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Executive Summary
The Afghanistan National Nutrition Survey (NNS) 2013 provides a recent benchmark of the national and provincial nutritional status of women, children, adolescent and elderly in Afghanistan and comparison with previous findings from 2004. The objectives of survey were to review the current nutritional situation, establish the trends and look for associated factors that influence the nutritional status of the population in Afghanistan.
The Afghanistan National Nutrition Survey 2013 was designed by the Aga Khan University (AKU),
Pakistan in close consultation with the Ministry of Public Health (MoPH) and UNICEF Afghanistan.
The survey field activities were implemented by Silk Route Training and Research Organization (SRTRO) with technical assistance from the Aga Khan University, Pakistan. The survey was independently monitored by Provincial Nutrition Officers (PNOs) of Public Nutrition Department (PND), the MoPH Afghanistan. The Ministry of Public Health Afghanistan was closely involved in the oversight of survey activities right from inception until the end of survey activities along with UNICEF Afghanistan.
NNS 2013 was conducted at national scale through a cross-sectional survey at household level.
Multistage (two stage) cluster sampling technique was used. The sampling frame and the list of enumeration areas were provided by Central Statistics Office (CSO). A Total of 1,020 enumeration areas (clusters) were selected using PPS methodology, 30 clusters from each of the 34 provinces. 18 households were selected from each cluster through systematic random sampling technique.
Height, weight, MUAC and bi-pedal oedema measurements were obtained to determine nutrition status of different target age groups. Height and weight measurements were taken from all survey target age groups (children 0-59 months, index mother, youngest women of reproductive age, unmarried adolescent girls (10-19 years of age) and elderly above 50 years of age). MAUC measurements were obtained from index mother and children (0-59 months). Bi-pedal oedema assessments were done only for children (0-59 months). The youngest child in the household was selected as the index child.
80 clusters (Enumeration areas) were selected using PPS methodology at national level for biochemical samples. Blood samples were collected from three target groups: children 6 to 59 months, women of reproductive age (15-49 years) and unmarried adolescent girls (10-19 years) for micronutrient assays. Urine samples were collected from women of reproductive age and children 7 to 12 years of age. Standard methods and procedures were adopted for collection and transportation of the specimens. Hemoglobin level were tested at the field, whereas other biochemical assessments including Ferritin, Vitamin A, Vitamin D, Zinc, Urinary Iodine, C reactive protein (CRP), alpha glycoprotein (AGP) and salt-iodization were analyzed at the Nutritional Research Laboratory, of the Aga Khan University, Karachi, Pakistan.
In addition to the quantitative component, qualitative methods were also employed to gather in-depth information regarding Infant and Young Child Feeding (IYCF) and nutrition indicators. Focus group discussions (FGD) and in-depth interviews (32 each) with key informants (mothers of children under 3 years, decision makers in the family (both male & female) and care providers) were conducted in eight regions of Afghanistan, considering the ethnic and geographical diversity.
Implementation of survey started in the last week of May 2013 with training of field staff. The field activities were implemented from the second week of June 2013 and continued till the end of October 2013. Survey activities were suspended from July 10 to September 5, 2013, due to diverse intake pattern of foods consumed during the holy month of Ramadan.
The finding of national nutrition survey 2013 revealed that the malnutrition rates among children 0–59 months of age at national level were as follows; stunting (HAZ <-2SD) 40.9% (95% CI 39.3-42.5), severe stunting 20.9% and moderate stunting at 20.0% r. Wasting (WHZ <-2SD) 9.5% (95% CI 8.73-10.4), moderate wasting 5.5% and severe wasting 4.0%. Whereas, 5.4% children were overweight (WAZ >+3SD). Proportion of children underweight (WAZ <-2SD) was 25.0% (95% CI 23.7-26.2).
Nutrition status of adolescent girls (10-19 years) was assessed for the first time in Afghanistan in NNS 2013. Findings of survey reported that, 8.0% (95% CI 6.8-9.3) of the adolescent girls were thin (BMIZ <-2SD) and 1.5% (95% CI 1.1-1.9) were severely thin (<-3SD). Furthermore 11.6% (95% CI 10.1-13.2) of adolescent girls were overweight (>+1SD) and only 2.7% were obese (>+2SD).
Among women of reproductive age (15-49 years); at national level 9.2% (95% CI 8.1-10.3) of women were thin or undernourished (BMI <18.5 kg/m2 ). The proportion of women with mild thinness (BMI 17.0-18.4 kg/m2 ) was 6.7% (95% CI 5.9-7.6) whereas, severe thinness (BMI <17 kg/m2 ) among women was 2.4% (95% CI 2.0-2.9). About one fifth (20.7%, 95% CI 19.1-22.2) of women were overweight (BMI 25-29 kg/m2 ), and 8.3% (95% CI 7.1-9.5) were obese (BMI 30 kg/m2 or above).
In the national nutrition survey 2013, elderly persons, above 50 years, were assessed to determine some aspects of their health and nutritional status. Overall, 2569 elderly persons were assessed revealing that more than half (53.0%) of the proportion of elderly persons had normal BMI (BMI 18.5-24.9 kg/m2 ) and 8.7% were thin or undernourished (BMI<18.5 kg/m2 ). The proportions of mild thinness (BMI 17.0-18.4 kg/m2 ) and severe thinness (BMI < 17 kg/m2 ) were 6.6% and 3.1%, respectively. Among elderly population 26.1% were pre-obese (BMI 25-29 kg/m2 ) and 12.3% obese (BMI > 30 kg/m2).
NNS 2013 indicated that micronutrient deficiencies are widespread in Afghanistan. Anemia (Hb levels <11.99gm/dl), was common in women of reproductive age (40.4%) and among children 6-59 months of age (44.9%). Vitamin A deficiency (< 0.70 μmol/l) was markedly more common in children 6-59 months of age (50.4%) than among women of reproductive age (11.3%). As per WHO classification, the prevalence of vitamin A among children 6-59 months is a severe public health problem for Afghanistan. Zinc deficiency was observed in both women and children, with a prevalence of 23.4% and 15.1% respectively. Similarly, Iodine deficiency was fairly common among both women of reproductive age and children 7-12 years of age, with a prevalence of 40.8% and 29.5% respectively. Majority of women of reproductive age (95.5%) and children 6-59 months (81.0%) were found to be deficient in vitamin D (<20.0 ng/mL) with a large proportion of women reproductive age (64.7%) suffering from severe vitamin D deficiency (<8.0 ng/mL) while a significant majority of children (64.2%) exhibited moderate deficiency (8.0-20.0 ng/mL).
The findings of KAP module revealed that knowledge about micronutrients was generally poor; around one third (38.7%) of respondents had knowledge about vitamins across the Afghanistan. Most Afghan mothers (69.8%) were not aware of vitamin A. The highest percentage for knowledge of vitamin A was in Panjshir (83.9%) with the lowest in Balkh (4.3%). Overall, 60.8% respondents had knowledge about anemia. At national level about 64.2% respondents were aware of iodized salt. A considerable variation existed between provinces ranging from 24.7% in Uruzgan to 96.0% in Baghlan. Among those who knew about iodized salt, the majority (52.6%) of them had heard about it from television. At the national level, 78.5% respondents reported use of iodized salt for cooking. The proportion of households using salt testing positive for iodine was 43.6% across Afghanistan. During the survey respondents were also asked about the usage of fortified commodities such as fortified flour, ghee/ oil, milk, etc. at household level. National results showed that 38.1% households used one or more fortified commodities, 48% of respondents reported that they were not using any kind of fortified food and 10.0% did not know about fortified foods.
At national level, 89.7% women reported hand washing with soap after defecation. Likewise, 90% women usually washed hands before preparing the meals. However, from observation by survey team merely 45.1% households had soap available at hand washing place. Hand washing places could not be observed by teams for 18.0% households at the time of visit.
Nationally, 48.1% women sought antenatal care (ANC) during their last pregnancy. Only 16.4% of women reported to have had four or more antenatal care visits during their last pregnancy. Among those women who accessed ANC, just 24.7% made their first ANC visit during the first trimester of pregnancy, 10.8% visited for the first time during 4-5th month and 12.1% after sixth month of pregnancy. The services utilized by pregnant women during antenatal care visits included blood pressure (BP) measurements (68.9%), weight measurements (35.8%), ultrasound scan (41.5%), urine sampling (22.3%), and blood sampling (15.4%). During ANC visits, 47.7% women received information and counseling about eating more nutritious food followed by advice to take extra rest (42.3%) and exclusive breast feeding (15.5%). Almost 21.9% women did not receive any relevant information during visits.
Information related to infant and young child feeding (IYCF) practices was collected from mothers of children under 24 months of age. Almost all infants aged 0-23 months (98.0%) were breastfed after birth. However, 69.4% infants aged 0-23 months were reported to be breastfeed within one hour of birth and 89.9% were breastfed within 24 hours of birth. Half the infants surveyed (52.4%) also received pre-lacteal feeds. Colostrum feeding practice was common (87.5%) across Afghanistan. More than half (58.4%) of the infants aged 0-6 months were exclusively breastfed and 76.3% infants in same age group were predominantly breastfed. More than half (59.9%) infants aged 6-23 months were currently being breastfed along with solid, semi-solid or soft foods. 55.2% infants of 0-23 months were appropriately breastfed. About one third (30.9%) infants of 6-8 months who were currently on breastfeed were introduced complementary food; however, 41.3% infants (6-8 months) were introduced complementary food irrespective of current breastfeeding status. Overall 24.5% of female children received minimum acceptable diet as compared to 19.6% of male children 6-23 months of age. The proportion of children aged 6-23 months receiving minimum acceptable diet increased with mother’s level of education and wealth index.
One of the primary objectives of NNS 2013 was to estimate the proportion of malnourished children enrolled in the Basic Package of Health Service’s Integrated Management of Acute Malnutrition (IMAM): IPD-SAM, OPD-SAM and OPD-MAM. Findings showed that only 2.5% children with acute malnutrition were registered in one of the above stated programs across Afghanistan during the survey period. Of these, 48.4% children under five years of age were hospitalized in IPD-SAM (TFU/SC), 21.4% in OTP and 17.3% in SFP. The high rate of hospitalization in IPD SAM is possibly due to the lack of sites providing OPD SAM, as a result of which even children without complications may have been admitted to IPD SAM.
NNS 2013 data based on Food Consumption Score showed that overall 75.7% households had acceptable food consumption, 18% had borderline and 6.3% had poor food consumption. Results based on Household Hunger Scale indicated that the majority of the households (84.2%) had no or light hunger scale with the score of 0-1, whereas 14% had moderate hunger with the score of 2-3, and only 0.9% of households were found to have severe hunger with the score of 4-6. The average reduced CSI defined by this NNS was 3.96, which was at the minimal level based on the country-specific classification. Only one province had RCSI at extremely severe coping level and another province at severe coping level. The results of these three indicators were similar to those identified by the Seasonal Food Security Assessment carried out in July-August 2013 in 34 provinces by the Food Security and Agriculture Cluster in Afghanistan.