nutritional anthropometric and mortality survey among internally … · 2018-03-12 · october 2014...

I

Ministry of Health / Kurdistan Region of Iraq

Dohuk Governorate

October 2014

Nutritional anthropometric and mortality survey among Internally Displaced

Populations in Duhok province - Iraq

(Sept - Oct 2014)

II

Acknowledgements The Department of nutrition of Dohuk Directorate of health would like to take the

opportunity to acknowledge the efforts of individuals and organizations involved in the

successful implementation of this survey.

We would like to acknowledge UNICEF Regional and Country Office for the financial and

technical support for conducting this survey as part of the strong collaboration and

partnership with the Kurdistan Ministry of health.

We are deeply appreciative for the helpful contributions of various individuals and

organizations on the design of the survey, its implementation, data analysis and report

review.

Special appreciations are expressed to survey team (supervisors, team leaders, enumerators

and drivers) for their tireless efforts to ensure that the survey was conducted professionally

and on time.

A special thanks to mothers caregivers and the whole community for the voluntary

participation in this survey and response to the interviewers.

III

Table of contents

Table of Contents Acknowledgements ......................................................................................................................................... ii

Table of contents ............................................................................................................................................ iii

List of Tables and figures .............................................................................................................................. iv

Acronyms and abbreviations ......................................................................................................................... v

Executive Summary ....................................................................................................................................... vi

I. Introduction ............................................................................................................................................ 1

1.1. Survey Objectives .......................................................................................................................... 1

II. Methodology ....................................................................................................................................... 2

2.1. Survey area .................................................................................................................................... 2

2.2. Sample size ..................................................................................................................................... 2

2.3. Sampling procedure: selecting clusters, households and children ............................................ 3

2.4. Inclusion criteria and case definitions ......................................................................................... 3

2.5. Training and supervision .............................................................................................................. 4

2.6. Data collection ............................................................................................................................... 5

2.7. Data analysis .................................................................................................................................. 6

III. Results ................................................................................................................................................. 6

3.1. Anthropometric results (based on WHO standards 2006): ....................................................... 6

a) Prevalence of Global Acute Malnutrition (GAM); wasting .......................................................... 7

b) Prevalence of underweight ............................................................................................................. 9

c) Prevalence of chronic malnutrition (Stunting) ........................................................................... 10

d) Prevalence of overweight based on WHZ .................................................................................... 11

3.2. Retrospective mortality results .................................................................................................. 11

3.3. Households socio-economic characteristics ............................................................................... 12

3.4. Infant and young child feeding practices .................................................................................. 13

3.5. Vitamin A supplementation and immunization ........................................................................ 14

3.6. Prevalence of child morbidity .................................................................................................... 14

3.7. Household food Security ............................................................................................................. 15

3.8. Water access and hygiene ........................................................................................................... 15

IV. Discussion ......................................................................................................................................... 16

V. Conclusions ...................................................................................................................................... 18

VI. Recommendations ............................................................................................................................ 18

VII. References ........................................................................................................................................ 18

VI. Annexes ............................................................................................................................................. 21

Annex 1: Calendar of events .................................................................................................................... 21

Annex 2: Plausibility Report .................................................................................................................... 22

Annex 3: Standardization test ................................................................................................................. 41

Annex 4: Assignment of clusters .............................................................................................................. 47

Annex 5: Maps of area ............................................................................................................................. 52

Annex 6: Questionnaires .......................................................................................................................... 53

IV

List of Tables and figures Table 1: The sample size calculation parameters ............................................................ 2 Table 2: Anthropometric and mortality indicators definition ....................................... 4 Table 3: Distribution of age and sex of sample ................................................................ 7

Table 4: Prevalence of Global Acute Malnutrition (GAM) by sex after exclusion of

SMART flags ................................................................................................................ 7

Table 5: Prevalence of acute malnutrition by age based on the weight for height ....... 8 Table 6: Prevalence of acute malnutrition by age, based on MUAC cut off's .............. 9 Table 7: Prevalence of underweight by sex and after exclusion of SMART flags ...... 10 Table 8: Prevalence of stunting by sex and after exclusion of SMART flags ............. 10 Table 9: Prevalence of overweight by sex ...................................................................... 11

Table 10: Crude and under five mortality rates ............................................................ 12

Table 11: Respondent background information and households socioeconomic

characteristics ............................................................................................................ 12

Table 12: Infant and young child feeding practices ...................................................... 13 Table 13: Vitamin A and measles coverage ................................................................... 14 Table 14: Prevalence of diarrhea and ARI .................................................................... 14 Table 15: Household food security .................................................................................. 15

Table 16: Access to safe water and household hygiene ................................................. 15

Figure 1: Distribution of the sample (1583 children) within the target districts .......... 7 Figure 2: Z-Score Distribution of Weight for Height for the sample ............................ 9

Figure 3: Z-Score Distribution of Weight for Age for the sample ............................... 10 Figure 4: Z-Score Distribution of Height for Age for the sample ................................ 11

V

Acronyms and abbreviations

ARI Acute Respiratory Infection

BMS Breastmilk Substitutes

C4D Communication for Development

CI Confidence Interval

CMAM Community Management of Acute Malnutrition

CMR Crude Mortality Rate

DoH Directorate of Health

DTM Displacement Tracking Matrix

ENA Emergency Nutrition Assessment

EPI Extended Program on Immunization

GAM Global Acute Malnutrition

HAZ Height-for-Age Zscore

IDP Internally Displaced Population

IMCI Integrated Management of Childhood Diseases

IOM International Organization for Migration

IYCF infant and Young Child feeding Practices

KRI Kurdistan Region of Iraq

MAM Moderate Acute Malnutrition

MICS Multiple Indicator Cluster Survey

MUAC Mid Upper Arm Circumference

SAM Severe Acute Malnutrition

SD Standard Deviation

SMART Standardized Monitoring of Relief and Transitions

SPSS Statistical Package for Social Sciences

U5MR under five Mortality Rate

UNICEF United Nations Children's Fund

WASH Water Sanitation and Hygiene

WAZ Weigh-for-Age Zscore

WHO World Health Organization

WHZ Weight-for-height Zscore

VI

Executive Summary

The Department of nutrition of Duhok - Directorate of preventive health affairs in

collaboration with UNICEF carried out a nutrition survey in the districts of Amedia, Akre,

Bardarash, Dohuk, Shikhan, Sumel and Zakho. This assessment was undertaken to increase

the understanding of the nutrition situation among the Internally Displaced Population

(IDPs) settled in the target districts. It also serves as baseline to gather key information that

support the implementation of evidence-based interventions to tackle the contributing

factors to malnutrition (triple burden of undernutrition, micronutrient deficiencies and

overweight).

The proposed sampling methodology was a two-stage cluster randomized sampling with

probability proportional to the size of the population. The Emergency Nutrition Assessment

(ENA) software for Standardized Monitoring of Relief and Transitions (SMART) version

(August 4th, 2014) was used to calculate the required sample size. The first level of sampling

identified IDPs locations (schools, unfinished buildings, camps, community centres, etc.)

that were included in this survey while the second stage sampling selected households using

the list of households available in each location. The data collection took 14 days from

September 20 to October 3 and involved 32 trained enumerators and 5 supervisors. Seven

districts and over 40 IDPs locations were visited. In addition to the anthropometric

measurements taken from each child 6 – 59 months of age, information related to household

socioeconomic characteristics, vitamin A and Measles coverage, infant and young child

feeding practices, child morbidity, household food security and access to water and

sanitation were also collected. The crude mortality rate and under five mortality rate were

also measured.

Overall, 1,600 children and 1,295 households were surveyed. The findings reveal that the

majority of respondents (95.8%) were married and 36.4% illiterate. The proportion of

unemployed reached 73.3%. The average number of household members is 7 while the

mean age of the respondents was 39 year-old. Anthropometric data were analysed using

WHO child growth reference and the prevalence of wasting, underweight and stunting was

3.7% (2.8 - 4.8), 7.0% (5.4 - 9.1) and 14.4% (12.1 - 17.1) respectively. There were no

significant difference between boys and girls. Overweight assessed using weight for height

above two standard deviation of the reference population was at 1.3% among the target

groups. These figures are better than the MICS4 results and are classified as “acceptable”

based on WHO nutrition crisis categorization.

The CMR was at 0.64 (0.36 – 1.16) death per 10,000 people per day while the U5MR was

0.46 (0.18 – 1.15) death par 10,000 children per day. Even though the CMR is high based

on Sphere standard in Middle East countries, most of the reported cases are related to killing

which is link to the current situation.

The investigation on child feeding practices indicated that over 440 children out of 653 were

not exclusively breastfed (67%). Among 264 children who were not breastfed during the

survey, 32% never did so. Vitamin A supplementation coverage was at 26% and target only

children 9 – 59 months. Proportion of women who lost or misplaced the vaccination was

high (73.5%) showing a need to improve sensitization activities on safe keeping of

vaccination card and follow up on vaccination calendar. Approximately one third of the

children were not immunized against Measles but a campaign was ongoing in the same

period.

VII

Fifty one percent among boys and 57% among girls had at least one episode of diarrhoea in

the last fifteen days. These proportions were not significantly different. Similarly, ARI was

dramatically high in this community and affected at least more than half of the sampled

children.

Out of 1,295 respondents, 1,140 (88%) reported having food shortage in the last six weeks.

However, over 97.4% have also indicated receiving food aid in the same period. Access to

safe drinking water was reported by 92% of the households and the main source are water-

trucking, household/institution connections and bottled mineral water. Overall, 67.6% of

sampled households use flush latrines, 18.1% improved latrines with slab and 14.3% open

defecation. However, a high proportion of households were still sharing toilets with an

average of 9 households sharing per toilet.

This survey shows that the nutrition situation, as measured by the prevalence of acute

malnutrition, underweight, stunting and overweight is not alarming. However, the caseload

should raise concerns due to the high number of internally displaced population settled in

the seven target districts. Besides, the inappropriate child feeding practices, high prevalence

of diarrhoea, hygiene issue related to sharing toilets call for immediate actions to address

the underlying causes of malnutrition to prevent further deterioration of the nutrition

situation through the capacity building, technical assistance and provision of supply and

medicines. Community based screening and breastfeeding counselling should be

implemented and scaled up. The underlying causes of undernutrition identified in this

survey call for an integrated approach with Communication for Development, Health

WASH and Nutrition to develop a mulsectoral interventions.

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I. Introduction Since June 2014, the continuous escalation of the armed conflict in northern Iraq has

triggered the displacement of thousands of Iraqis across the Country and mainly in Ninewa

and the Kurdistan Region of Iraq (KRI). Open armed conflict and the threat of sectarian-

based violence have dramatically undermined the living conditions and basic safety of

hundreds of thousands of Iraqis. Communities on the frontline are particularly vulnerable,

as many were already steeped in poverty and deprivation, and have limited capacity to cope

with the economic disruption and other shocks caused by conflict. Under the current

circumstances, the most vulnerable may rapidly succumb to death, injury and illness that is

otherwise preventable.

As of September 1st, International Organization for Migration (IOM) Displacement

Tracking Matrix showed that over 862 458 Internal Displaced Populations (IDPs) has been

settled in the KRI (Dohuk, Erbil and Sulaymaniyah). These three governorates are among

the top height that host the high number of IDPs.

While humanitarian organizations and local authorities continue responding to the most

immediate needs, there are serious concerns about the conditions of the displaced

population. Provision of food, water and sanitation and health services is somehow

challenging in some areas due the high burden and limited accessibility related to security.

Even though the overall population is affected, those living outside the urban areas and at

the boundaries of the disputed internal territories and Children and women in particular are

among the most in need.

In order to reinforce its strategic response to the humanitarian needs, UNICEF in close

collaboration with the Ministry of Health planned to carry out nutrition surveys in three

Governorates of Kurdistan. The purpose of these surveys was to assess the nutrition

situation of the IDPs and gathered additional indicators related to health , food security and

wash among internally displaced populations.

This first survey was carried out in Dohuk and cover the seven districts of the governorate

namely Amedia, Akre, Bardarash, Dohuk, Shikhan, Sumel and Zakho. Dohuk is one of the

three Governorates of Kurdistan. This population has shown a dramatic change since the

arrival of thousands of syrian refugees which was exacerbated by several vagues of IDPs

mainly fron Ninema and Anbar Governorates.

While humanitarian organizations and local authorities continue responding to the most

immediate needs, no representative health and nutrition survey targeting IDPs was carried

out so far. The present survey will serve as baseline information that will inform the current

program and provide evidence based information supporting further assessment on the

progress.

1.1. Survey Objectives

The overall objective of the survey is to assess the nutritional situation, related indicators

and retrospective mortality rate among IDPs settled in Amedia, Akre, Bardarash, Dohuk,

Shikhan, Sumel and Zakho.

The Specific objectives are to estimate the:

- Magnitude of the undernutrition (wasting, underweight and stunting) and crude

and under five mortality rate among the target IDPs

- Infant and Young Child Feeding practices among children 0 – 23 months

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- Coverage of measles vaccination and Vitamin A supplementation among children

- Diarrhoea and ARI rates among children 6 – 59 months in the 2 weeks prior to the

survey

- Food access and household food insecurity situation

- Proportion of households with access to safe water and sanitation

II. Methodology 2.1. Survey area

The nutrition assessment was carried out from September 20 to October 3 in the 7 districts

of Dohuk governorate namely, Amedia, Akre, Bardarash, Dohuk, Shikhan, Sumel and

Zakho. Anthropometric measurements (weight, height, MUAC) was taken from a

representative sample of children aged 6 – 59 months while mothers and caregivers of

children under five were questioned as primary respondent about the child health/nutrition

and household access to food and water.

2.2. Sample size

The proposed sampling methodology was a two-stage cluster randomized sampling with

probability proportional to the size of the population. The Emergency Nutrition Assessment

(ENA) software for Standardized Monitoring of Relief and Transitions (SMART) version

(August 4th, 2014) was used to calculate the required sample size. The sample was calculated

using the nutritional status (wasting) for children 6-59 months and the Crude Mortality Rate

(CMR) for the household sample. The sampling plan is designed to provide representative

estimates in the seven districts as a whole (Governorate level). Estimates for both

anthropometric and mortality indicators are presented in the Table 1 below.

In order to get a representative sample size, 40 clusters of at least 33 children each for a total

1,307 children 6-59 months from 1,559 households were needed for the anthropometric data

while the mortality rate requires 3,717 individuals living in 639 households. Anthropometric

measurement of all eligible children 6 -59 months were selected. In the last household, all

eligible children were included in the anthropometric measurement whether or not we

exceeded the required target number. The estimates of acute malnutrition of 50% was used

instead of MICS4 in 2011 survey data as we expected a deterioration of the nutrition

situation since 2011 following the crisis and the precarious living conditions.

Based on the size of the questionnaire and the travel time from one site to another, it was

estimated that each team would visit 12 households a day. Thus 10 teams of three surveyors

(enumerators and one team leader) for 14 days will be needed to complete the data

collection.

Table 1: The sample size calculation parameters

Estimates Malnutrition Mortality rate

Estimated Prevalence/death rate per 10 000/day 50 1

Desired Precision 4% 0.5

Design effect 2 2

Recall period 90 days

Average household Size 6 6

% of Children Under five 16%

% of non-response Households 3% 3%

Sample Size per

District Children to be included 1,307 3,717

Households to be included 1,559 639

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2.3. Sampling procedure: selecting clusters, households and children

The overall sampling universe was only IDPs settled in Amedia, Akre, Bardarash, Dohuk,

Shikhan, Sumel and Zakho. The target population was estimated to 465,168 as of September

among which an approximate 74,427 children 6 – 59 months. The first level of sampling

identified IDPs locations (schools, unfinished buildings, camps, community centres, etc.)

that were included in this survey. It is based on Directorate of health EPI database. This

database provide the list of health facilities which cover the IDPs locations (catchment

areas). Prior to the survey, DoH staff visited each selected health facility to collect the list

of IDPs locations in which one was randomly selected. If the selected location does not have

enough children, the team was instructed to proceed to the closest one to complete the

required number of children to be surveyed (a minimum of 33 per cluster).

For the second stage sampling, households were selected using the list of households

available in each location. As the IDPs were scaterred in different locations which were

unfinished buildings, camps, schools, community centres, etc., the selection procedure was

adapted to the location itself based on the type of settings. For unfinished buildings, schools,

community centres and similar location, the list of rooms were counted first and ranked.

Based on the list, the first room with IDPs households were randomly selected. All IDPs

living in the same rooms were surveyed whether or not they had an eligible child. The next

room with the closest door was selected and all eligible children included. The same process

was maintained on upon completion of the target children for the cluster.. For camps and

similar locations, the sample selection was based on the modified EPI randmon walk as

recommended by SMART methodology. First the centre of the camp was identified with

the support of the communities. Once the centre of the camp is identified survey teams

spinned a pen to randomly assign the direction towards the edge of the cluster then the team

walks to the boundary of the site. From that end of the location, survey team counts the

number of houses until they reached the other end of the location. Once all the houses in

that direction are counted and assigned consecutive numbers, survey team select a random

number to identify the starting household. Consecutive households were the one with the

closest door until the required number of children was reached. All eligible children 6 – 59

months ifrom selected households ncluded in the antropometric measurement. If the last

household had more than the required number of children to reach the needed sample, all

eligible children were included whether or not we exceeded the required target number.

While anthrometric measurments target only househoilds with eligible children, mortality

questionnaire was administrated to every single household whether or not their is an eligible

child.

2.4. Inclusion criteria and case definitions

The inclusion criteria for anthropometric measurements was children 6 – 59 months and

when the age is unknown a calendar of local events were used (see Annex 1). Households

without target children (6 – 59 months) were also include for mortality, food security and

WASH data. In order to be able to calculate anthropometric indicators (Table 2), the following

meaurement was taken from each eligible child.

Weight: It was measured using a portable mother/child electronic scale, 150kg x 100g. All

children was weighted without any clothes. If not feasible, the clothes was weighted right

after taking the anthropometric measurement and the weight was subtracted from the child

and clothes weight. Every morning, the accuracy of the scale was checked using a 5 kg

weight and no discrepancy was found between measurements during the survey.

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Height: it was determined using a measuring board (precision of 0.1cm). A cut-off point of

87cm was used to select children to whom height was measured lying down (length) or

standing up (height). Children less than 87cm were measured lying down, while those

greater than or equal to 87cm were measured standing up.

MUAC: It was measured at mid-point of the left upper arm of every single child. It has taken

to the closest millimetre using the standard coloured measurement tape.

Oedema: Bilateral pitting oedema was assessed by applying a thumb pressure on top of each

of the child’s feet simultaneously for a period of three seconds (enumerators were instructed

to count 101, 102, 103) and thereafter observe for the presence or absence a pit which mean

presence or absence of oedema.

The age of each child was identified using the existing child administrative or health

documents. When the dates is not known, a calendar of event was used to approximate the

child age. If there is no possibility to use the calendar of event, only child with height 65 to

130 cm were included in the survey.

The additional information including both child related data and household was collected

through a questionnaire divided in modules (see Annex 6).

The crude death rate and under five death rate as well as causes of death were collected and

computed using SMART recommended form. The recall period was approximately 90 days

and the reference date (starting point for the recall period) was 10 days after Mosul attack

by ISIS which falls to 9th of June.

Table 2: Anthropometric and mortality indicators definition

Indicators Definition Cut-off points

WHZ (wasting)

Number of children 6-59m who fall

below minus 2SD from the median

weight-for-height of WHO Growth

Standards

Normal: ≥ -2SD

Moderate: ≥ -3 & < -2SD and No

oedema

Severe: < -3 SD

WAZ (Underweight)



weight-for-age of WHO Growth

Standards

Normal: ≥ -2SD

Moderate: ≥ -3 & < -2SD

Severe: < -3 SD

HAZ (Stunting)



height-for-age of WHO Growth

Standards

Normal: ≥ -2SD

Moderate: ≥ -3 & < -2SD

Severe: < -3 SD

Mid-upper circumference Number of children 6-59m with a

MUAC value below 125mm

Normal: ≥ 125 mm

Moderate: ≥ 115 & < 125mm

Severe: < 115mm

Nutritional oedema

Number of children 6-59m with

bilateral pitting oedema (depression on

both feet after 3 seconds of thumb

pressure)

Yes: If any

Crude retrospective mortality Number of deaths within the overall

surveyed population during recall period

Emergency: 0.3 death/10 000

persons/day

Under five crude retrospective

mortality

Number of deaths within under five

children during recall period

Emergency: 0.5 death/10 000

U5/day

2.5. Training and supervision

Prior to field work, three days training of enumerators (32) and supervisors (5) took place

in Dohuk Preventive Health Affairs office in order to ensure accuracy and precision of

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collected data. The training covered an introduction to nutrition assessments, the survey

objectives, anthropometric measurements, the household selection procedures, data

collection and interviewing approach. The survey questionnaire was reviewed to ensure a

common understanding of each question. Following the discussions with the team and

Directorate of health focal person, the questionnaire was not translate into local languages.

With regard to the anthropometric measurement, each team comprising of two enumerators

and one team leader went through a standardization test. The team leader and the

enumerators took the weight, height and MUAC of 10 children twice. These measurements

were checked against the surveyor’s one for accuracy and precision. The accuracy i.e.

differences between the enumerator values and the Supervisor’s values and the precision

(differences between the two measurements from the same enumerator) was computed

using ENA software “evaluation of enumerators”. Standardization measurements (see

Annex 3) were repeated to ensure that all enumerators have the acceptable level of accuracy

and precision prior to data collection. Supervisors were trained how to control the quality

of data before leaving the area. They were instructed to check the completeness and

accuracy of information taking into consideration the link between questions and sign at the

first page for quality assurance.

2.6. Data collection

Data collection was carried out from September 20 to October 3 in the target districts.

Anthropometric, mortality and key child health and household variables were collected

using a standardized questionnaire. In addition to the team of three who were collecting the

data, five supervisors (from Dohuk DoH and UNICEF) oversaw the overall the data

collection and monitor data completeness and quality. Prior to the field visit, each team

received a list of locations already randomly selected (see Annex 4). In each location, the

team leader randomly select the first household to be interviewed using the aforementioned

standardized protocol.

With regard to the anthropometric measurements, data were collected from all children in

the selected households within the eligible age range (6 - 59 months) using anthropometric

questionnaire. Weight was measured using a portable mother/child electronic scale, 150kg

x 100g. All children were weighted without any clothes. If not feasible, the clothes weight

was taken and subtracted from the child and clothes weight. Height was determined using a

measuring board (precision of 0.1cm). A cut-off point of 87cm was used to select children

to be measured lying down or standing up. Children less than 87cm were measured lying

down, while those greater than or equal to 87cm were measured standing up. The age of

each child was identified using administrative or health documents (birth certificate,

vaccination card etc.). The calendar of events were not used even though the enumerators

were trained on how to use it if needed. For the accuracy of collected data, the weight scales

were calibrated every 2 days against 5kg weight. No discrepancy was observed all along the

survey.

In order to ensure the quality and validity of the information, the addition measures

described below were taken

• Children should be selected by using the house-to-house method and teams were not

allowed to gather all children at a central location for measurement

• If the team runs out of houses to measure, they were instructed to go to the next

nearest IDPs location not included in the selected list to completed the required

sample

• No Household substitution can be made for any reason

• If two eligible children are found in a household, both were included, even if they

6

are twins

• if there are no children under the age of five in a household, this house should remain

for the mortality survey

• If a child lives in the house but is not present at the time of the survey, The team

should continue to look him by re-visiting the household until they left the survey

area

• Disabled children should be included where possible. If weight or height can be

measured, it should be recorded as missing

Data entry for the anthropometric measurements were conducted and the data quality

ascertained by supervision before leaving the area. Morining meetings were set with the

teams to provide feedback on their data quality and solve any issues that were raised before

the following day.

2.7. Data analysis

Anthropometric and mortality data were analysed using ENA software 2011 (last updated

August 4th, 2014). All the remaining child related-data and household variables were

entered and analysed using SPSS 16.0. Prior to analysis collected anthropometric data were

double entered and cleaned while the other data were checked using SPSS and any

consistent information were double checked and corrected accordingly. Telephone number

of the respondents were collected in order to be able to call back if needed. Anthropometric

variables were analysed against World Health Organization 2006 growth standards.

Extreme z-score values were further investigated and appropriately excluded in the final

analysis if deviating from the observed mean (SMART flags). Anthropometric indices are

flagged when they are out the ranges below:

- Weight for Height: -3 Z-Scores WHZ < 3 Z-Scores

- Weight for Age: -3 Z-Scores WAZ < 3 Z-Scores

- Height for Age: -3 Z-Scores HAZ < 3 Z-Scores

III. Results 3.1. Anthropometric results (based on WHO standards 2006):

Data collection was carried out from September 20 to October 1, 2014. Overall, 1,295

households were visited in the seven districts and 1,600 children were reached. Among

these, 17 children were excluded in the analysis (15 were out of home during the field visits

despite several visits by the teams while 2 had inconsistent data). The distribution of the

selected children (n = 1,583) are summarized below (Figure 1).

Figure 1: Distribution of the sample

(1583 children) within the target

districts

Table 3 below summarizes the age and sex distribution of the surveyed children. The

distribution of the sample by age and sex for children the sampled population revealed that

the overall sex ratio was 1.0, which is expected for a normally distributed populations

Akre, 3%Amedia, 8%

Bardarash, 8%

Duhok, 24%

Sheikhan, 5%

Summel, 24%

Zakho, 28%

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especially for <5 years. The distribution of boys and girls within the different age groups

did not show any major discrepancies and ranges from 49% to 57.2% and from 42.8 to 51%

for boys and girls respectively.

Table 3: Distribution of age and sex of sample

Age group (months) Boys Girls Total Ratio

N % n % n % Boy: girl

6 – 17 195 49.0 203 51.0 398 25.2 1.0

18 – 29 166 51.4 157 48.6 323 20.5 1.1

30 – 41 180 52.5 163 47.5 343 21.7 1.1

42 – 53 176 52.5 159 47.5 335 21.2 1.1

54 – 59 103 57.2 77 42.8 180 11.4 1.3

Total 820 51.9 759 48.1 1579 100.0 1.1

a) Prevalence of Global Acute Malnutrition (GAM); wasting

The global acute malnutrition rate or wasted (WHZ) was estimated using weight for height

index expressed in z-score and or bilateral pitting oedema. Weight for height index are

calculated based on WHO 2006 growth standards. Results disaggregated by sex are

presented in Table 4 with the number of affected children and 95% Confidence interval.

The Global Acute Malnutrition (GAM) rate was 3.7% (95% CI: 2.8 – 4.8), with Severe

Acute Malnutrition (SAM) at 0.2% (95% CI: 0.1 – 0.6). No children had bilateral pitting

oedema. Besides, there is no significant difference between boys and girls with regard to

the level of acute malnutrition. These results indicate that the GAM prevalence is far below

15%, the emergency threshold as defined by WHO nutrition crisis categorization using

global acute malnutrition. The situation for both GAM and SAM are classified as

“Acceptable” in this community. Table 4: Prevalence of Global Acute Malnutrition (GAM) by sex after exclusion of SMART flags

Variables All

(n = 1555)

Boys

(n = 809)

Girls

(n = 746)

Prevalence of Global Acute Malnutrition

(GAM)

(<-2 z-score and/or oedema)

(n = 57) 3.7%

(2.8 - 4.8)

(n = 30) 3.7%

(2.5 - 5.4)

(n = 27) 3.6%

(2.4 - 5.3

Prevalence of Moderate Acute

Malnutrition (MAM)

(<-2 z-score and ≥-3 z-score, no oedema)

(n = 54) 3.5%

(2.7 - 4.5)

(n = 28) 3.5%

(2.3 - 5.2)

(n = 26) 3.5%

(2.4 - 5.1)

Prevalence of Severe Acute Malnutrition

(SAM)

(<-3 z-score and/or oedema)

(n = 3) 0.2%

(0.1 - 0.6)

(n = 2) 0.2%

(0.1 - 1.0)

(n = 1) 0.1%

(0.0 - 1.0)

The prevalence of oedema is 0.0%

The disaggregation of the acute malnutrition rate by age shows a GAM rate of 6.6% and

5.1% among children 6 – 17 months and 54 – 59 months respectively while it varies from

1.9% to 2.6% for the three other age groups (Table 5). If we consider only the 57

malnourished children, the age group 6 – 17 months old are the most affected ones (45.6%)

one compare to other age groups 18-29 (10.5%), 30-41 (15.8%), 42-53 (12.3%) and 54-59

(15.8%).

8

Table 5: Prevalence of acute malnutrition by age based on the weight for height

Age in months Total

children

Severe wasting

(<-3 z-score)

Moderate wasting

(≥-3 & <-2 z-score )

Total wasting

(<-2 z-score)

N n % n % n %

6 – 17 391 1 0.3 25 6.4 26 6.6%

18 – 29 317 0 0.0 6 1.9 6 1.9%

30 – 41 340 1 0.3 8 2.4 9 2.6%

42 – 53 331 1 0.3 6 1.8 7 2.1%

54 – 59 176 0 0.0 9 5.1 9 5.1%

Total 1555 3 0.2 54 3.5 57 3.7%

The distribution curve of sampled children as preented Figure 2 in are practically the same

that WHO distribution curve for the population of reference. This shows that the level of

acut malnutrition is in the accepatble range and is not a public health problem in this

community.

Figure 2: Z-Score Distribution of Weight for Height for the sample

Mid-upper arm circumference (MUAC) was used as a proxy of wasting. It is also known as

a good predictor of acutely malnourished children (6 – 59 months) most at risk of death.

Nutrition status was classified as severe, moderate or normal based on WHO cut-off point

(Table 6). Overall, the prevalence of wasting based on MUAC measurements is 2.1% among

which 0.6% are severely wasted. Children 6 – 17 months old (the youngest group) are the

most affected. This is in line with the expected results as younger children have smaller

MUAC than the older one and are more likely to be classified as malnourished (MUAC <

125mm).

9

Table 6: Prevalence of acute malnutrition by age, based on MUAC cut off's

Age in months Total children

Severe

wasting (< 115mm)

% (n)

Moderate wasting

(≥115 & < 125mm)

% (n)

Normal

(≥ 125mm)

% (n)

6 – 17 398 2.0 (8) 5.3 (21) 92.7 (369)

18 – 29 323 0.3 (1) 0.6 (2) 99.1 (320)

30 – 41 343 0.0 (0) 0.0 (0) 100.0 (343)

42 – 53 335 0.3 (1) 0.0 (0) 99.7 (334)

54 – 59 180 0.0 (0) 0.0 (0) 100.0 (180)

Total 1579 0.6 (10) 1.5 (23) 97.9 (1546)

b) Prevalence of underweight

Underweight (WAZ) is defined as weight for age below minus 2 SD of WHO 2006 growth

standards. Underweight is a combination of wasting (mostly seen as short term consequence

of growth failure) and stunting (mostly seen as long term consequence of growth failure). It

is often used for child growth monitoring programs. The results presented in Table 7 show

that 7.0% (95% CI: 5.4 - 9.1) of target children are underweight and there is no significant

difference between boys and girls. Similarly, the prevalence of severe underweight is 0.9%

(95% CI: 0.4 - 1.7) and 0.5% (95% CI: 0.2 - 1.4) for boys and girls respectively. No

significant difference is observed. Table 7: Prevalence of underweight by sex and after exclusion of SMART flags

Variables All

(n = 1567)

Boys

(n = 815)

Girls

(n = 752)

Prevalence of underweight

(<-2 z-score)

(n = 110) 7.0%

(5.4 - 9.1)

(n = 53) 6.5%

(4.5 - 9.3)

(n = 57) 7.6%

(5.9 - 9.7)

Prevalence of moderate underweight

(<-2 z-score and >=-3 z-score)

(n = 99) 6.3%

(4.8 - 8.2)

(n = 46) 5.6%

(3.8 - 8.4)

(n = 53) 7.0%

(5.4 - 9.1)

Prevalence of severe underweight

(<-3 z-score)

(n = 11) 0.7%

(0.4 - 1.2)

(n = 7) 0.9%

(0.4 - 1.7)

(n = 4) 0.5%

(0.2 - 1.4)

WHO classifies the severity of underweight as low when the prevalence is below 10%,

medium 10% – 19%, high 20% – 29% and very high when it is equal or above 30%. Based

on these cut-off point, the prevalence of underweight which is at 7.0% is not a public health

problem in this community. However and as presented in Figure 3, the distribution of the

sample with regard to underweight shows a slight shift to the left compared to WHO

population of reference. This findings revealed a public health issue even minor that need

to be address while developing prevention strategy.

10

Figure 3: Z-Score Distribution of Weight for Age for the sample

c) Prevalence of chronic malnutrition (Stunting)

Chronic malnutrition or stunting is defined as height-for-age (HAZ) beneath minus two

standard deviations of WHO child growth standards. As the other form of undernutrition

described above, it is a direct of cause of inadequate dietary intake and diseases over a

prolonged period. The survey findings summarized in Table 8 revealed that 14.4% (95% CI:

12.1 - 17.1) of the children have impaired linear growth among which 2.6% (95% CI: 1.8 -

3.6) are severe. The prevalence of stunting does not show any significant difference between

boys 13.5% (95% IC: 10.7 - 16.8 9 and girls 15.5% (95% CI: 12.2 - 19.5). Based on WHO

classification of the severity of stunting in a given community, the situation with regard to

chronic malnutrition is “low” as the cut-off point for emergency is when the prevalence

exceed 30%.

Table 8: Prevalence of stunting by sex and after exclusion of SMART flags

Variables All

(n = 1524)

Boys

(n = 793)

Girls

(n = 731)

Prevalence of stunting

(<-2 z-score)

(n = 220) 14.4%

(12.1 - 17.1)

(n = 107) 13.5%

(10.7 - 16.8 9)

(n =113) 15.5%

(12.2 - 19.5)

Prevalence of moderate stunting

(<-2 z-score and >=-3 z-score)

(n = 81) 11.9%

(9.8 - 14.4)

(n = 82) 10.3%

(8.2 - 13.0)

(n = 99) 13.5%

(10.5 - 17.2)

Prevalence of severe stunting

(<-3 z-score)

(n = 39) 2.6%

(1.8 - 3.6)

(n = 25) 3.2%

(1.9 - 5.1)

(n = 14) 1.9%

(1.1 - 3.4)

The distribution curve of stunting shows a deviation to the left in comparison to WHO child growth

reference population (Figure 4).

Figure 4: Z-Score Distribution of Height for Age for the sample

11

d) Prevalence of overweight based on WHZ

Overweight is defined as weight for height above 2 standard deviations without oedema of

WHO growth standard. It is a predictor of malnutrition among the target children and has

to be addressed as undernutrition. It is found (Table 9) that the prevalence of overweight is

1.3% (95% CI: 0.8 - 2.1) with no significant difference between boys and girls.

Table 9: Prevalence of overweight by sex

Variables All

(n = 1555)

Boys

(n = 809)

Girls

(n = 746)

Prevalence of overweight (WHZ > 2) (n = 20) 1.3%

(0.8 - 2.1)

(n = 10) 1.2%

(0.7 - 2.3)

(n = 10) 1.3%

(0.7 - 2.5)

Prevalence of severe overweight

(WHZ > 3)

(n = 0) 0.0%

(0.0 - 0.0)

(n = 0) 0.0%

(0.0 - 0.0)

(n = 0) 0.0%

(0.0 - 0.0)

3.2. Retrospective mortality results

Mortality rate is expressed as the number of death per 10,000 people among the target

population (or among children under five) per day. The crude mortality rate (CMR)

measures the death rate in the overall population while the under-five death rate (U5MR) is

specific to this age group. Death rate is a crucial indicator particularly in emergency where

an elevation of mortality may occur due to the living conditions and overwhelming unmet

needs. The results presented in Table 10 show 0.64 death (0.36 – 1.16; 95% CI) per 10,000

people per day while it is 0.46 death (0.18 – 1.15; 95% CI) per 10,000 children per day.

According to the Sphere project, the CMR and U5MR emergency thresholds are 0.3 and 0.5

respectively for Middle East countries. These figures demonstrate that the level of mortality

is high for the overall population as it is more than the double of the emergency threshold

while the U5MR is below the cut-off point for emergency.

Among the 40 reported deaths in the overall population 33 were adults and 7 were children

under five years old. The main causes of death were diseases (30.0%), killing (30.0%) and

unknown (22.5%). A throughout analysis of the reported diseases as causes of death among

adults are chronic diseases. The killing due to the current crisis was also reported as a main

causes of death. Even though the number of death among under five children is not high

based on WHO emergency threshold, most cause of death are preventable (43% were related

to dehydration, 29%, to hunger and 14% to diarrhoea.

Table 10: Crude and under five mortality rates

Total deaths (95% CI)

Crude mortality rate 0.64 (0.36 – 1.16; 95% CI)

Under five mortality rate 0.46 (0.18 – 1.15; 95% CI)

3.3. Households socio-economic characteristics

As summarized in Table 11, out of 1,295 persons questioned, more than 95% are married

followed by widowed 3%, single 1% and divorced 0.2%. There was no orphan among the

participants. The education level is low in this community with 36.4% with no formal

education. As main respondents were also women, this shows somehow the low level of

12

education among women. An overwhelming number of respondents (73.3%) are

unemployed. Government civil servants represent 26.6% of the sample while the other main

sources of income are wage employment (14.1%) and casual labour (7.3%). The mean age

of mothers or primary caregivers is 39 years. The distribution of age among interviewed

women revealed that 48.8% are between 14 to 35 years older while women represent 51.2%.

Approximately the average household size is 7 persons and 24.8% households did not have

a child under five years old. Among the 974 household that had, children under five year-

old, 42% had only one child under five years of age; 41% with two children, 11% with three

children under five and the remaining (3.3%) had four to nine children under five.

Table 11: Respondent background information and households socioeconomic characteristics

Variables % or mean ± SD

(n = 1295)

Respondent marital status

Married

Single

Divorced

Widowed

Orphan (under 18 years old)

95.8%

1.0%

0.2%

3.0%

0.0%

Respondent level of education

Illiterate

Read alone

Read and write

Secondary

Above secondary

36.4%

5.8%

15.1%

6.3%

7.0%

Respondent main occupation

Business

Vocational skills

Casual labour

Wage employment

Government employment

Unemployment

Retired

0.4%

2.3%

7.3%

14.1%

26.6%

73.3%

0.1%

Mean age of respondents 39.0 ± 12.4

Distribution of the age of the respondents (Years)

15 – 25

26 – 35

36 – 45

46 and older

10.7%

35.1%

31.3%

22.9%

Number of household members 6.9 ± 3.4

Number of children under five (n = 1058)

1.7 ± 1.0

Distribution by age among the youngest child in the household (mo)

0 – 5.9

6 – 23.9

24 – 59.9

60 & older

(n = 968)

14.4%

48.3%

35.2%

2.1%

3.4. Infant and young child feeding practices

Infant and young child feeding practices was assessed even though the sample was not

specifically designed to investigate these questions. Though, the findings were derived from

a sub sample of 592 children under 24 months of age with represents approximately 45.7%

of the target group (children 6 – 59 months) sample in this survey. As summarized in Table

13

12, the proportion of children being breastfed based on mothers recall was 59.5% and 58.4%

among boys and girls respectively. There is no significant difference between boys and girls

(p 0.05). Among the 264 children were not currently breastfed, approximately, 32% were

never breastfed. The disaggregation of this results by sex shows no significant difference

between boys and girls (p 0.05). In order to assess the exclusive breastfeeding rate among

the target community, the early introduction of food or liquid other than breast milk was

investigated. The findings revealed that over 440 women out of 653 (67.4%) of the sample

have provided food or liquid in the first three days after child birth. There were no significant

difference between boys and girls.

Table 12: Infant and young child feeding practices

Variables %

Children under 24 months currently breastfed

Total sample

Male (n = 284)

Female (n = 308)

(n = 592)

59%

59.5%

58.4%

Children under five that have never breastfed

Total sample

Male (n = 122)

Female (n = 142)

(n = 264)

31.8%

36.6%

26.2%

Children U5 that received food or liquid in the first three days

Total sample

Male (n = 307)

Female (n = 346)

(n = 653)

67.4%

69.4%

65.1%

3.5. Vitamin A supplementation and immunization It well known that micronutrient deficiencies are among the most widespread health public

problem worldwide and vitamin A supplementation has a positive impact on reducing child

morbidity and mortality. Based on this, WHO has recommended countrywide

supplementation of vitamin A targeting children 6 – 59 months at least twice a year.

In Iraq, vitamin A supplementation is part of the immunization calendar but target only

children from 9 – 59 months. In this survey, we measured the coverage of vitamin A

supplementation campaign; it was found the coverage of vitamin A supplementation is very

low among these children (Table 13). The results showed that over 26% among 658 children

9 – 59 months have received vitamin A supplementation within the last six months prior to

the survey (26% among girls and 22% among boys (p 5%)). Besides, a little proportion

of children had vaccination cards during the home visits (16.6%) while most of them have

received one but it was either lost or misplaced (73.5%). Mothers reported that 76.6% of the

children were vaccinated against Measles. This findings should be linked with the Measles

campaign which was ongoing in the targets districts during the survey period.

14

Table 13: Vitamin A and measles coverage

Variables %

Vitamin A supplementation coverage among children 9- 59 months

Total Sample

Boys (n = 365)

Girls (n = 293)

(n = 658)

25.7%

24.1%

27.6%

Children having vaccination card Yes, seen by interviewer Not available/ lost/misplaced Never had a card Don’t know

(n = 914)

16.6

73.5%

9.1%

0.8

Measles vaccine coverage

Total sample

Boys (n = 466)

Girls (n = 366)

(N = 832)

76.6%

77.5%

75.4%

3.6. Prevalence of child morbidity

The vicious cycle infections and malnutrition impairs the life and well-being on millions of

children worldwide. In this survey, we have assessed the frequency of the diarrhoea and

Acute Respiratory Infection (ARI) in the last two weeks before the survey. As presented in

Mothers reported

51% among boys and 57% among girls had at least one episode of diarrhoea in the last

fifteen days. These proportions were not significantly different. Similarly, ARI is

dramatically high in this community with at least more than half of the sample affected in

the last two weeks. The Table 14 revealed that at least 468 children were sick in the last two

weeks prior to the survey.

Table 14: Prevalence of diarrhea and ARI

Variables %

Children with diarrhoea in the last 2 weeks before the survey

Total sample

Boys (n = 516)

Girls (n = 419)

(N = 935)

53.6

51.2%

56.6%

Children with ARI the last 2 weeks before the survey

Total Sample

Boys (n = 518)

Girls (n = 419)

(N = 937)

58.1%

58.2%

3.7. Household food Security

Due to its impact on household diet diversity and undernutrition, food security was

investigated and the main findings were summarized in Table 15. Out of 1,295 respondents,

1,140 (88%) reported having food shortage in the last six weeks. However, over 97.4% have

also indicated receiving food aid in the same period. Observation data during the data

collection corroborated these findings as food from diverse organizations were found in

most of the visited households. Among 1,261 households that have received food aid, 78.5%

were provisioned three time or more, 13.7% twice and 7% once within six weeks. This is in

line with the reported number of meals. Almost, the overall selected households have at

least three meals a day. Even though the frequency of meals looks like adequate, the dietary

diversity and quality were not investigated.

15

Table 15: Household food security

Variables % (n = 1295)

Reported household food shortage the last 6 weeks 88%

Household that have received food aid the last 6 weeks 97.4%

Average number of food aid received

Once

Twice

Three or more

Don’t know

7.0%

13.7%

78.5%

0.8%

Average number of meals per day the last 6 weeks

Once

Twice

Three or more

0.5%

0.9%

98.5%

3.8. Water access and hygiene

Lack of potable water and poor hygiene has detrimental consequences on child morbidity

and survival. Access to safe water and household hygiene was explored and Table 16

summarized the main outcomes. With regard to drinking water, 92% of the households have

access to safe drinking water which are mainly water trucking, household/institution

connections and bottled mineral water. As shown in the table below, 67.6% of sampled

households use flush latrines, 18.1% improved latrines with slab and 14.3% open

defecation. Even though the proportion of household having access to improved latrines

was high, observations revealed poor latrines cleaning practices. Besides, more than three

quarter of the sample share the toilets (96.4%) with an average of 9 households sharing the

same toilet. Taking into consideration the average number of household members of six,

approximately 54 persons use the same toilet.

Table 16: Access to safe water and household hygiene

Variables % (n = 1295)

Household main source of drinking water

Safe Water Source (household connection, tap water, public

standpipe, borehole, protected dug well, protected spring, tanker

truck water, mineral water)

92.1%

Type of toilet facility

Flush latrine

Improved latrine with cement slab

Open air

67.6%

18.1%

14.3%

Households sharing toilets

Not shared

Shared households

Public toilet

Don’t know

3.4%

95.8%

0.6

0.2

Average number of household using the same toilets 8.7 ± 6.5

IV. Discussion The survey was carried out under the lead of the Department of nutrition of Duhok -

Directorate of preventive health affairs and target Internally Displaced Population settled in

the districts of Amedia, Akre, Bardarash, Dohuk, Shikhan, Sumel and Zakho. The data

16

collection took 14 days from September 20 to October 3 and involved 32 trained

enumerators and 5 supervisors. Seven districts and over 40 IDPs locations were visited.

Participation in the survey was on a volunteer basis and verbal consent was asked to all

respondents prior to any interviews or anthropometric measurements.

Following the influx of high number of refugees and IDPs in these districts and the potential

burden on the existing resources, it was expected critical nutrition situation among the target

children. Though, the sample size was calculated based on this assumption and using

SMART methodology as a standardized method to derive representative data from the target

community. Overall, the anthropometric measurement were taken from 1,600 children

among which 1,583 were used for final analysis. Nutrition status was calculated using

Emergency Nutrition Assessment software and against WHO 2006 child growth references.

The anthropometric findings revealed that the levels of wasting, underweight and stunting

were 3.7%, 7.0% and 14.4% respectively. These values are below the emergency threshold

as defined by the World Health Organisation. Besides, there were no significant difference

between boys and girls. Taking into consideration the lack of nutritional information on the

target population in their governorate of origin (Ninewa and Anbar), the present result was

compared to the last MICS4 survey which was carried out in 2011. MICS results showed

that a prevalence of wasting at 6.9%, underweight 8.4% and stunting 22.3%. These findings

revealed a significant higher prevalence of wasting and stunting in the Iraq population

compared to IDPs population while underweight was almost at the same level. Even though,

the nutrition status of the IDPs was much better, the lack of information on any seasonal

variation of the level of undernutrition does not allow any further conclusion. Similarly, the

level of overweight based on weight for height above two standard deviation of the reference

population was significantly low among IDPs (1.3%) while it reached 11.1% among the

overall population in 2011.

This survey shows that the nutrition situation, as measured by the prevalence of acute

malnutrition, underweight, stunting or overweight was not alarming. However, the caseload

should raise a major concern due to the high number of internally displaced population

settled in the seven target districts. As of October 2014, it was estimated that over 443,610

IDPs live in Dohuk. Based on these figures approximately 2,626 children are wasted, 4,968

underweight and 10,221 stunting. The wasting cases were particularly an issue due to the

lack of community-based screening to identify and refer malnourished children and the low

coverage of nutrition rehabilitation services. This situation calls for immediate action to

strengthen the management of acute malnutrition to ensure early identification of

malnourished child for treatment. This is particularly important as it is well established the

severely wasted children are at higher risk of death compared to those who are not wasted.

The risk is again higher when the child is both wasted and stunted. Besides, its short-term

consequences on child morbidity and mortality, stunting has also long-term consequences

that can jeopardize the future of affected children. The proposed actions should be integrated

into the overall Integrated Management of Childhood diseases combined with raising

awareness of key family practices.

The survey investigated the child feeding practices, vitamin A supplementation and measles

coverage and level of child morbidity. Caregivers were questioned about breastfeeding

practices and early introduction of food and liquid in the first three days after birth in

particular. It was found that 67.4% received food or liquid in the first three days after birth.

This shows that most of the target children were not exclusively breastfed. Among 264

children who were not breastfed, 32% never did so. These results were in line with the

17

MICS4 finding with an exclusive breastfeeding rate at 18.6% and revealed widespread

inappropriate child feeding practices among this community. It supports also the need to

introduce community and facility based infant and young child feeding capacity building to

raise awareness and provide counselling support to women in need. Breastfeeding is the

most effective way to protect infants and children from common childhood diseases. It is

well established that suboptimal breastfeeding play a critical role on child morbidity and

mortality. In addition to these findings, it was noted in several occasions that partners were

distributing breastmilk substitutes to IDPs without any control or specific support to mothers

and caregivers. This is a real concern and need immediate actions from the humanitarian

actors to implement mechanism to control the procurement, management and distribution

of breastmilk substitutes.

Providing vitamin A supplements to children 6 – 59 every 4 to 6 months is recommended

by the World Health Organization as a public health approach to improve child survival and

health. In this survey, it was notable that vitamin A Coverage was very low (25.7%).

Measles coverage was in opposite higher (76.6%). In comparison to MICS results which

was 64.2%, there is an improvement on the coverage but need to be scaled up to 90% at

least. It worth to note that there was Measles campaign ongoing during the survey and this

did not include vitamin A supplementation. This is a miss-opportunity as it could be used

to integrate activities and raise awareness on key family practices (IYCF, hand washing,

using iodized salt, etc.)

The high prevalence of diarrhoea (54%) and acute respiratory infection (58%) were among

the issues that need to be addressed by humanitarian actors due to their contribution on child

morbidity including malnutrition and mortality. The high level of diarrhoea, the high

proportions of households sharing the same toilet (96%) and the open defecation (14%)

should be considered together and call for intersectoral actions between Water and

Sanitation, health, communication for development and nutrition sectors.

With regard to food security, it was reported over 97% of the interviewed households have

received food aid the last 6 weeks prior to the survey. Even though the proportion of

household having food aid is high (88), the number of households receiving food aid and

the average number of meals support the fact that food access was not an issue. However,

observations along the data collection has shown the partners have not been using fortified

food for the general food distribution. These actions do not support the reduction of

micronutrient deficiency.

V. Conclusions The aim of this nutrition survey was to increase the understanding of the nutrition situation

among IDPs in the target districts. It also serves as baseline to gather key information that

support the implementation of evidence based interventions to tackle the contributing

factors to malnutrition (triple burden of undernutrition, micronutrient deficiencies and

overweight).

Even though, the nutrition indicators related to wasting, underweight and stunting was not

alarming, the inappropriate feeding practices (suboptimal breastfeeding), high level of child

diseases (diarrhoea and ARI in particular) and hygiene issues showed a need to develop a

multisectoral actions plan to prevent further deterioration of the situation.

This report should serve as a programmatic tool for the local authorities and partners to plan

and design interventions to improve promotion of children’s growth and wellbeing.

Considering the low coverage of the nutrition rehabilitations, in the Governorate and the

18

lack of referral system from IDPs sites to the health facilities, there is a real concern about

the management of these current cases of acute malnutrition. It is likely that most of the

wasted children will not have access to therapeutic or supplementary feeding services as

there is no mechanism in place to support early screening and referral of the children.

VI. Recommendations Although the nutrition situation as measured by the rates of wasting, underweight, stunting

and overweight is not alarming, the nutrition sector should reinforce the preventive activity

and work closely with other sectors such as health, C4D and WASH to develop integrated

approach to respond to the multifactorial causes of malnutrition. Meanwhile, specific

actions should be taken to treat existing cases. In order to respond to the issues identified in

this survey, the following actions should be implemented.

- Strengthen the nutrition rehabilitation centres as part of the Integrated Management

of Childhood Illnesses (IMCI) to ensure provision of services to the exiting cases

- Develop a nutrition surveillance system based on the routine data as the growth

monitoring activities which is already in place in many health facilities

- Trained Health professional on Infant and young child feeding practices and support

the implementation of IYCF activities at both health facilities and community level.

- Develop guidance for integrated management at community and health facility level

addressing ARI, diarrhea and malnutrition

- Develop guidance on BMS & advocate for the use of fortified food in both blanket

and target distribution

- Conduct an integrated vitamin A supplementation and advocate for the inclusion of

children from 6 months of age. Use every opportunity especially related to

immunization (Measles, polio..) to integrate Vitamin A supplementation

- Set up an integrated action plan between nutrition and other sectors such as C4D,

WASH and Health to develop a multisecoral approach to address the underlying

causes of undernutrition.

- Advocate for a nutrition working group to engage partners on nutrition interventions

VII. References 1. SMART. Measuring Mortality, Nutritional Status, and Food Security in Crisis

Situations: SMART Methodology, Version 1 (April 2006); 129 pages

2. IOM Iraq Displacement Tracking Matrix (DTM), January 1 to September 28, 2014

3. Iraq Multiple Indicator Cluster Survey 2011. Preliminary Report (April 2012); 68

pages

4. UNICEF. Rapid Assessment Sampling in Emergency Situations. 2010; 44 pages

5. Tanya Khara & Carmel Dolan, technical Briefing paper: The relationship between

wasting and stunting, policy, programming and research implications: Emergency

Nutrition Network (ENN); July 2014 39 pages

6. Robert E Black, Lindsay H Allen, Zulfi qar A Bhutta & al for the Maternal and Child

Undernutrition Study Group. Maternal and child undernutrition: global and regional

exposures and health consequences. Lancet 2008; 371: 243-60

7. Zulfi qar A Bhutta, Jai K Das, Arjumand Rizvi, & al for the Maternal and Child

Undernutrition Study Group. Evidence-based interventions for improvement of

maternal and child nutrition: what can be done and at what cost? Lancet June 6, 2013

http://dx.doi.org/10.1016/S0140-6736(13)60996-4

http://dx.doi.org/10.1016/S0140-6736(13)60996-4

19

8. Maaike Bruins and Klaus Kraemer. Public health programmes for vitamin A

deficiency control. Community Eye Health Journal 2013; 26 (84): 69 – 70

9. WHO. Guideline: Vitamin A supplementation in infants and children 6-59 months

of age. Geneva, World Health Organization, 2011

10. WHO. Malnutrition: Quantifying the health impact at national and local levels.

Environmental Burden of Disease Series, 2005; No. 12: 51 pages

11. Francesco Checchi and Les Roberts. Interpreting and using mortality data in

humanitarian emergencies: A primer for non-epidemiologists. Humanitarian Practice

Network 2005; 54: 41 pages

12. The Sphere Project. Humanitarian Charter and Minimum Standards in Humanitarian

Response, 2011: 203 pages

13. Helen Young, Annalies Borrel & al. Public nutrition in complex emergencies. Lancet

2004; 364: 1899–909

14. WHO. WHO child growth standards and the identification of severe acute

malnutrition in infants: A Joint Statement by the World Health Organization and the

United Nations Children’s Fund, 2009: 12 pages

15. Ma del Carmen Casanovas, Chessa K. Lutter & al. Multi-sectoral interventions for

healthy growth. Maternal and Child Nutrition (2013), 9 (Suppl. 2), pp. 46–57

16. IFE Core Group. Infant and Young Child Feeding in Emergencies: Operational

Guidance for Emergency Relief Staff and Programme Managers. IFE 2007;

Version2.1: 28 pages

17. Save the Children UK. Infant and Young Child Feeding in Emergencies: Why are we

not delivering at scale? A review of global gaps, challenges and ways forward. Save

the Children 2012; 52 pages

18. Jehangir Khan, Linda Vesel & al. Timing of breastfeeding initiation and exclusivity

of breastfeeding during the first month of life: Effects on neonatal mortality and

morbidity—A Systematic Review and Meta-analysis. Matern Child Health 2014 Jun

4 doi 10.1007/s10995-014-1526-8

19. Shams Arifeen, Robert E. Black & al. Exclusive Breastfeeding Reduces Acute

Respiratory Infection and Diarrhea Deaths Among Infants in Dhaka Slums. Pediatrics

2001; 108(4): e67

20. WHO. The WHO Child Growth Standards. http://www.who.int/childgrowth/en/.

September 2014

21. WFP. Measuring and interpreting malnutrition and mortality, 2005: 222 pages

22. WHO. Guidelines: Updates on the management of severe acute malnutrition in

infants and children. WHO 2013: 123 pages

23. John Hoddinott, Harold Alderman & al. The economic rationale for investing in

stunting reduction. Maternal and Child Nutrition (2013), 9 (Suppl. 2), pp. 69–82

http://www.who.int/childgrowth/en/

20

VI. Annexes

Annex 1: Calendar of events

Months 2009 2010 2011 2012 2013 2014 January

56 44 32 20 8

February 55 Chella

Zivastany (2

of February)

43 Chella

Zivastany (2

of February)

31 Chella

Zivastany (2 of

February)

19 Chella

Zivastany (2 of

February)

7

Chella Zivastany

(2 of February)

March 54 Nawroz (21 of

march)

42 Nawroz (21

of march)

30 Nawroz (21 of

march)

18 Nawroz (21 of

march)

6 Nawroz (21 of

march)

April 53 Red

Wednesday

(mid April)

41 Red

Wednesday

(mid April)

29 Red

Wednesday

(mid April)

17 Red

Wednesday

(mid April)

5 Red Wednesday

(mid April)

May 52 40 28 16 4

June 51

39

27

15

3 Mossul Attack

(June 20)

July 50 38 26 14 2

August 49 Chella

Haveny (2 of

August)

37 Chella

Haveny (2 of

August)

25

Chella Haveny

(2 of August)

13

Chella Haveny

(2 of August)

1

Chella Haveny

(2 of August)

September

48

36

24

12

0

October 59 Sheikh Hadi

visit (10-15

Oct)

47 Sheikh Hadi

visit (6-13

Oct)

35 Sheikh Hadi

visit (6-13

Oct)

23

Sheikh Hadi

visit (6-13 Oct)

11

Sheikh Hadi

visit (6-13 Oct)

November 58 46 34 22 10

December 57 Fasting Eid

(11-12 Dec)

45 Fasting Eid

(11-12 Dec)

33 Fasting Eid

(11-12 Dec)

21 Fasting Eid

(11-12 Dec)

9 Fasting Eid

(11-12 Dec)

21

Annex 2: Plausibility Report

Plausibility check for: 1_Overall_Compil_final.as

Standard/Reference used for z-score calculation: WHO standards 2006 (If it is not mentioned, flagged data is included in the evaluation. Some parts of this

plausibility report are more for advanced users and can be skipped for a standard

evaluation)

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Missing/Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5

(% of in-range subjects) 0 5 10 20 0 (1.3 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 0 (p=0.125)

Overall Age distrib Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 0 (p=0.140)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (3)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20

0 2 4 10 10 (21)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (6)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20

. and and and or

. Excl SD >0.9 >0.85 >0.80 <=0.80

0 2 6 20 0 (0.96)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 1 (-0.21)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 1 (0.26)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001

0 1 3 5 0 (p=0.592)

Timing Excl Not determined yet

0 1 3 5

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 12 %

The overall score of this survey is 12 %, this is good.

There were no duplicate entries detected.

Percentage of children with no exact birthday: 6 %

Age/Height out of range for WHZ:

HEIGHT:

Line=238/ID=2: 146.00 cm

22

Anthropometric Indices likely to be in error (-3 to 3 for WHZ, -3 to 3 for HAZ, -3 to

3 for WAZ, from observed mean - chosen in Options panel - these values will be

flagged and should be excluded from analysis for a nutrition survey in emergencies.

For other surveys this might not be the best procedure e.g. when the percentage of

overweight children has to be calculated):

Line=6/ID=2: WHZ (3.662), HAZ (-4.169), Height may be incorrect

Line=20/ID=2: HAZ (7.054), Age may be incorrect

Line=36/ID=1: WHZ (-3.998), Weight may be incorrect



Line=115/ID=1: WAZ (-4.114), Weight may be incorrect

Line=122/ID=1: WHZ (-4.052), Height may be incorrect


Line=132/ID=3: WAZ (2.743), Weight may be incorrect

Line=155/ID=4: WHZ (2.938), Height may be incorrect


Line=177/ID=3: WAZ (-4.125), Weight may be incorrect


Line=210/ID=2: HAZ (-3.922), Height may be incorrect

Line=221/ID=1: HAZ (-4.415), Age may be incorrect



Line=417/ID=3: HAZ (5.512), Height may be incorrect


Line=426/ID=1: HAZ (3.119), WAZ (2.665), Age may be incorrect






Line=548/ID=1: WHZ (5.629), WAZ (4.085), Weight may be incorrect

Line=562/ID=1: WHZ (-7.149), HAZ (12.950), Height may be incorrect








Line=692/ID=1: WHZ (-8.127), WAZ (-6.270), Weight may be incorrect









23


Line=865/ID=1: WHZ (-3.149), Height may be incorrect












Line=1185/ID=1: WHZ (-5.656), WAZ (-4.741), Weight may be incorrect

Line=1217/ID=1: HAZ (-7.655), WAZ (-5.819), Age may be incorrect


Line=1315/ID=1: WHZ (3.205), Height may be incorrect








Line=1472/ID=2: HAZ (-3.867), WAZ (-3.735), Age may be incorrect


Percentage of values flagged with SMART flags:WHZ: 1.3 %, HAZ: 3.4 %, WAZ:

0.8 %

Age distribution:

Month 6 : #################

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24

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Month 60 : #############

Age ratio of 6-29 months to 30-59 months: 0.84 (The value should be around 0.85).

Statistical evaluation of sex and age ratios (using Chi squared statistic): Age cat. mo. boys girls total ratio boys/girls

-------------------------------------------------------------------------------------

6 to 17 12 195/190.3 (1.0) 203/176.1 (1.2) 398/366.4 (1.1) 0.96

18 to 29 12 166/185.5 (0.9) 157/171.7 (0.9) 323/357.2 (0.9) 1.06

30 to 41 12 180/179.8 (1.0) 163/166.4 (1.0) 343/346.2 (1.0) 1.10

42 to 53 12 176/176.9 (1.0) 159/163.8 (1.0) 335/340.7 (1.0) 1.11

54 to 59 6 103/87.5 (1.2) 77/81.0 (1.0) 180/168.5 (1.1) 1.34

-------------------------------------------------------------------------------------

6 to 59 54 820/789.5 (1.0) 759/789.5 (1.0) 1.08

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

25

Overall sex ratio: p-value = 0.125 (boys and girls equally represented)

Overall age distribution: p-value = 0.140 (as expected)

Overall age distribution for boys: p-value = 0.296 (as expected)

Overall age distribution for girls: p-value = 0.217 (as expected)

Overall sex/age distribution: p-value = 0.011 (significant difference)

Digit preference Weight:

Digit .0 : ###########################################################

Digit .1 : ################################################

Digit .2 : ##########################################################

Digit .3 : ###################################################

Digit .4 : ################################################

Digit .5 : ############################################################

Digit .6 : ###################################################

Digit .7 : ############################################

Digit .8 : #######################################################

Digit .9 : ##################################################

Digit preference score: 3 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20

problematic)

p-value for chi2: 0.085

Digit preference Height:

Digit .0 : #############################################################

Digit .1 : ##################

Digit .2 : ####################

Digit .3 : ###################

Digit .4 : ###################

Digit .5 : ################################

Digit .6 : #####################

Digit .7 : ###############

Digit .8 : ############

Digit .9 : ##########


problematic)

p-value for chi2: 0.000 (significant difference)

Digit preference MUAC:

Digit .0 : ###################################################

Digit .1 : ###############################

Digit .2 : #####################################

Digit .3 : ####################################

Digit .4 : ##########################################

Digit .5 : #######################################################

26

Digit .6 : #####################################

Digit .7 : ################################

Digit .8 : ######################################

Digit .9 : ####################################


problematic)

p-value for chi2: 0.000 (significant difference)

Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using

the 3 exclusion (Flag) procedures . no exclusion exclusion from exclusion from

. reference mean observed mean

. (WHO flags) (SMART flags)

WHZ

Standard Deviation SD: 1.09 1.02 0.96

(The SD should be between 0.8 and 1.2)

Prevalence (< -2)

observed: 4.4% 4.1%

calculated with current SD: 4.3% 3.2%

calculated with a SD of 1: 3.1% 3.0%

HAZ



Prevalence (< -2)

observed: 15.0% 15.0% 14.4%

calculated with current SD: 19.8% 18.7% 15.4%

calculated with a SD of 1: 11.8% 12.1% 13.3%

WAZ



Prevalence (< -2)

observed: 7.3% 7.3%

calculated with current SD: 8.2% 8.0%

calculated with a SD of 1: 7.5% 7.5%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data:

WHZ p= 0.000 p= 0.000 p= 0.000

HAZ p= 0.000 p= 0.000 p= 0.000

WAZ p= 0.000 p= 0.000 p= 0.327

(If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the

data normally distributed)

Skewness

WHZ -0.84 -0.34 -0.21

HAZ 1.29 0.71 0.20

WAZ -0.08 0.01 0.00

If the value is:

-below minus 0.4 there is a relative excess of wasted/stunted/underweight subjects in the

sample

-between minus 0.4 and minus 0.2, there may be a relative excess of

wasted/stunted/underweight subjects in the sample.

-between minus 0.2 and plus 0.2, the distribution can be considered as symmetrical.

-between 0.2 and 0.4, there may be an excess of obese/tall/overweight subjects in the

sample.

-above 0.4, there is an excess of obese/tall/overweight subjects in the sample

Kurtosis

WHZ 5.16 1.36 0.26

HAZ 8.95 2.73 0.02

WAZ 1.75 1.33 0.12

Kurtosis characterizes the relative size of the body versus the tails of the distribution.

Positive kurtosis indicates relatively large tails and small body. Negative kurtosis

indicates relatively large body and small tails.

If the absolute value is:

-above 0.4 it indicates a problem. There might have been a problem with data collection or

sampling.

-between 0.2 and 0.4, the data may be affected with a problem.

27

-less than an absolute value of 0.2 the distribution can be considered as normal.

Test if cases are randomly distributed or aggregated over the clusters by calculation

of the Index of Dispersion (ID) and comparison with the Poisson distribution for: WHZ < -2: ID=0.93 (p=0.592)

WHZ < -3: ID=0.95 (p=0.561)

GAM: ID=0.93 (p=0.592)

SAM: ID=0.95 (p=0.561)

HAZ < -2: ID=2.30 (p=0.000)

HAZ < -3: ID=1.13 (p=0.266)

WAZ < -2: ID=2.07 (p=0.000)

WAZ < -3: ID=0.74 (p=0.879)

Subjects with SMART flags are excluded from this analysis.

The Index of Dispersion (ID) indicates the degree to which the cases are aggregated into

certain clusters (the degree to which there are "pockets"). If the ID is less than 1 and p >

0.95 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p

value is between 0.05 and 0.95 the cases appear to be randomly distributed among the

clusters, if ID is higher than 1 and p is less than 0.05 the cases are aggregated into certain

cluster (there appear to be pockets of cases). If this is the case for Oedema but not for

WHZ then aggregation of GAM and SAM cases is likely due to inclusion of oedematous

cases in GAM and SAM estimates.

Are the data of the same quality at the beginning and the end of the clusters? Evaluation of the SD for WHZ depending upon the order the cases are measured within

each cluster (if one cluster per day is measured then this will be related to the time of the

day the measurement is made).

Time SD for WHZ

point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 0.96 (n=40, f=1) #######

02: 1.19 (n=40, f=1) ################

03: 1.74 (n=40, f=3) ########################################

04: 1.16 (n=40, f=1) ###############

05: 1.30 (n=40, f=1) #####################

06: 1.02 (n=40, f=1) #########

07: 1.02 (n=40, f=0) #########

08: 1.13 (n=40, f=0) ##############

09: 1.04 (n=40, f=1) ##########

10: 1.02 (n=40, f=0) #########

11: 1.23 (n=40, f=1) ##################

12: 1.36 (n=40, f=1) #######################

13: 0.94 (n=40, f=0) ######

14: 0.90 (n=40, f=0) ####

15: 0.80 (n=40, f=0)

16: 0.92 (n=40, f=0) #####

17: 1.07 (n=40, f=1) ###########

18: 0.99 (n=39, f=0) ########

19: 1.05 (n=39, f=1) ##########

20: 0.91 (n=39, f=0) #####

21: 1.42 (n=39, f=1) ##########################

22: 1.10 (n=39, f=0) ############

23: 0.94 (n=39, f=0) ######

24: 0.96 (n=39, f=0) #######

25: 1.09 (n=39, f=0) ############

26: 1.35 (n=39, f=1) #######################

27: 0.90 (n=38, f=0) ####

28: 0.89 (n=35, f=0) ####

29: 0.98 (n=38, f=0) ########

28

30: 1.11 (n=38, f=1) #############

31: 1.00 (n=37, f=0) ########

32: 1.01 (n=38, f=0) #########

33: 1.03 (n=37, f=0) ##########

34: 1.01 (n=37, f=1) #########

35: 1.30 (n=34, f=1) #####################

36: 0.71 (n=31, f=0)

37: 1.14 (n=28, f=0) ##############

38: 1.60 (n=21, f=1) ##################################

39: 0.99 (n=18, f=0) OOOOOOOO

40: 0.69 (n=15, f=0)

41: 1.10 (n=14, f=0) OOOOOOOOOOOOO

42: 0.57 (n=11, f=0)

43: 1.71 (n=08, f=1) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

44: 0.78 (n=06, f=0)

45: 0.63 (n=06, f=0)

46: 0.62 (n=06, f=0)

47: 0.85 (n=06, f=0) ~~

48: 1.09 (n=05, f=0) ~~~~~~~~~~~~

49: 0.87 (n=05, f=0) ~~~

50: 0.76 (n=05, f=0)

51: 0.94 (n=04, f=0) ~~~~~~

52: 0.41 (n=04, f=0)

53: 1.63 (n=03, f=0) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

54: 0.66 (n=03, f=0)

55: 0.78 (n=03, f=0)

56: 0.44 (n=02, f=0)

(when n is much less than the average number of subjects per cluster different symbols are

used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART

flags found in the different time points)

Analysis by Team

Team 1 10 2 3 4 5 6 7 8 9 n = 164 160 159 159 160 157 141 157 165 157

Percentage of values flagged with SMART flags: WHZ: 3.1 0.6 0.6 3.8 2.5 0.6 0.7 0.6 2.4 0.0

HAZ: 3.0 3.8 3.1 6.9 1.9 4.5 2.1 0.6 5.5 3.2

WAZ: 1.2 1.3 0.6 1.3 1.3 0.6 0.0 0.0 0.6 0.6

Age ratio of 6-29 months to 30-59 months: 0.78 0.86 0.73 0.89 0.84 0.96 0.70 0.87 1.06 0.74

Sex ratio (male/female): 1.13 1.16 0.79 1.41 1.35 0.85 1.24 1.24 0.77 1.12

Digit preference Weight (%): .0 : 10 8 13 13 18 15 8 12 7 10

.1 : 6 9 13 10 8 9 12 10 12 4

.2 : 8 14 11 11 11 12 7 10 15 12

.3 : 9 13 11 6 10 9 8 13 7 12

.4 : 10 9 9 8 12 10 10 7 10 8

.5 : 15 11 10 15 12 12 10 9 10 11

.6 : 13 11 8 4 10 8 8 11 7 17

.7 : 12 3 8 11 9 8 8 8 10 8

.8 : 10 9 10 11 8 10 16 10 13 7

.9 : 8 13 7 11 3 8 14 9 11 11

DPS: 8 11 7 10 12 7 9 6 8 11

Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic)

Digit preference Height (%): .0 : 17 13 31 52 45 18 21 32 16 25

.1 : 9 11 6 3 2 8 14 11 10 7

29

.2 : 9 13 9 4 7 11 7 10 8 9

.3 : 12 14 8 3 6 11 9 8 8 6

.4 : 12 11 8 6 4 11 8 6 11 6

.5 : 11 9 17 21 19 11 13 9 9 22

.6 : 11 17 4 3 3 11 10 15 14 5

.7 : 7 7 4 4 9 4 6 4 7 12

.8 : 10 3 9 3 3 5 4 2 12 3

.9 : 4 3 3 2 3 9 9 3 5 5

DPS: 11 15 27 49 42 13 15 27 10 24


Digit preference MUAC (%): .0 : 7 11 13 25 21 8 10 10 15 11

.1 : 13 8 10 6 4 7 11 6 9 6

.2 : 9 8 13 6 10 9 12 8 7 13

.3 : 10 8 10 5 4 6 16 12 12 9

.4 : 15 14 11 5 10 15 6 11 7 13

.5 : 7 14 13 32 19 11 8 11 9 13

.6 : 9 11 9 4 4 8 8 17 18 6

.7 : 10 12 7 6 6 8 6 8 5 12

.8 : 10 6 10 8 10 13 11 10 9 7

.9 : 9 9 4 3 11 15 12 8 10 10

DPS: 8 9 9 32 19 10 9 9 12 8


Standard deviation of WHZ: SD 1.23 0.95 1.00 1.28 1.37 1.01 0.89 1.03 1.11 0.85

Prevalence (< -2) observed:

% 7.4 3.8 5.1 6.3 3.2 4.5 6.7

Prevalence (< -2) calculated with current SD:

% 5.9 3.2 5.9 9.4 2.2 3.7 6.3

Prevalence (< -2) calculated with a SD of 1:

% 2.7 3.1 2.3 3.6 2.1 3.4 4.4

Standard deviation of HAZ: SD 1.40 1.30 1.39 1.62 1.60 1.37 1.26 1.11 1.50 1.28

observed:

% 14.0 13.1 16.4 13.8 13.8 14.6 13.6 9.6 19.4 21.7

calculated with current SD:

% 18.7 20.1 21.6 19.7 23.2 18.0 18.5 11.6 21.3 22.9

calculated with a SD of 1:

% 10.6 13.7 13.6 8.4 12.1 10.5 13.0 9.4 11.6 17.1

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

Team 1: Age cat. mo. boys girls total ratio boys/girls

-------------------------------------------------------------------------------------

6 to 17 12 16/20.2 (0.8) 19/17.9 (1.1) 35/38.1 (0.9) 0.84

18 to 29 12 24/19.7 (1.2) 13/17.4 (0.7) 37/37.1 (1.0) 1.85

30 to 41 12 16/19.1 (0.8) 19/16.9 (1.1) 35/36.0 (1.0) 0.84

42 to 53 12 20/18.8 (1.1) 17/16.6 (1.0) 37/35.4 (1.0) 1.18

54 to 59 6 11/9.3 (1.2) 9/8.2 (1.1) 20/17.5 (1.1) 1.22

-------------------------------------------------------------------------------------

6 to 59 54 87/82.0 (1.1) 77/82.0 (0.9) 1.13

30






Overall sex/age distribution: p-value = 0.294 (as expected)


-------------------------------------------------------------------------------------

6 to 17 12 29/20.0 (1.5) 16/17.2 (0.9) 45/37.1 (1.2) 1.81

18 to 29 12 14/19.5 (0.7) 15/16.7 (0.9) 29/36.2 (0.8) 0.93

30 to 41 12 21/18.9 (1.1) 17/16.2 (1.0) 38/35.1 (1.1) 1.24

42 to 53 12 15/18.6 (0.8) 15/16.0 (0.9) 30/34.5 (0.9) 1.00

54 to 59 6 7/9.2 (0.8) 11/7.9 (1.4) 18/17.1 (1.1) 0.64

-------------------------------------------------------------------------------------

6 to 59 54 86/80.0 (1.1) 74/80.0 (0.9) 1.16








-------------------------------------------------------------------------------------

6 to 17 12 20/16.2 (1.2) 17/20.6 (0.8) 37/36.9 (1.0) 1.18

18 to 29 12 9/15.8 (0.6) 21/20.1 (1.0) 30/36.0 (0.8) 0.43

30 to 41 12 17/15.3 (1.1) 22/19.5 (1.1) 39/34.9 (1.1) 0.77

42 to 53 12 15/15.1 (1.0) 18/19.2 (0.9) 33/34.3 (1.0) 0.83

54 to 59 6 9/7.5 (1.2) 11/9.5 (1.2) 20/17.0 (1.2) 0.82

-------------------------------------------------------------------------------------

6 to 59 54 70/79.5 (0.9) 89/79.5 (1.1) 0.79






Overall sex/age distribution: p-value = 0.110 (as expected)


-------------------------------------------------------------------------------------

6 to 17 12 22/21.6 (1.0) 22/15.3 (1.4) 44/36.9 (1.2) 1.00

18 to 29 12 15/21.0 (0.7) 16/14.9 (1.1) 31/36.0 (0.9) 0.94

30 to 41 12 14/20.4 (0.7) 11/14.5 (0.8) 25/34.9 (0.7) 1.27

42 to 53 12 27/20.1 (1.3) 13/14.2 (0.9) 40/34.3 (1.2) 2.08

54 to 59 6 15/9.9 (1.5) 4/7.0 (0.6) 19/17.0 (1.1) 3.75

-------------------------------------------------------------------------------------

6 to 59 54 93/79.5 (1.2) 66/79.5 (0.8) 1.41

31


Overall sex ratio: p-value = 0.032 (significant excess of boys)






-------------------------------------------------------------------------------------

6 to 17 12 19/21.3 (0.9) 21/15.8 (1.3) 40/37.1 (1.1) 0.90

18 to 29 12 17/20.8 (0.8) 16/15.4 (1.0) 33/36.2 (0.9) 1.06

30 to 41 12 16/20.2 (0.8) 17/14.9 (1.1) 33/35.1 (0.9) 0.94

42 to 53 12 21/19.9 (1.1) 13/14.7 (0.9) 34/34.5 (1.0) 1.62

54 to 59 6 19/9.8 (1.9) 1/7.3 (0.1) 20/17.1 (1.2) 19.00

-------------------------------------------------------------------------------------

6 to 59 54 92/80.0 (1.1) 68/80.0 (0.9) 1.35




Overall age distribution for boys: p-value = 0.033 (significant difference)




-------------------------------------------------------------------------------------

6 to 17 12 15/16.7 (0.9) 22/19.7 (1.1) 37/36.4 (1.0) 0.68

18 to 29 12 23/16.3 (1.4) 17/19.2 (0.9) 40/35.5 (1.1) 1.35

30 to 41 12 13/15.8 (0.8) 24/18.6 (1.3) 37/34.4 (1.1) 0.54

42 to 53 12 15/15.5 (1.0) 20/18.3 (1.1) 35/33.9 (1.0) 0.75

54 to 59 6 6/7.7 (0.8) 2/9.1 (0.2) 8/16.8 (0.5) 3.00

-------------------------------------------------------------------------------------

6 to 59 54 72/78.5 (0.9) 85/78.5 (1.1) 0.85








-------------------------------------------------------------------------------------

6 to 17 12 13/18.1 (0.7) 12/14.6 (0.8) 25/32.7 (0.8) 1.08

18 to 29 12 23/17.6 (1.3) 10/14.3 (0.7) 33/31.9 (1.0) 2.30

30 to 41 12 18/17.1 (1.1) 14/13.8 (1.0) 32/30.9 (1.0) 1.29

42 to 53 12 14/16.8 (0.8) 14/13.6 (1.0) 28/30.4 (0.9) 1.00

54 to 59 6 10/8.3 (1.2) 13/6.7 (1.9) 23/15.0 (1.5) 0.77

-------------------------------------------------------------------------------------

6 to 59 54 78/70.5 (1.1) 63/70.5 (0.9) 1.24


32







-------------------------------------------------------------------------------------

6 to 17 12 14/20.2 (0.7) 25/16.2 (1.5) 39/36.4 (1.1) 0.56

18 to 29 12 19/19.7 (1.0) 15/15.8 (0.9) 34/35.5 (1.0) 1.27

30 to 41 12 21/19.1 (1.1) 12/15.3 (0.8) 33/34.4 (1.0) 1.75

42 to 53 12 19/18.8 (1.0) 11/15.1 (0.7) 30/33.9 (0.9) 1.73

54 to 59 6 14/9.3 (1.5) 7/7.5 (0.9) 21/16.8 (1.3) 2.00

-------------------------------------------------------------------------------------

6 to 59 54 87/78.5 (1.1) 70/78.5 (0.9) 1.24








-------------------------------------------------------------------------------------

6 to 17 12 26/16.7 (1.6) 23/21.6 (1.1) 49/38.3 (1.3) 1.13

18 to 29 12 14/16.3 (0.9) 22/21.0 (1.0) 36/37.3 (1.0) 0.64

30 to 41 12 14/15.8 (0.9) 14/20.4 (0.7) 28/36.2 (0.8) 1.00

42 to 53 12 12/15.5 (0.8) 22/20.1 (1.1) 34/35.6 (1.0) 0.55

54 to 59 6 6/7.7 (0.8) 12/9.9 (1.2) 18/17.6 (1.0) 0.50

-------------------------------------------------------------------------------------

6 to 59 54 72/82.5 (0.9) 93/82.5 (1.1) 0.77








-------------------------------------------------------------------------------------

6 to 17 12 21/19.3 (1.1) 26/17.2 (1.5) 47/36.4 (1.3) 0.81

18 to 29 12 8/18.8 (0.4) 12/16.7 (0.7) 20/35.5 (0.6) 0.67

30 to 41 12 30/18.2 (1.6) 13/16.2 (0.8) 43/34.4 (1.2) 2.31

42 to 53 12 18/17.9 (1.0) 16/16.0 (1.0) 34/33.9 (1.0) 1.13

54 to 59 6 6/8.9 (0.7) 7/7.9 (0.9) 13/16.8 (0.8) 0.86

-------------------------------------------------------------------------------------

6 to 59 54 83/78.5 (1.1) 74/78.5 (0.9) 1.12


33


Overall age distribution: p-value = 0.012 (significant difference)

Overall age distribution for boys: p-value = 0.005 (significant difference)



Evaluation of the SD for WHZ depending upon the order the cases are measured

within each cluster (if one cluster per day is measured then this will be related to the

time of the day the measurement is made).

Team: 1 Time SD for WHZ

point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 1.29 (n=15, f=1) #####################

02: 0.24 (n=06, f=0)

03: 0.49 (n=05, f=0)

04: 1.49 (n=07, f=0) #############################

05: 0.97 (n=06, f=0) #######

06: 1.51 (n=04, f=0) ##############################

07: 1.32 (n=06, f=0) ######################

08: 0.77 (n=05, f=0)

09: 1.39 (n=07, f=0) #########################

10: 0.35 (n=03, f=0)

11: 0.37 (n=03, f=0)

12: 0.67 (n=02, f=0)

13: 0.06 (n=02, f=0)

14: 2.77 (n=04, f=1) ################################################################

15: 0.56 (n=05, f=0)

16: 0.44 (n=04, f=0)

17: 0.36 (n=02, f=0)

19: 0.04 (n=02, f=0)

20: 2.33 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

22: 0.94 (n=03, f=0) ######

23: 2.17 (n=03, f=0) #########################################################

24: 1.27 (n=04, f=0) ####################

25: 1.81 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

26: 0.55 (n=05, f=0)

27: 0.69 (n=03, f=0)

28: 0.61 (n=03, f=0)

29: 0.21 (n=02, f=0)


31: 0.10 (n=02, f=0)

32: 1.07 (n=04, f=0) ############

33: 0.31 (n=02, f=0)

34: 1.42 (n=03, f=0) ##########################

35: 0.15 (n=03, f=0)

36: 0.35 (n=03, f=0)

37: 2.93 (n=05, f=1) ################################################################

38: 1.05 (n=04, f=0) ##########

39: 1.76 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

40: 0.33 (n=04, f=0)

42: 1.18 (n=02, f=0) OOOOOOOOOOOOOOOO

47: 0.71 (n=02, f=0)





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 0.80 (n=10, f=0)

02: 1.28 (n=09, f=0) ####################

03: 1.54 (n=07, f=1) ###############################

04: 0.80 (n=05, f=0)

05: 0.29 (n=03, f=0)

06: 0.75 (n=03, f=0)

34

07: 0.39 (n=04, f=0)

08: 0.82 (n=06, f=0) #

09: 0.39 (n=05, f=0)

10: 1.38 (n=04, f=0) ########################

11: 1.86 (n=05, f=0) #############################################

12: 0.77 (n=04, f=0)

13: 1.22 (n=05, f=0) ##################

14: 0.83 (n=04, f=0) #

15: 0.38 (n=05, f=0)

16: 0.43 (n=04, f=0)

17: 0.89 (n=07, f=0) ####

18: 0.67 (n=04, f=0)

19: 0.56 (n=03, f=0)

20: 0.44 (n=04, f=0)

21: 0.22 (n=03, f=0)

22: 0.54 (n=05, f=0)

23: 0.88 (n=06, f=0) ###

24: 0.95 (n=04, f=0) ######

25: 0.99 (n=04, f=0) ########

26: 1.50 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOO

27: 0.43 (n=05, f=0)

28: 1.12 (n=04, f=0) #############

29: 0.73 (n=05, f=0)

30: 0.69 (n=03, f=0)

32: 0.63 (n=04, f=0)

33: 0.49 (n=04, f=0)

36: 0.90 (n=03, f=0) OOOO

37: 1.75 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 1.14 (n=13, f=0) ##############

02: 1.08 (n=04, f=0) ############

03: 0.68 (n=07, f=0)

04: 0.39 (n=04, f=0)

05: 0.75 (n=05, f=0)

06: 0.91 (n=06, f=0) #####

07: 1.28 (n=05, f=0) ####################

08: 1.44 (n=05, f=0) ###########################

09: 0.70 (n=06, f=0)

10: 0.30 (n=02, f=0)

11: 1.06 (n=05, f=0) ###########

12: 0.76 (n=04, f=0)

13: 1.08 (n=02, f=0) OOOOOOOOOOOO

14: 0.66 (n=03, f=0)

15: 0.21 (n=02, f=0)

16: 0.75 (n=03, f=0)

17: 1.29 (n=04, f=0) ####################

18: 1.69 (n=04, f=0) #####################################

19: 0.32 (n=04, f=0)

20: 1.49 (n=04, f=0) #############################

21: 0.02 (n=02, f=0)

22: 0.75 (n=07, f=0)

23: 0.65 (n=04, f=0)

24: 0.39 (n=06, f=0)

25: 1.03 (n=04, f=0) ##########

26: 0.51 (n=03, f=0)

27: 1.12 (n=03, f=0) #############

28: 0.85 (n=06, f=0) ##

29: 0.60 (n=03, f=0)

31: 1.05 (n=02, f=0) OOOOOOOOOOO

32: 1.60 (n=03, f=0) #################################

33: 0.91 (n=03, f=0) #####

34: 1.38 (n=05, f=1) ########################

35: 1.66 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

36: 0.93 (n=03, f=0) #####

37: 0.73 (n=02, f=0)

38: 0.88 (n=02, f=0) OOO



35



point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 1.74 (n=12, f=2) #######################################

02: 0.86 (n=04, f=0) ###

03: 1.59 (n=05, f=1) #################################

04: 0.44 (n=06, f=0)

05: 1.46 (n=07, f=0) ############################

06: 1.60 (n=03, f=0) ##################################

07: 2.79 (n=04, f=1) ################################################################

08: 0.86 (n=05, f=0) ##

09: 0.94 (n=07, f=0) ######

10: 1.69 (n=07, f=1) ######################################

11: 0.75 (n=04, f=0)

12: 0.49 (n=05, f=0)

13: 2.27 (n=03, f=0) ##############################################################

14: 1.65 (n=04, f=0) ####################################

15: 1.12 (n=05, f=0) ##############

16: 0.61 (n=06, f=0)

17: 0.69 (n=04, f=0)

18: 0.96 (n=04, f=0) #######

19: 0.72 (n=02, f=0)

20: 0.30 (n=04, f=0)

21: 1.54 (n=03, f=0) ###############################

22: 0.27 (n=02, f=0)

23: 0.64 (n=04, f=0)

24: 0.94 (n=02, f=0) OOOOOO

25: 1.40 (n=04, f=0) #########################

26: 1.12 (n=05, f=0) ##############

27: 0.56 (n=02, f=0)

28: 0.37 (n=03, f=0)

29: 0.94 (n=02, f=0) OOOOOO

30: 1.23 (n=03, f=0) ##################

32: 1.30 (n=03, f=0) #####################

33: 1.69 (n=03, f=0) #####################################

34: 1.08 (n=02, f=0) OOOOOOOOOOOO

35: 0.78 (n=02, f=0)

36: 1.51 (n=03, f=0) ##############################

40: 0.50 (n=03, f=0)

42: 1.37 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOO

43: 0.63 (n=03, f=0)





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 2.55 (n=12, f=1) ################################################################

02: 0.61 (n=06, f=0)

03: 0.27 (n=04, f=0)

04: 1.09 (n=05, f=0) ############

05: 2.14 (n=06, f=1) ########################################################

06: 0.45 (n=05, f=0)

07: 0.98 (n=05, f=0) #######

08: 1.35 (n=05, f=0) #######################

10: 1.40 (n=03, f=0) #########################

11: 1.47 (n=04, f=0) ############################

12: 0.76 (n=07, f=0)

13: 0.34 (n=03, f=0)

14: 1.02 (n=06, f=0) #########

15: 0.46 (n=02, f=0)


17: 0.14 (n=02, f=0)

19: 0.57 (n=04, f=0)

20: 0.53 (n=05, f=0)

21: 0.35 (n=05, f=0)

22: 0.81 (n=03, f=0)

23: 0.89 (n=04, f=0) ####

24: 0.71 (n=03, f=0)

25: 1.34 (n=03, f=0) #######################

36

26: 2.94 (n=03, f=1) ################################################################

27: 0.88 (n=02, f=0) OOO

28: 0.85 (n=04, f=0) ##

29: 0.37 (n=02, f=0)

30: 1.64 (n=06, f=0) ###################################

31: 1.05 (n=05, f=0) ##########

32: 1.15 (n=06, f=0) ###############

33: 1.11 (n=06, f=0) #############

34: 0.49 (n=03, f=0)

35: 2.48 (n=03, f=0) ################################################################

36: 0.81 (n=04, f=0)

37: 0.09 (n=03, f=0)





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 0.69 (n=12, f=0)

02: 1.01 (n=07, f=0) #########

03: 1.34 (n=08, f=1) #######################

04: 0.90 (n=06, f=0) ####

05: 1.22 (n=06, f=0) ##################

06: 0.94 (n=03, f=0) OOOOOO

07: 0.42 (n=05, f=0)

08: 0.47 (n=05, f=0)

09: 0.30 (n=03, f=0)

10: 1.58 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

11: 1.26 (n=04, f=0) ###################

12: 1.50 (n=04, f=0) #############################

13: 0.68 (n=03, f=0)

14: 0.82 (n=05, f=0) #

15: 1.36 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOO

16: 0.06 (n=03, f=0)

17: 1.39 (n=05, f=0) #########################

18: 1.22 (n=04, f=0) ##################

19: 0.22 (n=03, f=0)

20: 0.85 (n=05, f=0) ##

21: 0.77 (n=04, f=0)

22: 0.59 (n=02, f=0)

23: 0.86 (n=04, f=0) ##

24: 0.46 (n=02, f=0)

25: 0.46 (n=03, f=0)

26: 0.56 (n=06, f=0)


28: 1.11 (n=05, f=0) #############

29: 1.00 (n=07, f=0) ########

30: 0.42 (n=03, f=0)

31: 0.58 (n=03, f=0)

32: 1.54 (n=04, f=0) ###############################

33: 1.01 (n=05, f=0) #########

34: 0.80 (n=02, f=0)

36: 1.33 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOO

39: 0.21 (n=02, f=0)

41: 1.34 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOO





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 0.99 (n=12, f=0) ########

02: 0.73 (n=07, f=0)

03: 0.62 (n=05, f=0)

04: 1.26 (n=03, f=0) OOOOOOOOOOOOOOOOOOO

05: 1.13 (n=03, f=0) OOOOOOOOOOOOOO

06: 0.66 (n=03, f=0)

07: 0.97 (n=04, f=0) #######

08: 0.62 (n=04, f=0)

09: 0.95 (n=03, f=0) OOOOOO

37

10: 0.41 (n=03, f=0)

11: 1.07 (n=05, f=0) ###########

12: 1.25 (n=06, f=0) ###################

13: 0.47 (n=05, f=0)

14: 1.12 (n=04, f=0) #############

15: 1.15 (n=04, f=0) ###############

16: 0.92 (n=04, f=0) #####

17: 0.70 (n=04, f=0)

19: 0.72 (n=07, f=0)

20: 0.73 (n=03, f=0)

21: 0.77 (n=06, f=0)

22: 1.01 (n=02, f=0) OOOOOOOOO

24: 0.98 (n=05, f=0) ########

25: 0.68 (n=04, f=0)

26: 1.24 (n=04, f=0) ##################

27: 0.69 (n=05, f=0)

28: 0.54 (n=04, f=0)

29: 0.84 (n=03, f=0) OO

30: 0.83 (n=03, f=0) O

32: 0.42 (n=02, f=0)

33: 1.95 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

34: 0.73 (n=02, f=0)

35: 0.85 (n=02, f=0) OO

36: 0.63 (n=02, f=0)

38: 0.05 (n=02, f=0)





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 0.93 (n=12, f=0) #####

02: 0.72 (n=08, f=0)

03: 1.68 (n=06, f=0) #####################################

04: 0.71 (n=07, f=0)

05: 0.81 (n=08, f=0)

06: 1.29 (n=07, f=0) #####################

07: 0.34 (n=04, f=0)

08: 0.88 (n=07, f=0) ###

09: 0.78 (n=04, f=0)

10: 0.65 (n=04, f=0)

11: 0.78 (n=02, f=0)

12: 1.02 (n=04, f=0) #########

14: 1.50 (n=03, f=0) ##############################

15: 0.72 (n=05, f=0)

16: 0.73 (n=04, f=0)

17: 1.54 (n=06, f=0) ###############################

18: 1.59 (n=05, f=0) #################################

19: 0.59 (n=04, f=0)

20: 0.14 (n=02, f=0)

24: 0.04 (n=02, f=0)

25: 1.50 (n=03, f=0) #############################

26: 0.48 (n=05, f=0)

27: 1.47 (n=04, f=0) ############################

28: 0.20 (n=03, f=0)


31: 0.42 (n=03, f=0)

32: 0.72 (n=05, f=0)

33: 1.50 (n=05, f=0) ##############################

34: 0.49 (n=03, f=0)


42: 0.28 (n=02, f=0)

45: 0.99 (n=02, f=0) OOOOOOOO






point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

38

01: 2.08 (n=11, f=1) ######################################################

02: 0.65 (n=08, f=0)

03: 0.93 (n=08, f=0) ######

04: 0.75 (n=06, f=0)

05: 1.64 (n=04, f=0) ###################################

06: 1.09 (n=04, f=0) ############

07: 1.26 (n=05, f=0) ###################

08: 2.65 (n=05, f=2) ################################################################

09: 0.98 (n=06, f=0) ########

10: 0.97 (n=03, f=0) #######

11: 1.38 (n=05, f=0) #########################

12: 0.79 (n=05, f=0)

13: 1.02 (n=03, f=0) #########

14: 0.75 (n=04, f=0)

15: 0.97 (n=06, f=0) #######

16: 1.25 (n=03, f=0) ###################

17: 0.61 (n=03, f=0)

18: 0.68 (n=02, f=0)

20: 0.90 (n=03, f=0) ####

21: 0.06 (n=03, f=0)

22: 0.92 (n=02, f=0) OOOOO

23: 2.05 (n=04, f=0) #####################################################

24: 0.71 (n=05, f=0)

25: 0.83 (n=04, f=0) #


27: 0.22 (n=03, f=0)

28: 0.53 (n=02, f=0)

29: 0.49 (n=03, f=0)

30: 0.61 (n=04, f=0)

31: 0.70 (n=05, f=0)

32: 1.64 (n=03, f=0) ###################################

33: 0.28 (n=02, f=0)

34: 0.03 (n=02, f=0)

35: 0.58 (n=04, f=0)

36: 0.37 (n=04, f=0)

37: 0.82 (n=03, f=0) #

38: 1.88 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

39: 0.91 (n=04, f=0) ####

41: 0.06 (n=02, f=0)

42: 0.37 (n=02, f=0)





point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3

01: 0.93 (n=12, f=0) ######

02: 1.29 (n=03, f=0) OOOOOOOOOOOOOOOOOOOO

03: 1.02 (n=06, f=0) #########

04: 0.54 (n=05, f=0)

05: 1.09 (n=07, f=0) ############

06: 0.77 (n=06, f=0)

07: 0.77 (n=06, f=0)

08: 0.74 (n=05, f=0)

09: 0.46 (n=07, f=0)

10: 0.52 (n=06, f=0)

11: 0.74 (n=04, f=0)

12: 0.17 (n=04, f=0)

13: 0.55 (n=05, f=0)

14: 0.96 (n=02, f=0) OOOOOOO

15: 0.79 (n=06, f=0)

16: 0.11 (n=03, f=0)

17: 0.60 (n=05, f=0)

18: 0.44 (n=06, f=0)

19: 0.78 (n=03, f=0)

20: 1.00 (n=02, f=0) OOOOOOOOO

21: 0.82 (n=02, f=0) O

22: 1.56 (n=03, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

23: 1.43 (n=04, f=0) ###########################

24: 0.88 (n=04, f=0) ###

25: 1.27 (n=04, f=0) ####################

26: 0.49 (n=04, f=0)

27: 1.32 (n=02, f=0) OOOOOOOOOOOOOOOOOOOOOO

28: 0.56 (n=04, f=0)

39

29: 1.01 (n=04, f=0) #########

30: 0.84 (n=03, f=0) OO

31: 0.62 (n=05, f=0)

32: 0.31 (n=03, f=0)

33: 1.02 (n=02, f=0) OOOOOOOOO

34: 1.16 (n=03, f=0) OOOOOOOOOOOOOOO




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

40

Annex 3: Standardization test

Standardisation test results

Prec

ision

Accurac

y OUTCOME

Weight

subjec

ts mean SD max

Technic

al error

TEM/

mean

Coef of

reliability

Bias

from

superv

Bias

from

median result

# kg kg kg

TEM

(kg)

TEM

(%) R (%) Bias (kg) Bias (kg)

Superviso

r 10 14.6 1.8 0 0 0 100 - -0.5

TEM

good R value good

Enumerat

or 1 10 14.6 1.9 0.2 0 0.3 99.9 0 -0.5

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 2 10 14.5 1.9 0.2 0.1 0.5 99.8 -0.1 -0.6

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 3 10 14.5 1.9 0.1 0.1 0.3 99.9 -0.1 -0.6

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 4 10 14.5 1.9 0.1 0 0.3 100 -0.1 -0.6

TEM

good

R value

good

Bias

good

Enumerat

or 5 10 14.5 1.8 0.4 0.2 1.1 99.2 -0.1 -0.6

TEM

poor

R value

good

Bias

good

Enumerat

or 6 10 14.5 1.8 0.5 0.1 1 99.4 -0.1 -0.6

TEM

poor

R value

good

Bias

good

Enumerat

or 7 10 14.5 1.9 1.3 0.3 2.1 97.5 -0.1 -0.6

TEM

reject

R value

acceptabl

e

Bias

good

41

Enumerat

or 8 10 14.5 1.9 0.1 0.1 0.4 99.9 -0.1 -0.6

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 9 10 14.6 1.9 0.2 0.1 0.5 99.9 -0.1 -0.6

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 10 10 14.5 1.8 0.9 0.2 1.6 98.3 -0.1 -0.6

TEM

reject

R value

acceptabl

e

Bias

good

enum

inter 1st 10x10 14.5 1.8 - 0.1 0.7 99.7 - -

TEM

acceptab

le R value good

enum

inter 2nd 10x10 14.5 1.8 - 0.2 1.4 98.8 - -

TEM

acceptab

le R value acceptable

inter

enum +

sup 11x10 14.5 1.8 - 0.2 1 99.3 - -

TEM

acceptab

le R value good

TOTAL

intra+inter 10x10 - - - 0.2 1.5 98.6 -0.1 -0.6

TEM

poor

R value

acceptabl

e

Bias

good

TOTAL+

sup 11x10 - - - 0.2 1.4 98.7 - -

TEM

acceptab

le R value acceptable

Height

subjec

ts mean SD max

Technic

al error

TEM/

mean

Coef of

reliability

Bias

from

superv

Bias

from

median result

# cm cm cm

TEM

(cm)

TEM

(%) R (%)

Bias

(cm) Bias (cm)

42

Superviso

r 10 97.9 8.6 0 0 0 100 - -1.3

TEM

good R value good

Enumerat

or 1 10 95.9 9.3 0.5 0.2 0.2 100 -2 -3.3

TEM

good

R value

good

Bias

good

Enumerat

or 2 10 97.7 8.9 1.5 0.5 0.5 99.7 -0.2 -1.5

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 3 10 96.9 8.4 1.6 0.4 0.4 99.8 -0.9 -2.3

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 4 10 97.4 8.6 1 0.3 0.3 99.8 -0.4 -1.8

TEM

good

R value

good

Bias

good

Enumerat

or 5 10 96.8 8.6 0.8 0.3 0.3 99.9 -1.1 -2.4

TEM

good

R value

good

Bias

good

Enumerat

or 6 10 97.8 8.2 2.1 0.8 0.8 99 -0.1 -1.4

TEM

poor

R value

acceptabl

e

Bias

good

Enumerat

or 7 10 97.1 8.5 2 0.6 0.6 99.5 -0.8 -2.1

TEM

acceptab

le

R value

good

Bias

good

Enumerat

or 8 10 92.5 21.1 95.1 21.3 23 -2 -5.4 -6.7

TEM

reject

R value

reject

Bias

good

Enumerat

or 9 10 96.2 8.4 5 1.3 1.3 97.8 -1.6 -3

TEM

reject

R value

acceptabl

e

Bias

good

Enumerat

or 10 10 97.3 8.1 1.1 0.4 0.4 99.8 -0.6 -1.9

TEM

good

R value

good

Bias

good

enum

inter 1st 10x10 97 8.4 - 1.4 1.5 97.1 - -

TEM

poor R value acceptable

enum

inter 2nd 10x10 96.1 12 - 9.6 10 36.4 - -

TEM

reject R value reject

43

inter

enum +

sup 11x10 96.7 10.2 - 5.3 5.5 69.7 - -

TEM


TOTAL

intra+inter 10x10 - - - 9.6 10 13.8 -1.3 -2.5

TEM

reject

R value

reject

Bias

good

TOTAL+

sup 11x10 - - - 9.2 9.5 19.1 - -

TEM


MUAC

subjec

ts mean SD max

Technic

al error

TEM/

mean

Coef of

reliability

Bias

from

superv

Bias

from

median result

# mm mm mm

TEM

(mm)

TEM

(%) R (%)

Bias

(mm)

Bias

(mm)

Superviso

r 10 153.1 4.3 0 0 0 100 - -3.9

TEM

good R value good

Enumerat

or 1 10 157.9 6.8 4 1.3 0.8 96.3 4.8 0.9

TEM

poor

R value

acceptabl

e

Bias

reject

Enumerat

or 2 10 158.3 5.1 8 2.9 1.9 67 5.1 1.3

TEM

reject

R value

reject

Bias

reject

Enumerat

or 3 10 153.4 4.8 10 2.5 1.6 71.9 0.3 -3.6

TEM

reject

R value

reject

Bias

good

Enumerat

or 4 10 154.9 12.1 4 0.9 0.6 99.4 1.8 -2.1

TEM

good

R value

good

Bias

accepta

ble

Enumerat

or 5 10 235.3 336.1 1502 335.9 142.8 0.1 82.1 78.3

TEM

reject

R value

reject

Bias

reject

Enumerat

or 6 10 160.1 8.3 20 5.9 3.7 50.3 7 3.1

TEM

reject

R value

reject

Bias

reject

44

Enumerat

or 7 10 157.7 6.1 13 4.3 2.7 51.2 4.6 0.7

TEM

reject

R value

reject

Bias

reject

Enumerat

or 8 10 156.1 5.7 13 3.4 2.2 65.5 3 -0.9

TEM

reject

R value

reject

Bias

poor

Enumerat

or 9 10 161.7 4.9 9 2.7 1.6 70 8.6 4.7

TEM

reject

R value

reject

Bias

reject

Enumerat

or 10 10 156.4 5.9 5 1.7 1.1 92.2 3.3 -0.6

TEM

poor

R value

poor

Bias

reject

enum

inter 1st 10x10 157.1 6.6 - 5.5 3.5 31.3 - -

TEM


enum

inter 2nd 10x10 173.2 150.7 - 150.1 86.7 0.7 - -

TEM


inter

enum +

sup 11x10 164.1 101.8 - 74.3 43.1 21.3 - -

TEM


TOTAL

intra+inter 10x10 - - - 150.2 91 -98.3 12.1 7.1

TEM

reject

R value

reject

Bias

reject

TOTAL+

sup 11x10 - - - 143.3 87.3 -98.3 - -

TEM


Suggested cut-off points for acceptability of

measurements

Parameter

MUA

C mm

Weig

ht Kg

Heig

ht cm

individual good <1.0 <0.04 <0.4

TEM acceptable <1.3 <0.10 <0.6

(intra) poor <2.1 <0.21 <1.2

reject >2.1 >0.21 >1.2

Team

TEM good <1.3 <0.10 <0.5

45

(intra+inte

r) acceptable <2.1 <0.21 <1.0

and Total poor <3.0 <0.24 <1.5

reject >3.0 >0.24 >1.5

R value good >99 >99 >99

acceptable >95 >95 >95

poor >90 >90 >90

reject <90 <90 <90

Bias good <1 <0.04 <0.4

From sup

if good acceptable <2 <0.10 <0.6

outcome,

otherwise poor <3 <0.21 <1.4

from

median reject >3 >0.21 >1.4

46

Annex 4: Assignment of clusters D

istr

ict

Su

b-d

istr

ict

Vaccination post U5 Population=(U5*100/16) Cluster

No

. o

f C

hil

dre

n

Dis

tric

t c

od

e

Su

b d

istr

ict

co

de

Du

ho

k

Duhok

Duhok

316 1975 1 1

Mateen

477 2981 RC 1 1

Khabat

866 5413 1 1

Barzan

430 2688 1 1

Zanest

368 2300 1 33 1 1

Sarhaldan

1,373 8581 2 33 1 1

Shahedan

2,194 13713 3 33 1 1

Qadi Muhammad

527

3294 4 33 1 1

Bahdenan

1,791 11194 5 33 1 1

47

11 Adhar

1,170 7313 6 33 1 1

Maltah

943 5894 1 1

Shendokha/PHD

1,355 8469 7 33 1 1

Mah.Salih

1,511 9444 8 33 1 1

Zaweta Zaweta

2,431 15194 9,10 66 1 2

Mangesh Mangesh

597 3731 1 3

Sh

eik

ha

n

Atrush Atrush

494 3088 11 33 2 1

Baadra Baadra

392 2450 2 2

Qasruk Qasruk

426

2663 2 3

Chira

312 1950 2 3

Kalakchy Kalakchy

689 4306 12 33 2 4

Am

ed

i Amedia Butan

728 4550 3 1

Rozana Rozana

312 1950 13 33 3 2

48

Sarseng Sarseng

1,328

8300 14 33 3 3

Qadesh

901 5631 3 1

Deraluk Deraluk

194 1213 3 4

Sheladizy Sery

106

663 3 5

Sheladizy

207 1294 15 33 3 5

Su

me

l Sumel

Duban

3,027 18919 16,17 66 4 1

Ashty

1,415 8844 RC 4 1

Sharia

2,440 15250 RC 4 1

Tenahi

1,046 6538 18 33 4 1

Khanik

6,429 40181 19,20,21,22 132 4 1

Batel Batel

2,434 15213 23,24 66 4 2

Za

kh

o

Zakho Saeed Peran

2,975

18594 25,26 66 5 1

Khabor

1,118 6988 27 33 5 1

49

Nawroz

2,763 17269 28,29 66 5 1

Dalal

2,971 18569 30,RC 33 5 1

Rezgary Tilkabar

1,423

8894 31 33 5 2

Barzan

4,384 27400 32,33,34 99 5 2

Derkar Derkar

1,277 7981 35 33 5 3

Batufa/ Batufa/

615 3844 5 4

Rezgary BK camp

2,896 18100 RC,36 33 5 2

Ba

rda

ras

h

Bardarash Bardarash

1,852 11575 37 33 6 1

Darato Darato

769 4806 38 33 6 2

Rovia Rovia

973 6081 39 33 6 3

Ak

re

Akre Akre

1,700 10625 40 33 7 1

Denarta Denarta

237 1481 7 2

Bejel Bejel

128 800 7 3

50

65,310 408188

51

Annex 5: Maps of area

52

Annex 6: Questionnaires

NUTRITION SURVEY HOUSEHOLD DATA COLLECTION FORM

Consent: My name is ______________________ and I am working with the Ministry of health. We are conducting a survey on the nutrition and health status of your family. I would like to ask you few questions about your family and we will also weigh and measure your children who are younger than 5 years of age. The survey usually takes about 30 minutes to complete. Any information that you provide will be kept strictly confidential and will not be shown to other people. Your name or any of the family members will not be mentioned to any document and report. This is voluntary and you can choose not to answer any or all of the questions if you want; however we hope that you will participate since your views are important. Do you have any questions?

Questionnaire cleared by:________________________

Section A : Household identification

Date: /______/______/ 2014: Team number: /__/__/

Governorate: _______________ /___/ District: _________________ /__/__/

Sub district: ______________ /__/__/ Cluster number: /____/____/

Respondent number: /__/__/__/__/ Household number: /__/__/__/__/__/__/__/__/__/__/__/__/__/

Section B : Socio economic Characteristics

Q 1. Respondent name : Phone Number ( if possible) :

____________________________________________

Q 2. Respondent age (in completed year)? /___/___/

Q 3. Respondent marital status? 1. Married 2. Single 3. Divorced 4. Widowed 5. Orphan (under 18 years old)

/___/

Q 4. What was the highest level of education did you (respondent) reach

1. Illiterate 2. Read Alone 3. Read And Write 4. Primary Level 5. Secondary Level 6. Above Secondary

/___/

________________________

Q. 5. What do you do for a living nowadays 1. Business 2. Vocational skills 3. Casual labour 4. Wage employment 5. Government employment 6. Unemployment 7. Other (Specify)

/___/

________________________

Q. 6. How many persons living in this household?

53

/___/___/

Q.7. How many children living in this household are under age five? /___/___/

Q 8. Can you please tell me the name of the Youngest? How old is (name of the youngest) Sex:

/___/____/ /___/____/

/____/_____/ (day/month/year) if not known age in months/____/____/

Male: /___/ Female: /____/

Read to Respondent: The following questions below refer to “Child’s name”

Section C : Infant and Young child feeding & health status

Q 1. Are you currently breastfeeding (NAME)? 1. Yes 2. No

/___/

If yes go to Q3

Q 2. Did you ever breastfeed (NAME)? 1. Yes 2. No

/___/

Q 3. During the first three days after delivery did you give (NAME)

any food or liquid other than your breast milk? 1. Yes 2. No 99. Don’t know

/___/____/

Q 4. Did (NAME) take a vitamin A dose like this during the last 6 months?

SHOW CAPSULE 1. Yes 2. No 99. Don’t know

/___/____/

Q 5. Do you have a card where (NAME) vaccinations are written down? May I see it please?

1. Yes, seen by interviewer 2. Not available/ lost/misplaced 3. Never had a card 99. Don’t know

/___/____/

If Yes, please report all vaccines and dates (interviewer to derive the information from the card) If Yes, please report all vaccines and dates BCG------------------------------------ OPV0 ----------------------------Hep B-----------------------------------------

Penta– 1-------------------------------OPV1--------------------------Rota 1-------------------------------------------- Tetra–

1--------------------------------OPV2--------------------------Rota 2-------------------------------------------- Penta– 2-----

--------------------------OPV3--------------------------Rota 3--------------------------------------------Measles--------------

----------------ViatminA-----------------------------MMR1------------------------------------- Tetra–2----------------------

-------------OPV1-Booster----------------------------Vit.A----------------------------- Tetra-3-Booster---------------------

------------- OPV2Booster-------------------------------------------------- MMR2 --------------

----------------------------------- Vitamin A----------------------------------------------------- Q 6. Has (NAME) had diarrhea in the last 2 weeks?

1. Yes 2. No

99. Don’t know

/___/____/

Q 6. Has (NAME) had ARI in the last 2 weeks? 1. Yes 2. No

Don’t know

/___/____/

Read to Respondent: The following question refer to the household

Section D : Household food security, water access and hygiene

Q 1. Did you experience food shortages during the past 6 weeks? 1. Yes 2. No

/___/____/

54

99. Would not tell

Q 2. Have you received food aid during any of the last 6 weeks?

1. Yes 2. No 99. Not aware

/___/____/

Q3. In the past 6 weeks, How many times have you received food aid?

1. Once 2. Two time 3. Three time or more 99. Don’t know

/___/____/

Q4. In the past 6 weeks, How many meals do you often have? 1. Once 2. Two 3. Three or more 99. Don’t know

/___/____/

Q 5. What is the main source of drinking water for your household at the moment?

1. Safe Water Source (household connection, tap water, public standpipe,

borehole, protected dug well, protected spring, tanker truck water, mineral water)

2. Unsafe water source (unprotected spring, unprotected well, rivers or

ponds)

/____/

Q 6. What kind of toilet facility does your household use? 1. Flush latrine 2. Improved latrine with cement slab 3. Open air (corner place in the compound) 4. Other (specify)

/____/

________________________

Q 7: How many households share this toilet? (observant) 1. Not shared 2. Shared households (with how many) 3. Public toilet 99. Don’t know

/___/____/

/____/ or don’t know /____/

Section E: Anthropometric data for children aged 6-59 months

Child no.

Child name Sex

(F/M)

Birth date (dd/mm/yyyy)

or age in month

Œdema (O/N)

Weight (00.0kg)

height (00.0cm)

MUAC (000mm)

55

Section F: Mortality questionnaire

No Household members Sex

(F/M)

Date of birth/ age in years

Joined during the

recall period

Born during recall period

Left during the recall

period

Died during recall period

Cause of death or

reason for leaving

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

nutritional anthropometric and mortality survey among internally … · 2018-03-12 · october 2014...

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