots exceeds the widely accepted threshold of 0.5% which defines vitamin A deficiency as a public health problem.  In addition, only about one-half of children have received vitamin A supplementation at any time in their lives. 

            The gum signs of scurvy are present in children less than 5 years of age, especially in children older than 12 months.  However, these signs may be due to many conditions, such as poor oral hygiene.  The more specific signs, including widespread bruising and perifollicular hemorrhage, are absent or much less common.  Although scurvy has been widely reported in western and central Afghanistan, the results of this survey do not clearly indicate that scurvy is a widespread, serious problem in Badghis Province in children less than 5 years of age at this time. 

            On the other hand, relatively specific signs of rickets, including rachitic rosary at the rib-cartilage junction and bowed legs, are more common.  This may indicate that vitamin D deficiency is a problem among children less than 5 years of age, especially those 24 months of age and older.  In other countries, vitamin D deficiency is a seasonal condition which largely resolves in the summer months when children spend more time outdoors in sunlight. 

            Although angular stomatitis is present in children in Badghis Province, it can result from may causes, including fungal infection, iron deficiency, and others.  In populations with widespread riboflavin deficiency, angular stomatitis can often be identified in a much larger proportion of the population.  For example, in Bhutanese refugee adolescents, angular stomatitis was found in 29% of those included in a population-based random sample.[9]   For these reasons, we cannot definitively conclude from the results of this survey that riboflavin deficiency is a serious or widespread public health problem in young children in Badghis Province

            Pallor is usually noted only in persons with moderate and severe anemia.  For this reason, the prevalence of 8.5% noted in this survey indicates that anemia may be quite common in children less than 5 years of age in Badghis Province.  The most likely cause of anemia is iron deficiency, and other causes are probably much less common.  The climate in Badghis Province may be incompatible with widespread helminth infection; helminth eggs generally do not survive cold winters or dry conditions.  Moreover, because the survey was done at the end of winter, malaria infection was probably rare. 

 

Infant feeding

            Overall, breastfeeding is widespread and prolonged in Badghis Province, and feeding with formula or dried milk and use of a baby bottle are very uncommon.  Introduction of complementary foods is recommended by age 6 months; however, in Badghis Province, complementary foods are not introduced early enough in infancy for many children.  Because this survey collected no data on the types of complementary foods, we can make no conclusions regarding the quality of complementary feeding.

 

III.  Child health and vaccination

 

Diarrhea and acute respiratory infection appear to be very common in children less than 5 years of age in Badghis Province during the weeks before survey data collection.  Moreover, these illnesses cause the majority of deaths in this age group. 

Measles vaccination coverage is poor and is probably not interrupting measles virus transmission.  Although some clusters, and therefore villages, have nearly universal coverage, there were many more which had intermediate or no coverage.  Moreover, measles accounted for 6% of deaths in children less than 5 years detected by the survey. 

The lack of BCG vaccination indicates that post-natal care is inadequate.  Presumably, the coverage for DPT vaccine, which is also given early in infancy and is not included in mass vaccination campaigns, is also very low. 

 

IV.  Women of reproductive age

 

Nutritional status

            The prevalence of severe and moderate malnutrition among women of reproductive age in Badghis Province is not greatly elevated; however, many women have mild malnutrition or may be at risk of malnutrition.  The mean BMI of 21.1 is lower than that found in China among women of reproductive age (21.2 - 21.7).[10]

            Iodine deficiency is a serious health problem among women as indicated by the high prevalence of goiter.  Nonetheless, the prevalence of goiter derived from this survey may be underestimated.  Although women were examined by physicians, these survey workers did not receive extensive training in examination for goiter and may have missed milder degrees of thyroid enlargement.  Iodation of salt used in Badghis Province would be difficult because most is in rock salt form and obtained from deposits in western Afghanistan by small harvesters and vendors. 

Many women reported nightblindness.  Although a specific word exists in the Dari language for this condition, some survey interviews were conducted in other languages, including Pushto and Uzbek.  It is not known whether the identification of nightblindness during these interviews was also based on a widely known local term.  

 

V.  Mortality

 

            The estimated crude mortality rate from this survey is somewhat elevated above 0.5 deaths per 10,000 per day, the widely accepted background rate in less-developed countries with young populations.  However, it does not exceed the emergency threshold of 1.0.

The mortality rate for children less than 5 years of age is substantially elevated above the background rate of 1 death per 10,000 per day.  Moreover, the estimated rate is almost statistically significantly greater than the widely accepted threshold defining an emergency situation (2.0 deaths per 10,000 children less than 5 years of age per day). 

     These rates demonstrate that the population of Badghis Province is in a condition of generally poor health.  The predominant causes of death are preventable and treatable communicable diseases. 

 

 

RECOMMENDATIONS

 

I.  Children

 

1)      In those areas judged to have substantial food insecurity, a regular supply of adequate food should be ensured.  Food self-sufficiency should be encouraged in all communities in Badghis Province.  Single blanket distributions of food probably have little impact on nutritional status and should be discouraged.

2)      If specific programs are implemented to address the nutritional status of children less than 5 years of age, they should also target the mothers of identified children. 

3)      A further investigation should be done of the prevalence, severity, and causes of anemia in children.  This investigation should include measurement of hemoglobin concentration in a representative sample of children.  Because iron deficiency is the most likely cause of anemia in Badghis Province, all health facilities should stock iron supplementation tablets or capsules for oral administration to those children with identified anemia and those at risk of developing anemia.  No specific interventions, such as routine deworming or use of bednets, should be implemented before the specific causes of anemia among children in Badghis Province are further understood.

4)      All wheat flour distributed to the population in Badghis Province, either in general distribution, supplemental feeding programs, food-for-work programs, or other programs, should be fortified with iron to international standards.

5)      An investigation of vitamin A status of children less than 5 years of age should include measurement of serum retinol concentration or other appropriate laboratory test.  Routine vitamin A supplementation should be encouraged in the meantime.

6)      Reported increases in the number of cases of scurvy should be promptly investigated.  Consideration should be given to supplying all health facilities with vitamin C tablets for treatment of scurvy cases and prevention of scurvy in those persons felt to be at risk.

7)      In the long term, health education should be provided to prospective or new mothers to encourage the earlier introduction of quality complementary food to infants. 

8)      Post-natal health services should be made accessible to mothers and newborns. 

9)      A mass measles vaccination campaign should be repeated in Badghis Province as soon as possible.  This campaign should also include vitamin A distribution for children less than 5 years of age. 

 

II.  Women

 

1)      The iodine intake of women of reproductive age should be increased.  Iodization or iodation of the salt used in Badghis households will be difficult; however, other methods for increasing dietary iodine should be explored, including iodine fortification of edible oil.  Large producers of salt in Afghanistan and countries from which salt is imported into Afghanistan should be encouraged to fortify their product. 

2)      The prevalence, level, and causes of anemia in women should be investigated further.  Such an investigation should include the measurement of hemoglobin concentration in a population-based sample of women of reproductive age. 

3)      The prevalence of vitamin A deficiency in women should be investigated further.  Such an investigation should include serum testing for retinol levels or other appropriate laboratory testing.

4)      All edible oil distributed as emergency relief in Badghis should be fortified with retinol to international standards. 

 

III.  General

 

1)      The causes of mortality, and presumably morbidity, should be addressed by prevention and treatment.  Water and sanitation are inadequate in the majority of Badghis households and should be improved as rapidly as possible.  In addition, adequate preventive and curative health services should be available and accessible to the population of Badghis Province.

2)      Training of Ministry of Public Health personnel in all aspects of nutrition and nutrition interventions should be given a priority.  A country-wide policy regarding nutrition monitoring and micronutrient fortification and supplementation should be developed and implemented in all provinces of Afghanistan.

3)      The protocol, data collection forms, data analysis program, and other materials used in the Badghis survey should be used or adapted for nutrition and health assessment surveys in other provinces and districts in Afghanistan as soon as possible.


REFERENCES

 

1.     WHO: World Health report. . Geneva, Switzerland: World Health Organization, 2000.

2.     Richards T, Little R: Afghanistan needs security to rebuild its health services. British Medical Journal 2002; 324: 318.

3.     Assefa F, Jabarkhil M, Salama P, Spiegel P: Malnutrition and mortality in Kohistan District, Afghanistan, April 2001. JAMA 2001; 286: 2723-2728.

4.     Myatt m, Desplats G, Collins S: Nutritional anthropometry, health, food security, and agriculture assessment: Concern programme areas, northeast Afghanistan. : Valid International, 2001.

5.     Afghanistan MICS2 Steering Committee: 2000 Afghanistan Multiple Indicator Cluster Survey (MICS2). . Islamabad, Pakistan: UNICEF, 2001.

6.     Anker M, Black R, Coldham C, et al.: A standard verbal autopsy method for investigating causes of death in infants and children. , vol WHO/CDS/CSR/ISR/99.4. Geneva, Switzerland: WHO, 1999.

7.     WHO: Physical Status: the Use and Interpretation of Anthropometry, Report of a WHO Expert Committee., Vol. 254. Geneva: World Health Organisation, 1995 WHO Technical Report Series).

8.     Shetty P, James W: Body mass index: a measure of chronic energy deficiency in adults. Food and Nutrition Paper No. 56. Rome: Food and Agriculture Organization of the United Nations, 1994.

9.     Woodruff BA, Blanck H, Duffield A, et al.: Prevalence of low body mass index and specific micronutrient deficiencies in adolescents 10-19 years of age in Bhutanese refugee camps, Nepal, October 1999. . Atlanta, Georgia USA: U.S. Centers for Disease Control and Prevention, United Nations ACC/Sub-Committee on Nutrition, U.N. High Commissioner for Refugees, Save the Children - U.K., and World Food Programme, 1999.

10.   Ge Kea: The body mass index of Chinese adults in the 1980s. European journal of clinical nutrition 1994; 48(Suppl. 3): S148-S154.


Table 1. Description of households included in survey, Badghis Nutrition and Health Survey, March 2001

 

Characteristic

Number (%)

Residence

      District of current residence                             Ghormach

                                                                               Jawand

                                                                              Murghab

                                                                                  Qadis

                                                                          Qala-e-Nau

                                                                                         

      Displaced from usual residence

 

50  (9.8)

72  (14.2)

98  (19.3)

97  (19.1)

191  (37.6)

 

12  (2.4)

Water Source

      Primary water source:                               River or stream

                                                                            Open well

                                                                       Lake or pond

                                                         Bore hole or close well

                                                           Central piped system

                                                             Truck or water seller

                                                                                  Other

 

      Same water source as in previous year                           
                                                                                         

      Time to water source (minutes):                               < 30

                                                                               31 – 60

                                                                                61-120

                                                                                  > 120

 

348  (68.6)

74  (14.6)

55  (10.9)

26   (5.1)

0  -

0  -

3         (0.6)

 

462    (92.6)

 

286  (57.0)

38  (7.6)

48  (9.6)

130  (25.9)

Food and Salt

      Receipt of relief food since Oct. 2001

 

      Household salt positive for iodine

 

270  (53.4)

 

12  (2.4)

 


Table 2. Description of children and women of reproductive age included in survey, Badghis Nutrition and Health Survey, March 2001.

 

Group and characteristic

        No.    (%)

Children less than 5 years

    Age (months)                         0 – 11

                                              12 – 23

                                              24 – 35

                                              36 – 47

                                              48 – 59

 

 

       90  (16.5)

     126  (23.1)

     150  (27.5)

     101  (18.5)

       78  (14.3)

 

Women of Reproductive Age

    Age (years)                          15 – 19

                                              20 – 24

                                              25 – 29

                                              30 – 34

                                              35 – 39

                                              40 – 44

                                              45 – 49

 

    Literate                                         

 

       87  (15.5)

       90  (16.0)

     110  (19.5)

       90  (16.0)

       87  (15.5)

       58  (10.3)

       41  (7.3)

 

         5  (0.9)

                                                                                                                                                             

 


Table 3.  Prevalence of acute and chronic malnutrition and underweight (as defined by z-score) in children less than 5 years of age, by age, Badghis Nutrition and Health Survey, March 2001.

 


Anthro-pometric Index

Age of Child

0 – 11 months

12 – 23 months

24 – 59 months

All ages

 

No.  (%)

 

95% C.I.*

 

No.  (%)

 

95% C.I.*

 

No.  (%)

 

95% C.I.*

 

No.  (%)

 

95% C.I.*

Acute**

Yes

Severe

Moderate

No

 

4  (4.6)

0

4  (4.6)

83  (95.4)

 

0.7,  8.5

-

0.7, 8.5

91.5, 99.3

 

20  (16.0)

5  (4.0)

15  (12.0)

105 (84.0)

 

9.2, 22.8

0,  8.1

7.6, 16.4

77.2, 90.8

 

11  (3.3)

6  (1.8)

5  (1.5)

316 (96.6)

 

0.5, 6.2

0.2, 3.5

0, 3.3

93.8, 99.5

 

35  (6.5)

11  (2.0)

24  (4.5)

504 (93.5)

 

3.9, 9.1

0.4, 3.7

2.8, 6.1

90.9, 96.1

 

Chronic**

Yes

Severe

Moderate

No

 

23  (26.7)

8  (9.3)

15  (17.4)

63  (73.3)

 

17.9, 35.6

3.0, 15.6

9.4, 25.5

64.4, 82.1

 

75  (59.5)

40  (31.7)

35  (27.8)

51  (40.5)

 

52.3, 66.8

23.4, 40.1

20.0, 35.5

33.2, 47.7

 

211 (64.9)

118 (36.3)

93 (28.6)

114 (35.1)

 

58.2, 71.7

30.2, 42.4

24.7, 32.5

28.3, 41.8

 

309 (57.5)

166 (30.9)

143 (26.6)

228 (42.5)

 

52.5, 62.5

26.1, 35.7

23.6, 29.7

37.5, 47.5

 

Underwt**

Yes

Severe

Moderate

No

 

19  (21.8)

6  (6.9)

13  (14.9)

68  (78.2)

 

12.8, 30.9

2.1, 11.7

6.4, 23.5

69.1, 87.2

 

66  (52.4)

34  (27.0)

32  (25.4)

60  (47.6)

 

44.8, 59.9

19.1, 34.8

19.0, 31.8

40.1, 55.2

 

120 (36.5)

39  (11.9)

81  (24.6)

209 (63.5)

 

29.1, 43.9

7.3, 16.5

19.6, 29.6

56.1, 70.9

 

205 (37.8)

79 (14.6)

126 (23.2)

337 (62.2)

 

32.4, 43.3

10.9, 18.3

19.2, 27.3

56.7, 67.6

 

*    Confidence Interval    **   See definition in text

 

 


 

Table 4.  Prevalence of acute and chronic malnutrition and underweight (as defined by % of median) in children less than 5 years of age, by age, Badghis Nutrition and Health Survey, March 2001.

 


Anthro-pometric Index

Age of Child

0 – 11 months

12 – 23 months

24 – 59 months

All ages

 

No.  (%)

 

95% C.I.*

 

No.  (%)

 

95% C.I.*

 

No.  (%)

 

95% C.I.*

 

No.  (%)

 

95% C.I.*

Acute**

Yes

   Severe

   Moderate

No

 

4  (4.5)

0

4  (4.5)

85  (95.5)

 

0.7, 8.3

-

0.68, 8.3

91.7,  99.3

 

14  (11.2)

2  (1.6)

12  (9.6)

111 (88.8)

 

4.8, 17.6

0,  3.8

4.4, 14.8

82.4, 95.2

 

12  (3.7)

7  (2.1)

5  (1.5)

315 (96.3)

 

0.7, 6.6

0.2, 4.1

0, 3.1

93.4, 99.3

 

30  (5.5)

9  (1.7)

21  (3.9)

511 (94.5)

 

2.9, 8.1

0.4, 3.0

2.2, 5.5

91.9, 97.1

 

Chronic**

Yes

   Severe

   Moderate

No

 

17  (18.9)

0

17  (18.9)

73  (81.1)

 

11.0, 25.7

-

11.0, 26.7

73.3, 89.0

 

52  (41.3)

1    (0.8)

51  (40.5)

74  (58.7)

 

31.4, 51.1

0, 2.3

30.6, 50.4

48.9, 68.6

 

167 (50.8)

14   (4.3)

153 (46.5)

162 (49.2)

 

43.7, 57.9

1.5, 7.0

39.8, 53.2

42.1, 56.3

 

236 (43.3)

15   (2.8)

221 (40.6)

309 (56.7)

 

37.8, 48.8

1.1, 4.4

35.2, 46.0

51.2, 62.2

 

Underwt**

Yes

   Severe

   Moderate

No

 

21  (23.6)

9    (10.1)

12  (13.5)

68  (76.4)

 

13.2, 34.0

3.8, 16.5

4.5, 22.5

66.0, 86.8

 

68  (54.4)

39  (31.2)

29  (23.2)

57  (45.6)

 

46.9, 61.9

23.3, 39.1

17.5, 28.9

38.1, 53.1

 

132 (40.4)

46   (14.1)

86   (26.3)

195 (59.6)

 

33.4, 47.4

9.4, 18.7

21.9, 30.7

52.6, 66.6

 

221 (40.9)

94   (17.4)

127 (23.5)

320 (59.1)

 

35.5, 46.2

14.0, 20.7

19.8, 27.2

53.8, 64.5

 

*    Confidence Interval    **   See definition in text

 

 


Table 5.  Potential risk factors for acute and chronic malnutrition in children < 5 years of age, Badghis Nutrition and Health Survey, March 2001.

 

 

 

Factor

Number in group

Number (%) with malnutrition

 

Risk ratio

95% confidence interval

Acute malnutrition

   Household received food aid

                                              No

                                            Yes

   Mother illiterate

                                            Yes

                                              No

   Mother has low BMI

                                            Yes

                                              No

   Mother's pregnancies

                                              5+

            0 – 4

 

 

274

263

 

504

8

 

81

400

 

333

188

 

 

13

21

 

32

0

 

10

22

 

21

11

 

 

(4.7)

(8.0)

 

(6.3)

0

 

(12.3)

(5.5)

 

(6.3)

(5.9)

 

 

0.59

 

 

undefined

 

 

2.2

 

 

1.1

 

 

 0.28, 1.2

 

 

-

 

 

1.3, 3.9

 

 

0.45, 2.6

Chronic malnutrition

   Household not received food aid

                                              No

                                            Yes

   Mother illiterate

                                            Yes

                                              No

   Mother has low BMI

                                            Yes

                                              No

   Mother's pregnancies

                                              5+

                                         0 – 4

 

 

272

263

 

503

8

 

80

400

 

333

187

 

 

155

153

 

293

3

 

47

227

 

202

100

 

 

(57.0)

(58.2)

 

(58.3)

(37.5)

 

(58.8)

(56.8)

 

(60.7)

(53.5)

 

 

0.98

 

 

1.6

 

 

1.0

 

 

1.1

 

 

0.81, 1.2

 

 

0.82, 2.9

 

 

0.87, 1.2

 

 

0.99, 1.31

 

Table 6.  Possible signs of micronutrient deficiencies in children less than 5 years of age, by age, Badghis Nutrition and Health Survey, March 2001.

 

 

 

Signs of micronutrient deficiency

Age (months)

0 – 11

12 – 23

24 – 59

All ages

 

No.   (%)

 

No.   (%)

 

No.   (%)

 

No.   (%)

 

Vitamin A

Nightblindness*

Bitots spot

ANY SIGN

 

Vitamin C

Bleeding gums spontaneously

Bleeding gums upon tapping

Painful, swollen joints

Bruises on legs

Perifollicular hemorrhage

ANY SIGN

 

Vitamin D

Bowed legs

Spinal deformation

Rachitic rosary

Hard, swollen joints

ANY SIGN

 

Riboflavin

Angular stomatitis

 

Anemia

Pallor

 

 

3  (10.7)

0

3  (3.3)

 

 

0

0

0

0

1  (1.1)

1  (1.1)

 

 

0

0

3  (3.3)

0

3  (3.3)

 

 

1  (1.1)

 

 

3  (3.4)

 

 

5  (6.8)

0

5  (4.0)

 

 

1  (0.8)

3  (2.4)

1  (0.8)

0

0

4   (3.2)

 

 

2   (1.6)

0

7   (5.6)

1   (0.8)

8   (6.3)

 

 

3   (2.4)

 

 

16   (12.9)

 

 

3   (1.0)

3   (0.9)

6   (1.8)

 

 

  9   (2.8)

10   (3.1)

  2   (0.6)

0

  1   (0.3)

12  (3.7)

 

 

 3  (0.9)

 1  (0.3)

 6  (1.8)

 4  (1.2)

10  (3.0)

 

 

15   (4.6)

 

 

27   (8.3)

 

 

11   (2.8)

3    (0.6)

14   (2.6)

 

 

10   (1.8)

13   (2.4)

  3   (0.6)

0

  2   (0.4)

17   (3.1)

 

 

 5  (0.9)

 1  (0.2)

16  (3.0)

 5  (0.9)

21  (3.9)

 

 

19  (3.5)

 

 

46  (8.5)

*  Frequently not available for young children

 

 

 

 


Table 7.  WHO breastfeeding indicators, Badghis Nutrition and Health Survey, March 2001.

 

Indicator

Age group

Number in group

Number (%) with indicator

Exclusive breast-feeding

Predominant breastfeeding

Timely complementary feeding

Continued breast-feeding – 1 year

Continued breast-feeding – 2 years

Bottle-feeding

< 4 months

< 4 months

6 – 9 months

12 – 15 months

20 – 23 months

< 12 months

40

39

19

54

25

89

38  (95)

39 (100)

4  (21)

52  (96)

13  (52)

6  (7)

 

 

 

 

Table 8.  Cumulative prevalence of diarrhea and pneumonia in previous 2 weeks in children less than 5 years of age, by age, Badghis Nutrition and Health Survey, March 2001.

 

 

Illness

 

Age (months)

 

0 – 11

Number  (%)

12 – 23

Number  (%)

24 – 59

Number  (%)

All ages

Number  (%)

Diarrhea

      Taken to health facility

Acute respiratory infection

      Taken to health facility

29  (32.2)

      2  (7)

28  (31.1)

      3  (11)

47  (37.3)

      5  (11)

52  (41.3)

      6  (12)

86  (26.2)

      11  (13)

104  (31.6)

      7  (7)

162  (29.8)

      18  (11)

184  (33.8)

      16  (9)

 

 

 

Table 9.  Reproductive outcomes among women of reproductive age, Badghis Nutrition and Health Survey, March 2001.

 

Age group (years)

Total number of women in age group

Number (%) pregnant

Median number of pregnancies

Median number of births

Median time since last delivery (months)

15 – 19

20 – 24

25 – 29

30 – 34

35 – 39

40 – 44

45 – 49

85

89

108

90

87

58

40

5  (5)

13  (15)

22  (20)

18  (20)

11  (13)

7  (12)

2  (5)

0.3

0.2

15.4

2.2

1.8

16.4

4.1

3.0

19.9

5.8

4.4

22.8

7.6

5.8

30.8

8.5

6.3

44.7

9.5

6.4

61.4

All ages

559

78  (14.0)

4.9

3.6

28.6

 

 


Table 10.  Prevalence of various categories of malnutrition (as defined by BMI) in non-pregnant women of reproductive age, Badghis Nutrition and Health Survey, March 2001.

 

BMI

Category*

Number

(%)

< 16.0

Severe thinness

14

(3.2)

16.0 – 16.9

Moderate thinness

10

(2.3)

17.0 – 18.4

Mild thinness

58

(13.1)

18.5 – 24.9

Normal

311

(70.0)

25.0 – 29.9

Overweight

43

(9.7)

> 30.0

Obese

8

(1.8)

*  See text for definitions

 

 

                       

 

 

 

 

 

Table 11.  Distribution of MUAC measurements in all women of reproductive age, Badghis Nutrition and Health Survey, March 2001.

 

 

MUAC measurement (cms)

Number (%) of women

< 15.0

15.0 – 15.9

16.0 – 16.9

17.0 – 17.9

18.0 – 18.9

19.0 – 19.9

20.0 – 20.9

21.0 – 21.9

22.0 – 22.9

23.0 – 23.9

24.0 – 24.9

25.0 – 25.9

26.0 – 26.9

27.0 – 27.9

28.0 – 28.9

29.0 – 29.9

> 30.0

0

1  (0.2)

0

0

2  (0.4)

21  (3.8)

23  (4.1)

48  (8.6)

92  (16.5)

104  (18.7)

100  (18.0)

58  (10.4)

47  (8.4)

32  (5.7)

14  (2.5)

9  (1.6)

6  (1.1)

 


Table 12.  Prevalence of various categories of malnutrition using the combination of BMI and MUAC, non-pregnant women of reproductive age, Badghis Nutrition and Health Survey, March 2001.

 

Category*

Number of women

(%)

Severe malnutrition (category III)

10

(2.2)

Moderate malnutrition (category II)

13

(2.9)

Mild malnutrition (category I)

31

(6.9)

Normal?

65

(14.5)

Normal

278

(62.2)

Overweight

50

(11.2)

*  See text for definitions

 

 

 

 

 

 

 

 

 

 

 

 

Table 13.  Age- and sex-specific death rates since Eid Qurban 1379 (7 March 2001), Badghis Nutrition and Health Survey, March 2001.

 

Age

group

(years)

Males

Females

Both sexes

Rate*

95% C.I.**

Rate

95% C.I.

Rate

95% C.I.

0 – 5

2.86

1.74, 4.30

2.23

1.36, 3.30

2.51

1.80, 3.47

5 – 14

0.20

0.01, 0.39

0.15

0.00, 0.33

0.18

0.06,  0.30

15 – 49

0.18

0.02, 0.34

0.47

0.11,  0.83

0.32

0.11, 0.55

50+

0.76

0.05, 1.50

0.69

0.00, 1.44

0.73

0.22, 1.26

All ages

0.69

0.41,  1.00

0.74

0.47, 1.02

0.72

0.49, 0.96

*  Number of deaths / 10,000 population / day

** C.I. = Confidence interval

 


Table 14.  Distribution of causes of death, by age group, for deaths with cause determined, Badghis Nutrition and Health Survey, March 2001.

 


Cause of Death

Age group (years)


All ages

No.   (%)

0 – 4

No.   (%)

5 – 14

No.   (%)

15 – 49

No.   (%)

> 50

No.   (%)

Bloody diarrhea

Watery diarrhea

Pneumonia

Measles

Tetanus

Meningitis

Malaria

Scurvy

Non-war injury

War-related injury

Other

ALL CAUSES

11 (21)

3  (6)

10 (19)

3  (6)

3  (6)

5  (9)

4  (8)

0

0

1  (2)

13 (25)

53 (100)

1 (17)

0

1 (17)

0

0

3 (50)

0

0

0

0

1 (17)

6 (100)

2 (17)

0

4 (33)

0

0

2 (17)

0

0

1 (8)

0

3 (25)

12 (100)

1 (13)

0

1 (13)

0

0

1 (13)

1 (13)

0

0

0

4 (50)

8 (100)

15 (19)

3 (4)

16 (20)

3 (4)

3 (4)

11 (14)

5 (6)

0

1 (1)

1 (1)

21 (27)

79 (100)


Persons who attended the Mazar workshop

 

ACF                                                    

Olivia Freire    

 

AMI

Sandrine Robin

Dr. Nadjib

Francoise Moriceau

 

Ankhoy Hospital

Dr. M. Sanjar Omar

 

GOAL

Katherine Jobber

 

ICRC

Said Taher

 

IFRC

Lina Tsitsou

 

IOM

Ghafary Nargis

Phillip

 

Medecins sans Frontieres (MSF)

Chris Tiley

Bruce Russel

 

MERU

Miwa Inoguchi

Hideki Higashi

 

Ministry of Public Health - Faryab

Dr. Sherin Hakimi

Dr. Asmafulk Rozy

 

Ministry of Public Health – Jawzjan

Dr. Asmatullah

 

Ministry of Public Health – Mazar-i-Sharif

Dr. Ashakoor Rahimi

 

SCA

Dr. A. Sabour

 

SCF-UK

Ah Kabmiz Hekmati

Frazana Mabarez

 

SCF-US

John Patten

 

UNICEF

Dr. Rafiqi

 

WHO

Dr. Ghaffary

 

ZOA

Kim Pulliam

 


Members of survey teams

 

Supervisors

Dr. Saed Rachid

Dr. Mirwais Azamy

Dr. Abdul Raouf Frengh

Dr. Gh. Sarwar Mohamday

Dr. Ataoullah

 

 

Interviewers

Ms. Tahera

Ms. Sharita

Ms. Latifa

Ms. Shafika

Ms. Luna

Mr. Mahamood

Mr. Abduk Khalik

Mr. Qadersha

Mr. Mohd Afzal Hydary


 

Logisiticians

Mr. Ahmad Shah Khan

Mr. Himaq

Mr. Jawid Ahmad

Mr. Jalad Kolalay

Mr. Hkodadad


List of villages visited during data collection

 

Cluster

District

Subdistrict

Area

Village

1

Jawand

 

Allah Yar

Pai Cheng

2

Jawand

 

Khawaja Surkhi

Besha

3

Jawand

 

piroji

Khas

4

Jawand

 

Tate-Jawand

Ghulghuli

5

Tagab Alam

 

Dawudy

Ghalak Kashta Pain

6

Ghormach

 

Tutak

Habibula

7

Ghormach

 

Ab Garmak

Mulla Barakat

8

Ghormach

 

Takht Katoun

Walijan

9

Qala-e-Nau

 

Chakaab

Cheshma Sharin

10

Qala-e-Nau

 

Tushpelaq

Tushpelaq Daizangi

11

Qala-e-Nau

 

Aab Kamari

Sar Cheshma Aab Kamari

12

Qala-e-Nau

 

Kham Abasi

Kham Abasi Sharq

13

Qala-e-Nau

 

Baghak

Murdby Barati

14

Qala-e-Nau

 

 

Tagaab Ismail Junobi

15

Qala-e-Nau

 

Kocha Zard

Karim Dad

16

Qala-e-Nau

Laman Valley

Laman Valley

Abdal

17

Qala-e-Nau

Moqoor

Sherq Woloswali

Mohammad Zayee Aqa Mohd

18

Qala-e-Nau

Sang Atesh

 

Kolari Kalta Shoor

19

Qala-e-Nau

Sang Atesh

 

Kalan Khana

20

Murghab

 

Morichaqu

 

21

Murghab

 

Chapchel

 

22

Murghab

 

Chalunak

 

23

Murghab

 

Joi Gange

 

24

Murghab

 

Bazartoo

 

25

Murghab

 

Quroto

 

26

Qadis

 

 

Telake Aalm Chwb

27

Qadis

 

 

Kaminji Ulia

28

Qadis

 

 

Aab Garmak & Joye Sorkh

29

Qadis

 

 

Jawaleq Sufla

30

Qadis

 

 

Arbaban

 

 

 

 

 

 

 


Nutrition and Health Survey, Afghanistan,  2002

Province ______________________  District  _____________________   Village __________________

Cluster number:  _________       Household number:  _____________

Team code:  __________            Interviewer code: __________           Date of interview:  ______ / _______

           Day        Month

HOUSEHOLD DATA

1)  Does your family now live in your usual place of residence? (circle one)........................................ Yes  /  No  /  Unk

         1a)  If NO, how long since the family has lived there?.......................................... ______ months OR _____ years

2)  Has anyone in the family received any relief food since the change in government?..................... Yes   /   No   /   Unk

3)  What is your main source of water? (circle one).................... Central piped system / Truck or water seller / Bore hole

                                                                                                     Open Well / River or stream / Lake or pond / Other

4)  Do you use the same source of water now as you did this time last year?.................................. Yes   /   No   /   Unk

5)  How long does it take you to fetch water each time you go to get it?............................................ ________ minutes

6)  Results of iodine testing of salt used for last night's food (circle one)........................ Positive  /  Negative  /  Not Done

 

I would like to ask you about each person who lived in this household at the time of Eid Qurban 1379 (2001 Gregorian calendar) and children who were born since the time of Eid Qurban:

HOUSEHOLD MEMBERS

 

 

 


Personno.

Age (years)

Sex

(circle one)

Current Status

as of TODAY

(circle one)

If missing or dead, since when?  (mm/yy)

Died of which cause? (ask questions)

Malnutrition?

Pregnant or in Chel??

1

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

2

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

3

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

4

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

5

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

6

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

7

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

8

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

9

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

10

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

11

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

12

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

13

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

14

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N

15

 

M   /   F

1     2     3     4

/

 

Y    /    N

Y     /     N


LIVING WOMEN OF CHILDBEARING AGE (15 – 49 years)

 

Person no.

from table 1 above.

Literate?

Night blind-ness

Goiter

Num-ber of preg-nancies

Num-ber of live births

Date of last delivery

mm/yy

Preg-nant now?

No. of doses  tetanus vaccine

MUAC

(cms)

Weight

(kgs)

Height

(cms)

Hemoglobin

(gms)

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 

Y /  N

Y  /  N

Y  /  N

 

 

/

Y  /  N

 

___  ___ , ___

___  ___ , ___

___ ___ ___ , ___

___  ___ , ___

 


Nutrition Survey, Afghanistan 2002 -- Data collection form (Child 0-59 months)

Cluster number:........ ______  HH: _____  Child's person number: _____  Mother's person number: _______

Questions for adult caretaker

Place mother's blood label here

 
1)  Relationship of respondent to child: ..........................  Mother   Father   Grandmother Grandfather  Other

2)  Is this child's mother alive?.................................................................................. Yes   /   No   /   Unk

3)  Sex ....................................................................................................................... Male   /   Female   

4)  Date of birth OR Age in months.......................................... _____ / _____ / _____  OR  ______ months

                                                                                                           Day     Month   Year .

5)  Does this child have difficulty seeing at night or in the evening when other people do not?Yes   /   No   /   Unk

6)  Since this time yesterday, has this child breast fed? ............................................  Yes   /   No   /   Unk

         6a) If YES, was breast milk this child's main source of food since yesterday? ...   Yes   /   No   /   Unk

         6b) If YES, how long after birth did this child first breastfeed?...................................... _______ hours

7)  Since this time yesterday, has this child received anything other than breast milk?.. Water, tea, or juice /

     (circle all that are true)............. Powered milk or infant formula  / Semi-solid or solid food / None of these

8)  Since this time yesteday, has this child drunk anything from a bottle with a nipple?.. Yes   /   No   /   Unk

9)  Has this child received any vitamin A? Vitamin A is given as drops from a capsule.... Yes   /   No   /   Unk

         (show example)

10) Since 2 weeks ago, has this child had diarrhea?  ................................................. Yes   /   No   /   Unk

     Diarrhea is 3 or more stools in 24 hours.

         10a) If YES, was this child taken to a clinic or hospital for this problem? ............. Yes   /   No   /   Unk

11) Since two weeks ago, has this child had fever and difficulty breathing? ................... Yes   /   No   /   Unk

         10a) If YES, was this child taken to a clinic or hospital for this problem? ............. Yes   /   No   /   Unk

12) Since the change of government, has this child received measles vaccination? ....... Yes   /   No   /   Unk

         This vaccine is given by injection.

Examination of child

13) Bitot's spots............................................................................................................... Yes     /     No

14) Gums bleeding spontaneously..................................................................................... Yes     /     No

15) Gums bleed upon tapping............................................................................................ Yes     /     No

16) Angular stomatitis....................................................................................................... Yes     /     No

17) Pallor in palms of hands.............................................................................................. Yes     /     No

18) BCG scar................................................................................................................... Yes     /     No

19) Row of ricketts............................................................................................................ Yes     /     No

20) Perifollicular hemorrhage.............................................................................................. Yes     /     No

21) Swollen joints – soft and painful.................................................................................... Yes     /     No

22) Swollen joints – hard and not painful............................................................................. Yes     /     No

23) Bruises or eccymosis on legs...................................................................................... Yes     /     No

24) Bowed legs................................................................................................................ Yes     /     No

25) Bilateral edema........................................................................................................... Yes     /     No

26) Spinal deformity.......................................................................................................... Yes     /     No

27) Does this child have a physical deformity making it difficult to obtain an accurate height? . Yes     /     No

Anthropometry and laboratory

28) Weight: (kgs) ..............................................................................................  _____   _____  ,  _____

29) Length/Height: (cms) ........................................................................  _____  _____   _____  ,  _____

30) MUAC: (cms) ..............................................................................................  _____   _____  ,  _____

31) Hemoglobin: ...............................................................................................  _____   _____  ,  _____


Verbal autopsy to determine cause of death

 

1)      Did _____ die from car accident, fall, drowning, poisoning, burn, bite, sting,................................ If YES........... Go to next question

         or other violence or injury?                                                                                                       If NOSkip to question #3

 

2)      Was this injury from a bullet, bomb, mine or otherwise related to the war?.................................. If YES... STOP.  Record code 1

                                                                                                                                                      If NO..... STOP.  Record code 2

 

3)      Did _____ have (local term for measles)?................................................................................. If YES.... STOP. Record code 3

                                                                                                                                                      If NO Go to next question

 

4)      Did _____ have (local term for tetanus)?................................................................................... If YES.... STOP. Record code 4

                                                                                                                                                      If NOGo to next question

 

5)      Did _____ have liquid, watery, soft, OR frequent stools?............................................................ If YES........... Go to next question

                                                                                                                                                      If NOSkip to question #8

 

6)      Did _____ have (local term for diarrhea)?.................................................................................. If YES........... Go to next question

                                                                                                                                                      If NOSkip to question #8

 

7)      Did _____ have blood in the stool?........................................................................................... If YES.... STOP. Record code 5

                                                                                                                                                      If NO...... STOP. Record code 6

 

8)      Did _____ have fever OR hot body?.......................................................................................... If YES........... Go to next question

                                                                                                                                                      If NOSkip to question #10

 

9)      Did _____ have stiff neck OR bulging fontanelle?....................................................................... If YES... STOP.  Record code 7

                                                                                                                                                      If NOGo to next question

 

10)     Did _____ have cough OR difficulty breathing?.......................................................................... If YES........... Go to next question

                                                                                                                                                      If NOSkip to question #12

 

11)     Did _____ have fast breathing OR chest indrawing?................................................................... If YES.... STOP. Record code 8

                                                                                                                                                      If NOGo to next question

 

12)     Did _____ have convulsions?................................................................................................... If YES... STOP.  Record code 9

                                                                                                                                                      If NOGo to next question

 

13)     Did _____ have seialengia (Dari term for scurvy)?                                                                       If YES... STOP.  Record code 10

                                                                                                                                                      If NO..... STOP.  Record code 11