Anthropometric Nutrition and Mortality Surveys

MINDANAO, PHILIPPINES MUNICIPALITIES OF ARAKAN AND PRESIDENT ROXAS, NORTH COTABATO, REGION XII
AND

MUNICIPALITY OF KAPATAGAN, LANAO DEL SUR, ARMM

October-December 2010

Bernardette Cichon

Funded by :

ACKNOWLEDGEMENTS
Firstly ACF would like to thank the municipalities of President Roxas, Arakan and Kapatagan for their help in the implementation of these surveys in particular: - Hon. Mayor Jaime Mahimpit, Mayor of the municipality President Roxas - Hon. Mayor Gerardo B. Tuble, Mayor of the municipality of Arakan - Hon. Mayor Nashrudin B Maglangit, Mayor of the municipality of Kapatagan Much appreciation is also extended to the DoH-ARMM and the DoH-Region XII. ACF would also like to thank the surveyors for their hard work, as well as the barangay officials, health workers and families who provided valuable information and allowed the survey teams to measure their children. Last but not least ACF thanks AECID for funding this survey and the upcoming project.

TABLE OF CONTENTS
Acknowledgements............................................................................................................................... 2 Table of contents................................................................................................................................... 3 List of Tables.......................................................................................................................................... 6 List of Figures......................................................................................................................................... 9 List of Abbreviations............................................................................................................................10 Executive Summary .............................................................................................................................11 Background......................................................................................................................................11 Objectives ........................................................................................................................................11 Methodology ........................................................................................................................................11 Results..............................................................................................................................................12 Recommendations...........................................................................................................................14 1. Background......................................................................................................................................15 1.1. General .....................................................................................................................................15 1.2. Nutrition ...................................................................................................................................16 1.3. Food Security ............................................................................................................................17 1.4. Water and Sanitation................................................................................................................18 1.5. Infant and Young Child Feeding................................................................................................19 1.6. Health Care ...............................................................................................................................20 1.7. Nutrition programmes..............................................................................................................20 2. Objectives........................................................................................................................................22 Main Objective.................................................................................................................................22 Specific Objectives:..........................................................................................................................22 3. Methodology ...................................................................................................................................23 3.1. Type of Survey ..........................................................................................................................23 3.2. Taget Population.......................................................................................................................23 3.3. Sample Size ...............................................................................................................................23 3.4. Sampling Methodology.............................................................................................................28 3.4.1. Arakan ......................................................................................................................................28 3.4.2. Kapatagan and President Roxas...............................................................................................28 3.5. Special Cases.............................................................................................................................29 3.6. Data Analysis.............................................................................................................................30 3.7. Training .....................................................................................................................................30 3.8. Supervision ...............................................................................................................................31 3.9. Data Collection.........................................................................................................................31 3.9.1. Variables collected as part of the anthropometric survey: .....................................................31 3.9.2. Variables collected as part of the retrospective mortality survey:..........................................32 3.10. Indicators ...............................................................................................................................32 3.11. Limitations and Potential Bias ................................................................................................35
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4. Results .............................................................................................................................................36 4.1 Anthropometric and Mortality Survey of the Municipality of President Roxas ....................... 36 4.1.1. Description of the Sample........................................................................................................36 4.1.2. Age and Sex Distribution..........................................................................................................36 4.1.3. Acute Malnutrition...................................................................................................................37 4.1.3. Acute malnutrition according to Muac Measurements...........................................................39 4.1.4. Chronic Malnutrition................................................................................................................40 4.1.5. Underweight ............................................................................................................................41 4.1.6. Diarrhea ...................................................................................................................................42 4.1.7. Measles vaccination coverage .................................................................................................43 4.1.8. Deworming coverage ...............................................................................................................43 4.1.9. Vitamin A supplementation coverage .....................................................................................43 4.1.10. Mortality Rates.......................................................................................................................44 4.2 Anthropometric and Mortality Survey of the Municipality of Arakan...................................44 4.2.1. Description of the Sample........................................................................................................44 4.2.2. Age and Sex Distribution..........................................................................................................45 4.2.3. Acute Malnutrition...................................................................................................................46 4.2.4. Acute malnutrition according to Muac Measurements...........................................................48 4.2.5 Chronic Malnutrition.................................................................................................................49 4.2.6. Underweight ............................................................................................................................50 4.2.7. Diarrhea ...................................................................................................................................51 4.2.8. Measles vaccination coverage .................................................................................................51 4.2.9. Deworming coverage ...............................................................................................................52 4.2.10. Vitamin A supplementation coverage ...................................................................................52 4.2.11. Mortality Rates.......................................................................................................................52 4.3 Anthropometric and Mortality Survey of the Municipality of Kapatagan................................53 4.3.1. Description of the Sample........................................................................................................53 4.3.2. Age and Sex Distribution..........................................................................................................54 4.3.3. Acute Malnutrition..................................................................................................................55 4.3.4. Acute malnutrition according to Muac Measurements...........................................................57 4.3.4. Chronic Malnutrition................................................................................................................58 4.3.5. Underweight ............................................................................................................................59 4.3.6 .Diarrhea ...................................................................................................................................60 4.3.7. Measles vaccination coverage .................................................................................................60 4.3.8. Deworming coverage ...............................................................................................................61 4.3.9. Vitamin A supplementation coverage .....................................................................................61 4.3.10. Mortality Rates.......................................................................................................................61 5. Discussion.. ...................................................................................................................................62 5.1. Acute Malnutrition...................................................................................................................62
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5.2. Stunting....................................................................................................................................64 5.3. Underweight .............................................................................................................................65 5.4. Health........................................................................................................................................65 6. Recommendations ..........................................................................................................................66 7. References.......................................................................................................................................68 8. Annexes ...........................................................................................................................................69 Annex 1: Map of Mindanao....................................................................................................69 Annex 2. Map of Region XII (indicating location of the municipalities of Arakan and President Roxas).....................................................................................................................70 Annex 3. Map of ARMM (Indicating location of the municipality of Kapatagan) ..................70 Annex 4: Map of the municipality of Arakan .........................................................................71 Annex 5: Map of the municipality of President Roxas ...........................................................72 Annex 6: Map of the municipality of Kapatagan....................................................................73 Annex 7. Anthropometric survey data form ..........................................................................74 Annex 8. Household enumeration data collection form for a death rate calculation survey (one sheet/household)...........................................................................................................75 Annex 9. Cluster selection for the municipality of President Roxas ......................................76 Annex 10. Cluster Selection for Kapatagan............................................................................76 Annex 11. Plausibility Report Municipality of President Roxas .............................................77 Annex 12. Plausibility Report Municipality of Arakan............................................................88 Annex 13. Plausibility Report Municipality of Kapatagan ......................................................97 Annex 14. Anthropometric survey results according to NCHS standards (Municipality of President Roxas) ........................................................................................109 Annex 15. Anthropometric survey results according to NCHS standards (Municipality of Arakan).......................................................................................................111 Annex 16. Anthropometric survey results according to NCHS standards (Municipality of Kapatagan) .................................................................................................113

LIST OF TABLES
Table 1: Prevalence of acute malnutrition in the municipalities of President Roxas, Arakan, Kapatagan (October-December 2010)......................................................................................12 Table 2: MUAC distribution in the municipalities of President Roxas, Arakan and Kapatagan (October December 2010)...12 Table 3: Prevalence of stunting based on height-for-age z-scores (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)...................................................................13 Table 4: Prevalence of diarrhea in the 2 weeks before the survey (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010).13 Table 5: Coverage of vitamin A supplementation in the six months before the survey (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)13 Table 6: Coverage of measles vaccination in 9-59 months old children (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010).13 Table 7: Coverage of Deworming in 12-59 months old children (Municipalities of President Roxas, Arakan and Kapatagan, October-December 2010).14 Table 8: Mortality Rates (Municipalities of President Roxas, Arakan and Kapatagan, OctoberDecember 2010)..14 Table 1.1: Municipalities of Arakan, President Roxas and Kapatagan..15 Table 1.2: Overview of available data about acute malnutrition.16 Table 3.1: Sample size calculation for the anthropometric survey in the municipality of Arakan......24 Table 3.2: Sample size calculation for the anthropometric survey in the municipality of President Roxas.........................................................................................................................................25 Table 3.3: Sample size calculation for the anthropometric survey in the Municipality of Kapatagan.................................................................................................................................26 Table 3.4: Sample size calculation for the mortality survey in the municipality of Arakan................27 Table 3.5: Sample size calculation for the mortality survey in the municipality of President Roxas..27 Table 3.6: Sample size calculation for the mortality survey in the municipality of Kapatagan...........27 Table 3.7: Definition of severity of acute mlanutrition according to weight-for-height, MUAC and Oedema ....................................................................................................................................33 Table 3.8: Definition of severity of malnutrition according to MUAC cut offs....................................33 Table 4.1: Characteristics of the sample (municipality of President Roxas, October/November 2010)36 Table 4.2: Distribution of age and sex of the anthropometric sample (Municipality of President Roxas October/November 2010)..............................................................................................37 Table 4.3: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of President Roxas, October/November 2010).................................38 Table 4.4: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of President Roxas, October/November 2010).....................................38 Table 4.5: Distribution of acute malnutrition and oedema based on weight-for-height z-scores......38 Table 4.6: MUAC distribution (municipality of President Roxas, October/November 2010)39 Table 4.7: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of President Roxas, October/November 2010).............................................................................40 Table 4.8: Prevalence of stunting by age based on height-for-age z-scores (Municipality of President Roxas, October November 2010)..............................................................................................40 Table 4.9: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of President Roxas, October/November 2010).............................................................................41 Table 4.10: Prevalence of underweight by age, based on weight-for-height z-scores and oedema.....................................................................................................................................42 Table 4.11: Association between diarrhea and malnutrition (municipality of President Roxas, October/November 2010)42 Table 4.12: Measles Vaccination Coverage (municipality of President Roxas, October/November 2010).........................................................................................................................................43
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Table 4.13: Deworming Coverage (municipality of President Roxas, October/November 2010).........................................................................................................................................43 Table 4.14: Vitamin A supplementation (municipality of President Roxas, October/November 2010)43 Table 4.15: Births and deaths by age groups (municipality of President Roxas, October/November 2010)44 Table 4.16: Characteristics of the sample (municipality of Arakan, November 2010)..45 Table 4.17: Distribution of age and sex of the anthropometric sample (municipality of Arakan, November 2010).......................................................................................................................45 Table 4.18: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of Arakan, November 2010)..............................................................46 Table 4.19: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of Arakan, November 2010)..................................................................47 Table 4.20: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of Arakan, November 2010)................................................................................47 Table 4.21: MUAC distribution (municipality of Arakan, November 2010)..48 Table 4.22: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of Arakan, November 2010)..........................................................................................................49 Table 4.23: Prevalence of stunting by age based on height-for-age z-scores (municipality of Arakan, November 2010).......................................................................................................................49 Table 4.24: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of Arakan, November 2010)..........................................................................................................50 Table 4.25: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of Arakan, November 2010)................................................................................50 Table 4.26: Association between diarrhoea and malnutrition (municipality of Arakan, November 2010)51 Table 4.27: Measles Vaccination Coverage (municipality of Arakan, November 2010)51 Table 4.28: Deworming Coverage (municipality of Arakan, November 2010)52 Table 4.29: Vitamin A supplementation (municipality of Arakan, November 2010)..52 Table 4.30: Births and deaths by age groups (municipality of Arakan, November2010)....................53 Table 4.31: Characteristics of the sample (municipality of Kapatagan, November/December 2010)53 Table 4.32: Distribution of age and sex of the anthropometric sample (municipality of Kapatagan, November/December 2010).....................................................................................................53 Table 4.33: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of Kapatagan, November/December 2010)......................................55 Table 4.34: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of Kapatagan, November/December 2010)..........................................55 Table 4.35: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of Kapatagan November/December 2010)........................................................ 56 Table 4.36: MUAC distribution (municipality of Kapatagan, November/December 2010)57 Table 4.37: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of Kapatagan, November/December 2010)..................................................................................57 Table 4.38: Prevalence of stunting by age based on height-for-age z-scores (municipality of Kapatagan, November/December 2010)..................................................................................58 Table 4.39: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of Kapatagan November/December 2010)...................................................................................59 Table 4.40: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of Kapatagan November/December 2010).........................................................59 Table 4.41: Association between diarrhea and malnutrition (municipality of Kapatagan, November/December 2010)60 Table 4.42: Measles Vaccination Coverage (municipality of Kapatagan, November/December 2010)...61

Table 4.43: Deworming Coverage (municipality of Kapatagan, November/December 2010).61 Table 4.44: Vitamin A supplementation (municipality Kapatagan, November/December 2010).61 Table 4.45: Births and Deaths by age groups (municipality of Kapatagan, November/December 2007).........................................................................................................................................61 Table 8.1: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of President Roxas, October-November 2010).108 Table 8.2: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of President Roxas, October-November 2010)108 Table 8.3: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of President Roxas, October-November 2010)108 Table 8.4: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of President Roxas, October-November 2010).108 Table 8.5: Prevalence of underweight by age, based on weight-for-height z-scores and oedema municipality of President Roxas, October-November 2010).109 Table 8.6: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of President Roxas, October-November 2010).109 Table 8.7: Prevalence of stunting by age based on height-for-age z-scores (municipality of President Roxas, October-November 2010).109 Table 8.8: Mean z-scores, Design Effects and excluded subjects (municipality of President Roxas, October-November 2010)..109 Table 8.9: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of Arakan, November 2010)110 Table 8.10: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of Arakan, November 2010).110 Table 8.11: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of Arakan, November 2010).110 Table 8.12: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of Arakan, November 2010)110 Table 8.13: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of Arakan, November 2010).111 Table 8.14: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of Arakan, November 2010)111 Table 8.15: Prevalence of stunting by age based on height-for-age z-scores (municipality of Arakan, November 2010)..111 Table 8.16: Mean z-scores, Design Effects and excluded subjects (municipality of Arakan, November 2010).111 Table 8.17: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality Kapatagan, November/December 2010)..112 Table 8.18: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality Kapatagan, November/December 2010)112 Table 8.19: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality Kapatagan, November/December 2010).112 Table 8.20: Prevalence of underweight based on weight-for-age z-scores by sex (municipality Kapatagan, November/December 2010).112 Table 8.21: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality Kapatagan, November/December 2010).113 Table 8.22: Prevalence of stunting based on height-for-age z-scores and by sex (municipality Kapatagan, November/December 2010).113 Table 8.23: Prevalence of stunting by age based on height-for-age z-scores (municipality Kapatagan, November/December 2010)113 Table 8.24: Mean z-scores, Design Effects and excluded subjects (municipality Kapatagan, November/December 2010)113

LIST OF FIGURES
Figure 4.1: Population age and sex pyramid (Municipality of President Roxas October/November 2010).........................................................................................................................................37 Figure 4.2: Distribution of weight-for-height z-scores (Muncipality of President Roxas, October/November 2010)39 Figure 4.3: Distribution of height-for-age z-scores (Municipality of President Roxas, October/November 2010)41 Figure 4.4: Population age and sex pyramid (Municipality of Arakan, November 2010)...................46 Figure 4.5: Distribution of weight-for-height z-scores (Muncipality of Arakan, November 2010)48 Figure 4.6: Distribution of height-for-age z-scores (Municipality of Arakan, November 2010)..50 Figure 4.7: Population age and sex pyramid (Municipality of Kapatagan, November/December 2010)......... . .............................................................................................................................54 Figure 4.8: Distribution of weight-for-height z-scores (Municipality of Kapatagan, November/December 2010)..56 Figure 4.9: Distribution of height-for-age z-scores (Muncipality of Kapatagan, November/December 2010)58

LIST OF ABBREVIATIONS

ACF-S AECID AFP ARMM BHC BHW BNS CDR DHS DoH ENA FGD FNRI FS GAM HH INGO IYCF LGU MAM MERN MILF MUAC MSF NCHS NGOs NNC NNS NPA OTP PD RHU RR SAM SMART UN UNFPA UNICEF WASH WHO WFP

Action Contre la Faim - Spain Agencia Espaola de Cooperacin Internacional para el Desarrollo Armed Forces of the Philippines Autonomus Region of Muslim Mindanao Barangay Health Centre Barangay Health Workers Barangay Nutrition Scholars Crude Death Rate Demographic and Health Surveys Department of Health Emergency Nutrition Assessment Focus Group Discussion Food and Nutrition Research Institute Food Security Global Acute Malnutrition Households International Non-governmental Organisations Infant and Young Child Feeding Local Government Units Moderate Acute Malnutrition Mindanao Emergency Response Network Moro Islamic Liberation Front Mid Upper Arm Circumference Mdecins sans Frontires National Centre for Health Statistics Non-governmental Organisation National Nutrition Council National Nutrition Survey New Peoples Army Outpatient Therapeutic Programme Positive Deviance Rural Health Unit Risk Ratio Severe Acute Malnutrition Standardized Monitoring and Assessment of Relief and Transitions United Nations United Nations Population Fund United Nations Childrens Fund Water, Sanitation and Hygiene World Health Organisation World Food Programme

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EXECUTIVE SUMMARY
BACKGROUND
All types of malnutrition are a problem in the Philippines. This is caused by inadequate consumption of food, inadequate access to health care and sanitation facilities as well as food insecurity. In April 2010, ACF-S carried out a rapid assessment in Central Mindanao and decided, with support from AECID, to launch a four year integrated Food Security, Nutrition and Water and Sanitation programme in three municipalities, namely the municipality of Kapatagan, Lanao del Sur, ARMM and the municipalities of President Roxas and Arakan in the Province of North Cotabato, Region XII. These surveys serve as a baseline survey for this programme.

OBJECTIVES
MAIN OBJECTIVE To assess nutritional status of children aged 6-59 months and the retrospective mortality rate of the population in the municipalities of Arakan, President Roxas and Kapatagan. SPECIFIC OBJECTIVES: - Determine the prevalence of acute malnutrition among children aged 6-59 months in the three municipalities1. - Determine the rates of stunting and underweight among children aged 6-59 months. - Determine the crude death rate of children under 5 and the general population (over a recall period of approximately 5 months in Arakan and President Roxas and 3 months in Kapatagan). - Determine the coverage of vitamin A supplementation in the last 6 months. - Determine coverage of measles vaccination among children aged 9-59 months. - Determine coverage of deworming among children 12-59 months in last 6 months. - Determine prevalence of diarrhea in the 2 weeks before the survey.

METHODOLOGY
In the municipalities of President Roxas and Kapatagan a two-stage cluster survey was carried out. In Arakan simple random sampling was used since population lists were available. All three surveys were carried out using the SMART methodology. The target population for the anthropometric survey was all children aged 6-59 months. The target population for the mortality survey was the entire population. The recall period for the mortality surveys was 145, 152 and 88 days for President Roxas, Arakan and Kapatagan, respectively. For the two cluster surveys households were selected using simple random sampling at the second stage.

Since the new WHO growth standards are being used in the Philippines, malnutrition rates in the main part of the report will be presented according to WHO standards. Results according to NCHS standards will be presented in the Annexes.

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The total sample size calculated was of 768 children and 1704 HH (57 clusters of 30 households) in Presidents Roxas, 354 children and 784 households in Arakan and 560 and 1241 HH (62 clusters of 20 HH) in Kapatagan. During the surveys 3 clusters in President Roxas and 6 in Kapatagan became inaccessible due to security reasons. This lead to a total sample size of 1620 HH and 953 children in President Roxas, and 1112 HH and 903 children in Kapatagan. The household list provided for the municipality of Arakan was more inadequate than first expected and a total of 756 HH (398 children) were visited during the survey.

RESULTS
GAM was 10.3%, 5.9% and 6.9% and SAM 2%, 0.9% and 1% in the muncicipalities of President Roxas, Arakan and Kapatagan, respectively (see table 1). Malnutrition rates according to MUAC measurements were a lot lower, namely 1.3%, 1.5% and 1.1% in President Roxas, Arakan and Kapatagan, respectively (see table 2). While acute malnutrition rates in Arakan and Kapatagan are below the 10% alert level, rates of stunting are very high2 (see table 3). Data collected about prevalence of diarrhea and coverage of basic health services are shown in tables 4-7. Retrospective mortality rates in the three municipalities are shown in table 8. While mortality rates in Kapatagan are higher than those in the other two municipalities, all are under alert level. Table 1: Prevalence of acute malnutrition in the municipalities of President Roxas, Arakan, Kapatagan (October-December 2010)
President Roxas n = 861 10.3 % (n=89) (95% C.I.: 8.1 - 13.1) 8.4 % (n=72) (95% C.I.: 6.5 - 10.7) 2.0 % (n=17) (95% C.I.: 1.2 - 3.2) Arakan n = 338 5.9 % (n=20) (95% C.I.: 3.9 - 9.0) 5.0 % (n=17) (95% C.I.: 3.2 - 7.9) 0.9% (n=3) (95% C.I.: 0.3 - 2.6) Kapatagan n = 829 6.9 % (n=57) (95% C.I.: 5.2 - 9.0) 5.9 % (n=49) (95% C.I.: 4.5 - 7.8) 1.0 % (n=8) (95% C.I.: 0.5 - 2.0)

Prevalence of GAM (<-2 z-score and/or oedema) Prevalence of MAM (<-2 z-score and >=-3 z-score, no oedema) Prevalence of SAM (<-3 z-score and/or oedema)

Table 2: MUAC distribution in the municipalities of President Roxas, Arakan and Kapatagan (October December 2010)
President Roxas n = 851 0.2% (n=2) 1.1% (n=9) 5.9% (n=50) 92.7% (n=789) Arakan n =329 0.3% (n=1) 1.2% (n=4) 7.6% (n=25) 90.9% (n=299) Kapatagan n = 807 0% (n=0) 1.1% (n=9) 7.3% (n=59) 91.6 (n=739)

MUAC < 115 MUAC >115 & <125 MUAC >125 & <135 MUAC >135

According to the WHO classification 40% of stunting is considered very high. (WHO global database on Child Growth and Malnutrition available at: http://whqlibdoc.who.int/hq/1997/WHO_NUT_97.4.pdf)

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Table 3: Prevalence of stunting based on height-for-age z-scores (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)
President Roxas n = 860 Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=3 z-score) Prevalence of severe stunting (<-3 z-score) (441) 51.3 % (46.9 - 55.6 95% C.I.) (302) 35.1 % (32.1 - 38.3 95% C.I.) (139) 16.2 % (12.8 - 20.2 95% C.I.) Arakan n = 334 (204) 61.1 % (55.8 - 66.2 95% C.I.) (118) 35.3 % (30.4 - 40.6 95% C.I.) (86) 25.7 % (21.4 - 30.7 95% C.I.) Kapatagan n = 806 (440) 54.6 % (49.8 - 59.3 95% C.I.) (230) 28.5 % (25.3 - 32.0 95% C.I.) (210) 26.1 % (22.0 - 30.6 95% C.I.)

Table 4: Prevalence of diarrhea in the 2 weeks before the survey (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)
Diarrhea Yes No Dont know Total President Roxas 14.2% (n=126) 82.3% (n=734) 3% (n=27) 100% (n=887) Arakan 14.2% (n=51) 83.6% (n=300) 2.2% (n=8). 100% (n=359) Kapatagan 7.2% (n=62) 91.5% (n=785) 1.3% (n=12) 100% (n=859)

Table 5: Coverage of vitamin A supplementation in the six months before the survey (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)
Vitamin A supplementation Yes No Dont know Total President Roxas 70.7% (n=627) 25.8% (n=229) 3.5% (n=31) 100% (n=887) Arakan 80.2% (n=288) 17.3% (n=62) 2.5% (n=9) 100% (n=359) Kapatagan 46% (n=395) 51.6% (n=443) 2.4% (n=21) 100% (n=859)

Table 6: Coverage of measles vaccination in 9-59 months old children (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)
Measles vaccination Yes (mother) Yes (Card) No Dont know Total President Roxas 40.3% (n=339) 47.3% (n=398) 7.9% (n=66) 4.5% (n=38) 100% (n=841) Arakan 41.4% (n=141) 46% (n=157) 9.1% (n=31) 3.5% (n=12) 100% (n=341) Kapatagan 35.1% (n=278) 26.1% (n=207) 36.9% (n=293) 1.9% (n=15) 100% (n=793)

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Table 7: Coverage of deworming in 12-59 months old children (municipalities of President Roxas, Arakan and Kapatagan, October-December 2010)
Deworming Coverage Yes No Dont know Total President Roxas 33.8% 62.3% 3.9% 100% Arakan 73.3% 23.9% 2.7% 100% Kapatagan 34.8% 62.5% 2.7% 100%

Table 8. Mortality rates (municipalities of President Roxas, Arakan and Kapatagan, OctoberDecember 2010)
Mortality Rates (deaths/10.000people/day) Age President Roxas Arakan 0.12 (95%CI=0.06-0.26) 0 (95% CI=0-0.54). Kapatagan 0.27 95%CI=0.15-0.51). 0.45 (95% CI=0.14-1.52)

Crude Mortality Rate 0.15 (95% CI: 0.09-0.25) Under five Mortality 0.21 (95% CI= 0.07-0.66) Rate

RECOMMENDATIONS
Set up OTPs in all three municipalities. Since rates are highest in President Roxas, this municipality should be the priority. Because of the large difference in malnutrion rates according to MUAC and weightfor-height, the possibility of using weight-for-height in active case finding instead of MUAC to avoid missing many of the severe cases should be discussed. Substantial effort should be made towards reducing stunting over the next four years. Stunting should be prevented through the community based component of the programme (PD/Hearth, nutrition education and campaigns). Advocate for improved coverage of basic health services, such as immunizations, vitamin A supplementation in particular in the municipality of Kapatagan. Since prevalence of acute malnutrition is not alarming, funds limited and the main focus of the programme should be prevention of stunting, the option of reducing the frequency and of SMART surveys and carrying out a coverage survey instead should be considered.

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1. BACKGROUND
1.1. GENERAL
Mindanao is the second largest of the Philippines 7107 islands and is located in the south of the country (see map in Annex 1). It has a total population of 21.6 million (as of August 2007) [1], 61% of which are catholic, 20% are Muslim, the remaining 9% have other christian faiths or indegenous beliefs [2]. Mindanao consists of regions IX, X, XI, XII, XIII and ARMM, which are further divided into 26 provinces, 422 muncipalities and 33 cities [1]. While Muslims are a minority in the Philippines, in the Autonomous Region of Muslim Mindanao (ARMM) they make up 90% of the population [2]. Despite an abundance of natural resources, ARMM and Region XII (also known as Central Mindanao) are among the poorest in the country [3], which can partly be attributed to political instability in the region. Mindanao has been affected by a conflict that consists of a conflict between the AFP and MILF3, AFP and NPA4 as well as political and clan based rivalries (Rido), for the last four decades. The conflict between AFP and MILF last flamed up after the failed signing of a Memorandum of Agreement on Ancestral Domain in August 2008 and left more than 500,000 people displaced in the provinces of Lanao del Sur (ARMM), Maguindanao (ARMM) and North Cotabato (Region XII) [4]. Many people in Central Mindanao do not have access to adequate healthcare, water and sanitation facilities and nutritious food causing widespread malnutrition. In addition to political instability, droughts, floods, poor productivity, under-investment in rural infrastructure, unequal land and income distribution, high population growth and the low quality of social services lie at the root of rural poverty in Central Mindanao [4]. In April 2010 ACF carried out a rapid assessment in Central Mindanao and decided, with support from AECID, to launch an integrated Food Security, Nutrition and Water and Sanitation programme in three municipalities with the overall objective to contribute to poverty reduction in these areas. The municipalities chosen for this programme are the municipality of Kapatagan in Lanao del Sur, ARMM as well as the municipalities of Arakan and President Roxas in the province of North Cotabato, Region XII (see maps in Annex 2-6). Some information about the three municipalities is shown in the table 1.1 below. There are no IDPs resulting from the 2008 violence in the three chosen municipalities. However one of the barangays (Salat) in President Roxas was affected by a local conflict, leading to population displacement. This barangay was excluded from the survey. Table 1.1. Municipalities of Arakan, President Roxas and Kapatagan [3,5,6,7]
Number of barangays5 Total land area Total Population
3 4 5

Arakan 28 69,432 hectares 47,000 (2007 estimate)

President Roxas 25 61,825 hectares 43,133 (2007 estimate)

Kapatagan 15 11,640 Hectares 10777 (2010 estimate)

The MILF or Moro Islamic Liberation Front is a muslim separatist group. The militant wing of the communist party of the Philippines. Barangay is the Filipino term for village or district.

15

Population Groups

Illongo (59%) Cebuano (20%) Manobo (7%) Bagobo (7%) Other (7%) 55%

Poverty Incidence6

Illongo (47%) Cebuano(24%) Ilocano (16%) Teroray (3.5%) Manobo (5.0%) Other (4.5%) 55%

Maranao (91%) Illongo (2.5%) Cabuano (2%) Iranon (1%) Other (3.5%) 59%

1.2. NUTRITION
All types of malnutrition (stunting, underweight, acute malnutrition, micronutrient deficiencies and nutrition related chronic diseases) are a problem in the Philippines. Malnutrition is more common in Mindanao than in other parts of the Philippines and FGDs carried out as part of the rapid assessment in April 2010 have revealed that it is recognized as a problem by both the population and health workers. Surveys and assessments carried out in ARMM and Region XII have generally shown that rates of acute malnutrition range from 5-10% (see table 1.2.). Although acute malnutrition rates do currently not reach the emergency cut off of 15%, it is, nevertheless, considered to be a concern by the local health authorities, INGOs and UN agencies, especially since the presence of aggravating factors such as political instability, droughts and floods, inadequate water and sanitation and widespread food insecurity mean that rates of acute malnutrition could increase quite dramatically over a short period of time. Rates of stunting and underweight are high and range from 20-50% and 26.6-31.5%, respectively (see table 1.2.) In addition to survey data, underweight data is available at municipal level from Operation Timbang. Operation Timbang or Operation Weighing Scale is a government run initiative that aims to measure children regularly using the weight-forage indicator. However this data is often questionable because of faulty equipment and lack of representativeness of the sample. According to data collected as part of operation Timbang in 2009, 9.6%, 20.5% and 13% of children are underweight in the muncipalities of President Roxas, Arakan and Kapatagan, respectively. Table 1.2. Overview of available data about acute malnutrition [8, 9, 10, 11, 12]
Date 2006 Type of Survey Baseline Nutrition and food security Assessment in Mindanao Organisation UNICEF/WFP/ FNRI Acute Malnutrition Lanao del Sur: 5.9% North Cotabato: 8.3 % Stunting North Cotabato: 21.9 % Lanao del Sur: 37.7% Underweight North Cotabato: 26.6% Lanao del Sur: 28.5%

Data for poverty incidence is at provincial level

16

2008

National Nutrition Survey January- Joint Emergency March Nutrition and Food 2009 Security Assessment of the conflictaffected Persons in Central Mindanao7 March Follow-up 2010 Emergency Nutrition Assessment9

FNRI UNICEF/FNRI

Region XII: 5.4% ARMM 9.6% 9.8% GAM 2.2% SAM8

47.3%

39.9%

Save the Children

GAM: 7.8% SAM: 1.1%10

50.2%

31.5%

With regard to micronutrient deficiencies, anemia in particular is a problem. According to the National Nutrition Survey in 2003, 32.4% of 6 month to 5 year old children suffered from iron deficiency anemia, and 66.2% in children 6-11 months indicating a severe public health problem for children of weaning age [12]. The Baseline Nutrition and Food Security Assessment carried out in 2006 showed an anemia prevalence of 43.4% in Lanao del Sur and 38.4% in North Cotabato [13]. According to the 2003 National Nutrition survey Iodine deficiency was 35.8% and Vitamin A deficiency was 40.1% [12]. In addition to undernutrition, nutrition related chronic diseases including cardiovascular disease, hypertension and diabetes were found to be a concern according to health records provided by the municipalities. The Philippines are therefore affected by the so-called double burden of malnutrition. Malnutrition in Mindanao is caused by a combination of factors including: inadequate access to food, inadequate sanitation facilities and access to clean water, inadequate dietary diversity and disease. 20% of children in Philippines are born with low birthweight [13], indicating that malnutrition in some cases starts before birth and that nutrition for mothers before, during and after pregnancy is a concern. Access to health care also appears to be a problem especially in terms of cost, lack of staff and distance to health centres [13,15]. The underlying conflict and poverty as well as a recent drought caused by the el Nino phenomenon also impacts on malnutrition rates. These factors will be discussed in more detail below.

1.3. FOOD SECURITY

Mindanao has been regarded as the food basket of the Philippines and yet, food insecurity is wide spread. It has been estimated that in times of peace one in four households in Mindanao is severely food insecure [14]. Agriculture is main source of income for the population [5,6,7,15]. The land is fertile and ideal for year round crop production. The main crops produced include: coconut, banana, sugar cane, corn, rice, pineapple, rubber, mango, sweet potato and coffee [5,6,7,10].
7
8

This assessment covered the conflict affected population of Lanao Del Norte, Lanao Del Sur, Maguindanao and North Cotabato. WHO Standards 9 Carried out in Save the Children in their project areas (19 muncipalities in Maguindanao and North Cotabato) 10 WHO Standards

17

Farmers in Mindanao face many problems meaning that they are unable to produce food to the lands full potential. Many do not have access to irrigation system, fertilizers, pesticides and improved seeds, mainly due to lack of financial resources. In addition many lack knowledge of improved farming practices. Farm inputs are expensive and since savings are generally low, farmers are forced to buy farm inputs on credit. These credits usually have to be paid back to the traders at high interest rates meaning that a large proportion of their income usually goes directly to the traders to pay off debt. Moreover, access to post harvest facilities such as storage, threshers and solar dryers are a problem. Farmers that do not have access to post harvest facilities have to pay for use of storage facilities or sell their produce straight after the harvest at low prices, again reducing their income. Many farmers are tenants which means that they are not in control of what they plant and have to give a large proportion of their income to the landowners as payment for the rent of the land cultivated [10,15]. In addition to the problems faced by many farmers, food insecurity is caused by lack of financial and physical access to food. Markets are far away for a large proportion of the population, access is difficult in the rainy season11 and transport expensive. FGDs carried out in April 2010 by ACF revealed that many families do not have enough money to buy food for their families and can only afford 1-2 meals per day. Households usually consume rice, vegetables or fish. If rice and other foods are not available, which is often the case, households substitute it with root crops such as sweet or wild potato or cassava. Meat is usually only consumed at special occasions [15]. If income is low families are forced to reduce quality and quantity of food eaten which can have a long term impact on nutritional status and health, especially for young children.

1.4. WATER AND SANITATION

Access to safe water is a problem in Lanao del Sur and North Cotabato, particularly in rural communities. 39.7% and 99.8% of the population in Lanao del Sur and North Cotabato, respectively have access to safe water [16]. There are however big differences between municipalities within these provinces and locations within the muncipalities. Those in rural areas further away from the centre of the municipalities and the indigenous population are the most vulnerable to unsafe water sources. A study conducted by ACF in 2005 indicated that Lanao del Sur is among the worst off with regard access to safe water and ranking 75th out of 82 provinces in the Philippines [17]. Access to safe water is better in Arakan and President Roxas than in Kapatagan, with 32.4% and 15% of the population getting water from a doubtful source [18]. Springs are the main source of water in all areas. Spring water is generally considered safe but many springs are unprotected and so water often gets contaminated during the rainy season due to overflowing and in the dry season water often runs out [15,17]. Hygiene and sanitation facilities as well as hygiene practices are a cause for concern in the area. 14.6% and 51% of households have access to sanitary facilities in Lanao del Sur and North Cotabato, respectively [16]. Access to sanitary facilities differs between areas and
The wet or rainy season also known as first monsoon lasts from May until September. A second monsoon exists between november and february, this is however not considered as wet season since rainfall is small compared to the first monsoon. 18
11

ethnic groups and is worse among the indigenous people [17]. In addition to poor access to safe water and hygiene and sanitation facilities, poor sanitation practices are also major cause of disease and the resulting malnutrition. FGDs carried out by ACF as part of the rapid assessment in April 2010 revealed that while the population was aware that handwashing is essential for good health and practice it regularly when soap and water are available, the latter two are, however, often lacking. At the time of these surveys a more detailed WASH assessment was being carried out by ACF that will shed more light on the situation.

1.5. INFANT AND YOUNG CHILD FEEDING

Adequate infant and young child feeding is crucial for health as well as mental and physical development of children. WHO recommends exclusive breastfeeding for the first six months of life followed by progressive introduction of safe and nutritious complementary food with continued breastfeeding until the age of two years [19]. Breastmilk is a safe and convenient food that provides all the energy and nutrients a child needs as well as antibodies to protect the child from infection. Breastfeeding is therefore particularly important in an environment where access to safe water and sanitation facilities are a concern. The risk of disease and thus malnutrition for young children increases when they start interacting more with their environment (crawling and walking) and are being weaned from breastmilk to complementary foods. Previous assessments in Mindanao have expressed a concern with regard to infant feeding practices [10, 11, 13]. According to the DHS survey 2008, 40.5% and 52.3% of children 6-23 month old children were adequately fed according to infant feeding recommendations in ARMM and region 12 respectively. Similarly a short survey carried out as part of ACFs rapid assessment in April 2010 revealed that many mothers do not have access to adeqaute information about infant feeding and as a result only 35.7%, 25% and 16.6% of respondents infants and young children were adequately fed12 in Arakan, President Roxas and Kapatagan, respectively [15]. According to the latest DHS survey 34% of under six months old children were exclusively breastfed at national level and dietary diversity was lower than recommended13. In addition to lack of knowledge about IYCF practices and financial means to provide nutritious food for their children, cultural beliefs play an important role. In Kapatagan it was stated that feeding children with water with sugar for the first 3 days after delivery, before starting to breastfeed, is a common practice in Maranao women. It is believed that this cleanses the body [15]. Inadequate infant and young child feeding practices explain the finding of surveys that acute malnutrition is higher in the 6-24 months group [9, 10]. The UNICEF/WFP survey carried out in early 2009 showed that while GAM was just under 10%, in the younger age group (6-24 months) it was over 22% [10]. Similar results were demonstrated by the 2008 NNS where at national level GAM was 6.1% but 14% in those 12-23 months [9].
Here defined as: children under six months that are exclusively breastfed; children between 6-24 months who are breastfed and receive the minimum number of meals (2 times for six to eight months old children; 3 times for bf 9-24 months old children, 4 times 6-24 months old non breastfed children) and the minimum number of food groups.
12

19

1.6. HEALTH CARE

Disease increases energy and nutrient needs, reduces appetite and in case of diarrhea reduces nutrient absorption. Morbidity rates, in particular diarrhea, are therefore often related to prevalence of malnutrition. The assessment carried out by WFP/UNICEF showed that 72% of acutely malnourished children had been ill in the previous 2 weeks [10]. The most common diseases in the three municipalities include upper respiratory tract infection, fever/flu, diarrhea, hypertension, intestinal parasitism, diabetes, pulmonary TB, anemia and skin diseases [5,6,7,15]. Underfive mortality was 34 and 94 per 1000 live births in region XII and ARMM respectively [13]. Access to health facilities in the three municipalities is a concern. There are rural health units (RHUs) in the centre of the municipalities and a few baranagay health stations. Barangay Health stations are present in most barangays in Arakan and President Roxas, but in Kapatagan there is only one in addition to the RHU. Medicines and staff are often lacking, doctors are rarely available and midwives or BHWs and BNSs are usually overworked. In addition high cost of treatment and transport makes it impossible for some families to seek care [13, 15]. If money is not enough, people tend to go see a traditional healer. There are 3 hospitals within reach from Arakan and President Roxas: a private hospital in Antipas, the government run hospital in Kidapawan and the German Doctors hospital in Buda and two within reach from Kapatagan: Malabang hospital and the hospital in Cotabato City. However, most can not afford to pay for the transport to get there. Appropriate care for women and children is crucial to preventing childhood malnutrition. Women need care before during and after pregnancy. According to the DHS survey only a small amount of women receive appropriate pre-natal care [13]. Currently a large proportion of girls and women deliver their children at home [7, 13], and during FGDs many mentioned that they learn about child care and infant feeding either from a relative of have to teach themselves. Immunization rounds are usually carried out every month by nurses or BHWs that visit the BHCs [15]. According to latest DHS survey vaccination coverage needs to be improved since 30.6% and 77% of children have received all basic vaccinations in ARMM and Region 12 respectively [13]. Similarly measles vaccination coverage was 24.5 % In Lanao del sur 75% in North Cotabato according to the 2006 Baseline Nutrition and food security assessment [8].

1.7. NUTRITION PROGRAMMES

In Mindanao a number of stakeholders are working towards improving nutritional status of the population. These include the Department of Health, the National Nutrition Council, UN agencies (UNICEF and WFP) as well as a number of NGOs (MERN, the Assissi Foundation and PIE for Life) and INGOs (Save the children, MSF, The Committee of German Doctors and ACF). The government has made a significant effort towards tackling malnutrition by establishing the Barangay Nutrition Scholar (BNS) scheme14. In Arakan and President Roxas these are
14 BNSs are community volunteers that receive a basic training in nutrition. They are involved in Operation Timbang and provide information about health and nutrition to the community.

20

present in nearly every barangay. In Kapatagan this scheme is currently in the initial stages. The National Nutrition Council was a key player in setting this up. In 2007 the NNC created the anti-hunger task-force. The anti-hunger taskforce conducts training, advocacy and education with regard to malnutrition. Their priorities include infant feeding and treatment for SAM. The health centres carry out quarterly growth monitoring as part of what is known as Operation Timbang (Operation weighing scale). In order to combat micronutrient deficiencies the government provides iron supplements and conducts universal vitamin A supplementation twice a year. The vitamin A supplementation rounds, also known as Garantisadong Pambata, are accompanied by other basic health services, such as deworming and immunisation According to the DHS survey carried out in 2008 coverage of vitamin A supplementation in the six months before the survey for 6-59 months old children was 48% and 72.7 % in ARMM and Region 12 respectively and 46% of women received a vitamin A supplement postpartum. Coverage of deworming was 29.3% in ARMM and 42.6% in Region XII [13]. Iron supplementation coverage among children remains low: according to the DHS survey 15.6% and 25.4% of 6 to 59 months old children received iron supplements in the 7 days preceding the survey in ARMM and Region 12 respectively. UNFPA has built a birthing clinic in Kapatagan in order to provide adequate facilities especially in far flung areas. PIE for life has recently started community nutrition workshops in the barangay Kapatagan proper. The Assisi Foundation is involved with Water and Sanitation programmes in Kapatagan and have recently started a supplementary feeding programme in the barangay Minimao, Kapatagan. WFP and the Department of Education provide supplementary food and Save the Children and UNICEF are providing SAM treatment in some municipalities with support from the DoH and local partners. SAM treatment is however not available in the three municipalities chosen for ACF activities. The Committee of German doctors runs a hospital in Buda where SAM treatment is available and is reachable from Arakan and President Roxas. Transport to the hospital is however too expensive for most families and most parents are not able to stay in the hospital with their children for long periods of time. It is for this reason that ACF has chosen these 3 municipalities for a new four year integrated Nutrition, Food Security and Water and Sanitation programme. The objective of this programme is to make SAM treatment available in the communities, according to the CMAM strategy promoted by WHO/UNICEF, and to prevent all types of malnutrition through community based activities including PD Hearth, Nutrition Education as well as WASH and FS interventions. The anthropometric and mortality surveys carried out from October to December 2010 serve as a baseline for this project.

21

2. OBJECTIVES
MAIN OBJECTIVE
To assess nutritional status of children aged 6-59 months and the mortality rate of the population in the municipalities of Arakan, President Roxas and Kapatagan.

SPECIFIC OBJECTIVES:
Determine the prevalence of acute malnutrition among children aged 6-59 months in the three municipalities15. Determine the rates of stunting and underweight among children aged 6-59 months. Determine the crude death rate of children under 5 and the general population (over a recall period of approximately 5 months in Arakan and President Roxas and 3 months in Kapatagan). Determine the coverage of vitamin A supplementation in the last 6 months. Determine coverage of measles vaccination among children aged 9-59 months. Determine coverage of deworming among children 12-59 months in last 6 months. Determine prevalence of diarrhea in the 2 weeks before the survey.

15

Since the new WHO growth standards are being used in the Philippines, malnutrition rates in the main part of the report will be presented according to WHO standards. Results according to NCHS standards will be presented in the Annexes.

22

3. METHODOLOGY
3.1. TYPE OF SURVEY
Three anthropometric and mortality surveys were carried out. One in the municipality of Kapatagan, Autonomus Region of Muslim Mindanao, one in the municipality of President Roxas and one in the municipality of Arakan, Province of North Cotabato Region XII according to the SMART (Standardized Monitoring and Assessment of Relief and Transitions) methodology. Data collection was carried out from 29th of October- 2nd of December over a total of 27 working days. Data on malnutrition and mortality rates were collected simultaneously. Since household lists were available for the municipality of Arakan and the area covered by the survey is relatively small, simple random sampling was used to select HHs. The HH lists were compiled in 2009, and since there are no IDPs in the area and no major population movements have taken place since 2009 it was believed that these lists were adequate enough. In President Roxas and Kapatagan household lists were too incomplete and unavailable, respectively, to enable simple random sampling. A two stage cluster survey was therefore carried out in these municipalities with the barangays as the primary sampling unit. For barangays that contained more than one cluster and/or more than 250 HH, a segmentation was carried out (see section 3.4). Within clusters households were selected using simple random sampling. The surveys cover the whole of each municipality, however 1 barangay in President Roxas (Salat), and one in Kapatagan (Matimos) had to be excluded before the start of the survey for security reasons. Maps of each municipality are shown in Annexes 3-6.

3.2. TARGET POPULATION

The target population for the anthropometric survey was all children aged between 6 and 59 months of age because they represent the most vulnerable portion of the population. The target group for the mortality survey included the whole population. The mortality questionnaire was administered in all households even those with no children aged 6-59 months. Where possible the head of the household was chosen as the primary respondent. If he or she was unavailable the mothers or carers of the children were asked. The anthropometric and mortality questionnaire can be found in Annex 7 and 8. The questionnaires used were standard ENA questionnaires slightly adapted to this survey. The questionnaires were in English and interviews were carried out in the local language.

3.3. SAMPLE SIZE

Since it is impossible to measure the entire population a representative sample of the population was selected for the survey. The sample size calculation for the anthropometric and mortality components for all three surveys was carried out using

23

ENA software (Emergency Nutrition Assessment)16 . The sample size calculations for all three surveys are shown in tables 3.1-3.6. The calculated sample sizes consisted of 784 households in Arakan, 1704 households for President Roxas and 1241 for Kapatagan. Since simple random sampling was used in Arakan the sample size there was much smaller. The number of HH to be visited for the mortality survey was slightly lower than for the anthropometric survey. Nevertheless, the mortality questionnaire was completed in all HH, even those without children. Table 3.1: Sample size calculation for the anthropometric survey in the municipality of Arakan
Amount Total population 42430 Source/Justification 2009 community census of Arakan plus annual population growth17 National average according to the DHS survey (2008).

% of children under 5 Estimated number of children under five Estimated number of children between 6-59 months (90% of all under five year old children) Average HH size

11.6%

4922

443018 According to DHS survey (2008) and HH community census of Arakan Estimation based on a number of surveys carried out in the region between 2006 and 2010 (see section 1.2) Since cluster sampling is not used the design effect is one

4.8

Estimated prevalence Precision Design effect Non response (HH) Number of children Number of HH to be visited

10% 3% 1 10% 354 784

16
17

September 2010 Version. Population in Arakan according to the 2009 community census was 41,619. An annual population growth of 1.95% (http://www.nscb.gov.ph/pressreleases/2006/27April06_PR-2006-04-SS2-03_popnprojection.asp) was added to estimate the population number for 2010. In order to quality check the results of the 2009 community census, this value was compared to the results of the 2007 census plus annual population growth which lead to a similar result (41026) 18 Since the estimated target population is less than 4500, the correction for small population size was applied in ENA.

24

Table 3.2: Sample size calculation for the anthropometric survey in the municipality of President Roxas
Amount Total population 44,668 Source/Justification 2009 community census plus annual population growth19,20 National average according to the DHS survey (2008).

% of children under 5 Estimated number of children under five Estimated number of children between 6-59 months Average HH size Estimated prevalence Precision

11.6%

5181 4663 4.8 10% 3% The population was believed to be heterogeneous but the design effect was unknown. A design effect of two was therefore chosen by default. 90% of all under five year old children According to DHS survey (2008) Estimation based on a number of surveys carried out in the region between 2006 and 2010 (see section 1.2)

Design effect

Non response (HH) Number of children

10% 768 0.5011 children aged 6-59 months per HH. 768/0.5011=1533 HH. Plus 10% for non response = 1704 Number of clusters chosen so that each team can finish one cluster per day Number of HH divided by Number of clusters.

Number of HH to visit

1704

Number of clusters

57

Number of HH per cluster

30

19

Population in President Roxas according to the 2009 community census was 43,814. An annual population growth of 1.95% (http://www.nscb.gov.ph/pressreleases/2006/27April06_PR-2006-04-SS2-03_popnprojection.asp) was added to estimate the population size for 2010. In order to quality check the results of the 2009 community census, this value was compared to the results of the 2007 census plus annual population growth which lead to a similar result according to which it was 43262. 20 Data excludes the barangay of Salat, since this one could not be visited due to security reasons. 1284 persons had to be excluded.

25

Table 3.4: Sample size calculation for the anthropometric survey in the municipality of Kapatagan
Amount Total population 19,713 11.6% Source/Justification 2007 population census + anuual population growth21,22 National average according to the DHS survey (2008).

% of children under 5

Estimated number of children under five Estimated number of children between 6-59 months (90% of all under five year old children) Average HH size Estimated prevalence Precision

2287

205823 4.8 10% 3% The population was believed to be heterogeneous but the design effect was unknown. A design effect of two was therefore chosen by default. According to DHS survey (2008). Estimation based on a number of surveys carried out in the region between 2006 and 2010 (see section 1.2)

Design effect

Non response (HH) Number of children

10% 560 Number of children/ number of children per HH +10% Number of clusters chosen so that each team can finish one cluster per day Number of HH divided by Number of clusters.

Number of HH to visit

1241

Number of clusters Number of HH per cluster

62 20

Population in Kapatagan according to the 2007 Census was 18.603 (excluding the Barangay of Matimos). Annual population growth rate in Philippines is 1.95% according to the National Statistical coordination board (http://www.nscb.gov.ph/pressreleases/2006/27April06_PR-2006-04-SS2-03_popnprojection.asp). 22 The Barangay of Matimos had to be excluded due to security reasons.
23

21

Since the target population is less than 4500, the correction for small population sizes was applied in ENA

26

Table 3.4: Sample size calculation for the mortality survey in the municipality of Arakan
Amount Estimated mortality rate (deaths/10000/day) Precision Design effect Non response (HH) Recall period (days) Sample size Number of HH to visit 0.13/10000/ day 0.1 1 10% 152 3068 682 Calculated from independence day (14th of June) until the midpoint point of the survey (11th of November) Sample size/average HH size Source/Justification CDR= 4.8/1000/year24 population according to UN data

Table 3.5: Sample size calculation for the mortality survey in the municipality of President Roxas
Amount Estimated mortality rate (deaths/10000/day) Precision Design effect Non response (HH) Recall period (days) Sample size Number of HH to visit 0.13/10000/day 0.12 2 10% 145 4375 911 Calculated from Independence Day (14th of June) until the Midpoint of the survey (4th of November) Sample size/ average HH size Source/Justification CDR= 4.8/1000 population/ year25 according to UN data

Table 3.6: Sample size calculation for the mortality survey in the municipality of Kapatagan
Amount Estimated mortality rate (deaths/10000/day) Precision Design effect Non response (HH) Recall period (days) Sample size Number of HH to visit 0.13/10000/day 0.125 2 10% 88 days 5353 1239 Sample size/ average HH size Calculated from National Heroes Day (30th of August) until the midpoint of the survey (25th of November) Source/Justification CDR= 4.8/100026 according to UN data

24 25 26

http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A65 http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A65 http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A65

27

3.4. SAMPLING METHODOLOGY

In order to be able to project the results of the survey sample onto the whole population, the sample must be representative of the whole population. A sample is believed to be representative of the population if every household in that population has the same chance of being selected. Random sampling enables us to do this. Two different survey types and thus different kinds of sampling methodologies were used. For Arakan, simple random sampling, the best and simplest method was used. For Kapatagan and President Roxas a two-stage sampling methodology was used since the population data available were not recent, reliable and detailed enough. Both methods are described in more detail below. In each selected household all children aged between 6-59 months were measured and the mortality questionnaire was filled out. 3.4.1. ARAKAN Each HH in this municipality was assigned a number. The ENA software was then used to randomly select the needed number of HHs to be visited. The list of households is not included in the Annexes but is available upon request. 3.4.2. KAPATAGAN AND PRESIDENT ROXAS Selection of Clusters The ENA software was used to select clusters. All barangays and their population were entered into ENA and clusters were then selected according to probability proportional to size in order to ensure that each HH has the same chance of being selected. Cluster allocations for both municipalities are shown in Annex 9 and 10. Selection of HHs Within each cluster a total of 30 and 20 HH were selected for President Roxas and Kapatagan, respectively, using simple random sampling. The teams started by numbering all HH in the cluster at the beginning of each day. Once all HHs in the cluster were given a number the adequate number of HH to be visited was chosen using simple random sampling. The definition of a household is all people living under the same roof and sharing the same meal. Barangays that had more than one cluster were divided into equal parts and each part contained 1 cluster. For clusters that were bigger than 250 HH a segmentation was carried out and one segment was chosen at random. Steps for segmentation are shown below: 1. Division of the cluster into equal parts of no more than 250 HH together with the chief. 2. Calculation of the cumulative population of all segments Example: Cumulative population Segment A = 150 150 Segment B = 200 350 Segment C = 150 500

28

3. Choice of a segment: A number is chosen at random using a random number table. For example if the cumulative population is 500, a random number between 1 and 500 has to be chosen. If the randomly chosen number is between 1 and 150 segment A should be chosen, if the number is between 150 and 350 segment B etc. 4. Within each segment the HH will be numbered and the adequate number of HHs will be chosen at random using simple random sampling, as described above.

3.5. SPECIAL CASES

If the home was empty If the residents were absent, the teams returned to the households at the end of the day. If the family was still absent the mortality questionnaire was filled out with the help of the neighbours and the children were marked as absent. If the neighbours were unable to provide information the household was marked as absent. If the home was completely abandoned, the teams tried to out why. If the home is empty because all members had died or the family left because of a death, the questionnaires were filled out with the help of the neighbours answers. In this case the household was part of the households in the cluster and was not replaced by another one. If another event caused the family to abandon the home, the teams noted it down but did not give a number to this family in the questionnaires. For the survey in Arakan, where simple random sampling was used, the teams made a note if a selected address no longer existed. The households were not replaced with another one intially. However, the survey officer pre-selected an extra 10% of households, these would be visited only if the household lists were so inadequate that more than 10% of HH no longer existed or were inaccessible. Households without children If a selected household did not have any children between 6-59 months of age, the mortality questionnaire was filled out. Absent children If children were absent the reason behind the childs absence was identified. If the child (or children) was close to the home, the surveyors asked someone to go and get the child. If the child was expected to return before the survey team left the barangay, the team revisited the household at the end of the day to measure the child. If the child was not found before the team left the village, the child was given a number and marked as absent. Children in nutritional or health centres If children were located in health centres within reach the survey team were supposed to visit the child in the health centre. If this was not possible the child was given an ID number and marked as absent.

29

Disabled children Disabled children were included in the survey. If a physical deformity prevented the measurement of childs weight or height, the child was given an ID number and the data was recorded as missing. Homes that could not be visited If the residents of the household refused to participate in the survey or could not participate the family was not replaced by another household. Not enough households in the village If after visiting all the households in a cluster area it was determined that there were not enough households to complete the cluster, the closest neighbouring barangay or sitio was supposed to be used to complete the cluster. The same sampling methodology was applied for the remaining households. Houses with several women and their children In case of polygamous families it was determined whether they can be considered as one household or more. The definition of a HH is living under the same roof and sharing meals. If it was determined that there were several HH each one was assigned a number and one was chosen randomly.

3.6. DATA ANALYSIS

Data was entered into the ENA software27. Data analysis was carried out using ENA, Excel and EPI info28. Anthropometric measurements were compared to the new WHO growth standards to determine the malnutrition rates. Malnutrition rates according to NCHS standards can be found in Annexes 14-16. Data cleaning was done by the survey officer at the end of each survey. Boundaries for SMART flags were defined as -3SD to +3SD of the survey population.

3.7. TRAINING
A total of 12 surveyors were recruited. These, together with 9 ACF nutritionists, received a total of four days of training between the 20th and 28th of October 2010. The training consisted of 2 days theoretical training and 2 days of practical training. Topics included in the theoretical training were: Malnutrition, anthropometry, survey methodology, the use of weight-for-height tables, events calendar and survey questionnaires. The practical part of the training consisted of a standardisation test and a field test. During the standardisation test each surveyor practiced anthropometric measurements on ten children. During the field test all teams visited 1 barangay in the municipality of President Roxas to practice HH selection, measurements and filling out of questionnaires. At the end of the training all surveyors had to pass a test to evaluate the quality of the training and the comprehension of the surveyors. Results of the written test as well as the standardisation test influenced the composition of the teams and the role of each surveyor within a team. Teams were composed of three people, one team leader and two measurers.
27 28

Emergency Nutrition Assessment, September 2010 version. EPI Info version 3.5.1., August 2008. 30

The team leaders were in charge of ensuring that the correct methodology for household selection was followed, presenting the objectives to the local authorities and families, conducting the interviews and filling out questionnaires. The measurers took anthropometric measurements, evaluated presence of nutritional oedema and were responsible for the material.

3.8. SUPERVISION
The teams were supervised by the survey officer during the survey. During the first two surveys the survey officer accompanied the teams every day. Supervision was reduced during the last survey in order to allow time for data collection and analysis. In addition the survey officer entered data at the end of every day in order to quality check the data and enable improvement of the teams during the survey.

3.9 DATA COLLECTION

3.9.1. VARIABLES COLLECTED AS PART OF THE ANTHROPOMETRIC SURVEY: Sex: The sex of all children was entered in the anthropometric questionnaire and coded m for male and f for female. Age: The age of the children was recorded in months. The parents were asked to show the surveyors a proof of age. If this is not possible the surveyors used the events calendar to ensure that the age stated by the parents was correct. Weight: Weight was measured using electronic scales. The children were measured naked. If it was not possible to measure a child naked the team leader indicated this on the questionnaire. Weight was recorded to the nearest 100g. Every day before the departure the teams tested the scales with a standard weight of 5 kgs. Height: Height was measured using plastic height boards produced by the company Seca. Children taller than 87cm were measured standing up and those shorter than 87cm were measured lying down. Oedema: The measurers checked children for oedema by applying pressure with the thumbs to both feet for three seconds. Children were considered to suffer from oedema if an imprint was left on both feet for at least a few seconds. In the questionnaire oedema was coded Y for yes and N for no. MUAC: MUAC measurements were taken on all children taller than 65cm. MUAC was measured on the left arm at midpoint between shoulder and elbow using a coloured MUAC tape. MUAC was measured in mm to the nearest mm. Measles Vaccination Coverage: The survey teams asked the mother to see the vaccination card, in order to find out whether the child has been vaccinated. If the mother did not have the card she was asked whether the child has been vaccinated. The response was coded as follows : 1=vaccination confirmed by card, 2=vaccination confirmed by mother, 3=no and 4=dont know. Morbidity: The surveyors asked the mother or guardian whether the child suffered from diarrhea in the two weeks prior to the survey. The response was coded as follows : 1=yes, 2=no and 3=dont know. Vitamin A supplementation: The mother was asked whether the child has received a vitamin A supplement in the last 6 months before the survey. The response was coded as 1=yes, 2=no and 3=dont know.
31

Deworming: The mothers were asked whether children received deworming treatment. The response was coded as 1=yes, 2=no and 3=dont know. 3.9.2. VARIABLES COLLECTED AS PART OF THE RETROSPECTIVE MORTALITY SURVEY: The recall period covered by the retrospective mortality surveys differed between the three surveys and is stated in tables 3.4-3.6 above. In all households the mortality interview was conducted with the head of the household or the mother of the children. The following information was recorded: - The sex, age and number of people that were part of the households at the beginning of the recall period. - The number of people that left and joined the households since the beginning of the recall period. - The number of births during the recall period. - The number of deaths during the recall period. - The cause of death: Diarrhea, fever, measles, difficulty breathing, malnutrition, violence or other. Diarrhea was defined as the passing of three liquid stools per day with or without blood. Suspicion of measles was be defined as a rash accompanied by fever and cough. - Location of death: Current location, during migration, in place of last residence or other.

3.10. INDICATORS
Weight-for-Height The prevalence of acute malnutrition (or wasting) was determined using the weight-for height-index as an indicator of current nutritional status. A childs nutritional status is estimated by comparing it to the weight-for-height curve of a reference population (WHO growth standards29). This curve has a normal shape and is characterized by the median weight and its standard deviation (SD or z-score). The weight-for-height index of a child from the sample was expressed in z-scores for WHO standards and in z-scores and % of the median for NCHS standards. In addition a child was also considered to suffer from SAM if he/she had bilateral oedema. Table 3.7 below shows the definition of acute malnutrition. Table 3.7: Definition of severity of acute mlanutrition according to weight-for-height, MUAC and Oedema
Moderate Acute malnutrition (MAM) z-score W/H <-2 z-score and -3 z-score and absence of oedema and/or MUAC 115mm and <125mm Severe Acute Malnutrition (SAM) z-score
29

% of the Median (for NCHS standards only) W/H < 80% and 70% and absence of oedema and/or a MUAC115mm and <125mm % of the Median

Results according to the NCHS standards will be added in the survey report in annexes 32

W/H <-3 z-score and/or presence of bilateral oedema and/or MUAC<115mm

W/H <70% and/or presence of bilateral oedema and/or MUAC<115mm

Height-for-Age Index The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age z-score is below -2 z-scores are considered short for their age (stunted) and are chronically malnourished. Children who are below -3 z scores are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. MUAC The mid upper arm circumference changes only marginally in children under 5 years with height equal to or above 65 cm and does not need to be related to any other anthropometric measurement. It is a good predictor of mortality. The MUAC cut-offs used are shown in the table 3.8 below. Table 3.8: Definition of severity of malnutrition according to MUAC cut offs. Severity MUAC (mm) Severe acute malnutrition MUAC<115mm Moderate acute malnutrition 115< MUAC<125mm At risk of malnutrition 125< MUAC<135mm Adequate nutritional status MUAC135mm Bilateral Oedema Bilateral oedema starting from the feet is a sign of Kwashiorkor, one of the clinical forms of acute malnutrition. When associated with marasmus (severe wasting), it is called marasmic-kwashiorkor. Children with bilateral oedema are automatically categorized as being severely malnourished, regardless of their weight-for-height. Measles Vaccination Coverage Rates The measles vaccination coverage rate was calculated for all children aged between 959 months as follows: Number of vaccinated children aged 9-59 months x 100 Vaccination Rate = Total number of children aged 9-59 months in the sample Diarrhea The retrospective morbidity rates for diarrhea was calculated as follows: Number of children having suffered from diarrhea in the 15 days before the survey Morbidity Rate = Total number of children aged 6-59 months in the sample

x 100

33

Vitamin A coverage rate The vitamin A supplementation coverage rate was calculated as follows: Number of children having received a vitamin A supplement in the last 6 months Vitamin A coverage Rate = x 100 Total number of children aged 6-59 months in the sample Deworming coverage The deworming coverage will be calculated for all children aged between 12-59 months as follows : Number of vaccinated children aged 12-59 months x 100 Deworming Coverage Rate= Total number of children aged 12-59 months in the sample

Retrospective mortality Rate Determination of the mortality rate gives a good indication of the sanitary conditions in the surveyed area. The mortality rate for children under 5 and for the whole population was calculated according to the following formula: Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), where: a = Number of recall days (see tables 4-6) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period The result is expressed per 10,000 people / day. Mortality thresholds are defined as follows30: Total CMR: Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day Under five CMR: Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day

30

Health and nutrition information systems among refugees and displaced persons, Workshop report on refugees nutrition, ACC / SCN, Nov. 95, 1995. 34

3.11. LIMITATIONS AND POTENTIAL BIAS

Due to security reasons 2 barangays had to be excluded from the survey (Matimos in Kapatagan and Salat in President Roxas). Two further barangays had to be excluded during the survey also due to security reasons (Lebpas in President Roxas and Sigayan in Kapatagan). In addition data collection in the barangay Barao, Kapatangan could not be completed due to a conflict between the incoming and outgoing barangay captain leading to a total 6 clusters that were not completed in Kapatagan (9.7%) and 3 in President Roxas (5.5%). In addition a large number of children were absent: 8.2% and 7.4% of all children included in the sample in President Roxas and Kapatagan, respectively. Nevertheless, the number of clusters visited and number of children measured were higher than the required sample size for both of these surveys (see section 4.1 and 4.3). The household list for the municipality of Arakan was more inaccurate than expected. In addition a very large number of children were absent (15%) which might have introduced some bias in results. As a result the number of children included in anthropometric analysis was slightly less than the required sample size, namely 338 vs 354 (see section 4.2. for more detail). The Seca 217 heightboards used during the survey came in two parts: one for measurement of children greater than 87 cm and one for children less than 87 cm. Unfortunately on the heightboard used for measuring children lying down, cms were divided into intervals of 2 mm each instead of 1 mm. This introduced a digit preference for even numbers and had a negative impact on overall survey quality scores (see plausibility reports in annexes 11-13).

35

4. RESULTS
4.1 ANTHROPOMETRIC AND MORTALITY SURVEY OF THE MUNICIPALITY OF PRESIDENT ROXAS
4.1.1. DESCRIPTION OF THE SAMPLE
A total of 54 clusters of 30 households were visited during the survey leading to a total of 1620 households. The three remaining clusters (cluster numbers 55, 56 and 57) could not be visited due to security reasons. Of the 1260 households included 23 were absent and it was not possible to gather information from neighbours, thus leading to a total sample size of 1597 HH for the mortality survey and 953 children for the anthropometric survey. Of the 953 children, 78 were absent (8.2%) and for 1 height could not be measured. In addition 11 and 6 SMART flags were excluded from weight-for-height analysis under WHO and NCHS standards, respectively leading to a total of 861 children included for analysis under WHO standards and 866 under NCHS standards. 12 SMART had to be excluded from height-for-age analysis under WHO standards leading to a total sample size of 860 children. The total sample size required for this survey was 768 children (see table 3.2.), the number of children included in the analysis was therefore more than enough. Since MUAC measurements were only taken for children of a minimum height of 65 cm, the sample for MUAC measurements were less than those included for weight-for-height, namely 851 children. 887 Children were included for diarrhea and coverage of vitamin A supplementation, 841 for measles vaccination and 788 for deworming.

Table 4.1: Characteristics of the sample (municipality of President Roxas, October/November 2010) 4.1a. Anthropometric nutrition survey
Total number of children Children aged 6-29 months Children aged 30-59 months Girls Boys Ratio m/f n 953 444 509 458 495 1.1 Percentage (%) 100% 46.6% 53.4% 48.1% 51.9% -

4.1b. Mortality survey

n Total Number of households Total Number of people Total Number of Children under five Average Number of people per household Average Number of under five year olds per household 1620 7697 974 4.75 0.6 Percentage (%) 12.6% -

4.1.2. AGE AND SEX DISTRIBUTION Table 4.2 below shows the age and sex distribution of the sample. The sample consists of 46.6% of children aged 6-29 (n=444) months and 53.4% of children aged 30-39 months (n=509). With

36

7.8%, the 54-59 months age group is slightly underrepresented. The boy/girl ratio is 1.1 and therefore within the norm31. The age and sex distribution of the total population included in the mortality survey is shown in Figure 4.1 below. Table 4.2: Distribution of age and sex of the anthropometric sample (municipality of President Roxas, October/November 2010)
Boys AGE (months) 6-17 18-29 30-41 42-53 54-59 Total n 104 119 123 110 39 495 % 48.1 52.2 53.5 53.7 52.7 51.9 n 112 109 107 95 35 458 Girls % 51.9 47.8 46.5 46.3 47.3 48.1 n 216 228 230 205 74 953 Total % 22.7 23.9 24.1 21.5 7.8 100.0 Ratio Boy:girl 0.9 1.1 1.1 1.2 1.1 1.1

Figure 4.1: Population age and sex pyramid (municipality of President Roxas, October/November 2010)

Error! No se encuentra el origen de la referencia.

4.1.3 ACUTE MALNUTRITION

A total of 861 children were included for calculation of acute malnutrition rates under WHO standards and 866 under NCHS standards. All results are according to WHO standards. Results according to NCHS growth standards are shown in Annex 14. GAM prevalence is 10.3%, and 2% of children were found to suffer from SAM. No cases of oedema were found during the survey. Table 4.3 shows that both GAM and SAM are slightly higher in boys than in girls, this difference was however shown to be statistically insignificant (p>0.05)32.

31 32

Acceptable range is from 08-1.2 RR =0.9 [95% CI : 0.6- 1.3] ; 2= 1.4 ; p= 0.35 (Yates corrected : 2= 0.7 ; p= 0.39)

37

Table 4.3: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of President Roxas, October/November 2010)
All n = 861 10.3 % (n=89) (8.1 - 13.1 95% C.I.) 8.4 % (n=72) (6.5 - 10.7 95% C.I.) 2.0 % (n=17) (1.2 - 3.2 95% C.I.) Boys n = 442 10.0 % (n=44) (7.1 - 13.9 95% C.I.) 8.4 % (n=37) (5.9 - 11.8 95% C.I.) 1.6 % (n=7) (0.8 - 3.2 95% C.I.) Girls n = 419 10.7% (n=45) (8.1 - 14.1 95% C.I.) 8.4 % (n=35) (6.1 - 11.3 95% C.I.) 2.4 % (n=10) (1.4 - 4.1 95% C.I.)

Prevalence of GAM (<-2 z-score and/or oedema) Prevalence of MAM (<-2 z-score and >=-3 z-score, no oedema) Prevalence of SAM (<-3 z-score and/or oedema)

Table 4.4: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of President Roxas, October/November 2010)
Severe wasting (<-3 z-score) n % Moderate wasting (>= -3 and <-2 z-score ) n % Normal (> = -2 z score) n % Oedema n %

Age (months) 6-17 18-29 30-41 42-53 54-59 Total

Total Number of Children 189 208 210 188 66 861

6 3 3 3 2 17

3.2 1.4 1.4 1.6 3.0 2.0

19 18 17 12 6 72

10.1 8.7 8.1 6.4 9.1 8.4

164 187 190 173 58 772

86.8 89.9 90.5 92.0 87.9 89.7

0 0 0 0 0 0

0.0 0.0 0.0 0.0 0.0 0.0

In line with other surveys carried out in the region the children were further divided into 6-23 months and 24-59 months age groups. GAM was 12.3% (n=37) in the 6-23 months age group and 9.3% in the 2459 months age group. The difference in GAM prevalence was statistically insignificant33. SAM was 2.7% (n=8) in the 6-23 months olds and 1.6% (n=9) in the older age group. Similarly to GAM rates this difference was statistically insignificant34. Table 4.5. below shows the distribution of different types of SAM encountered during the survey.

Table 4.5: Distribution of acute malnutrition and oedema based on weight-for-height z-scores
Oedema present Oedema absent <-3 z-score Marasmic kwashiorkor n= 0 (0.0 %) Marasmic n=23(2.6 %) >=-3 z-score Kwashiorkor n=0 (0.0 %) Not severely malnourished N= 849 (97.4 %)

The figure below shows the distribution of weight-for-height z-scores compared to the reference population (WHO standards). The mean of the curve is shifted to the left by -0.79 zscores, which shows that the nutritional status of the survey population is worse than that of
33 34

RR =1.3 [95% CI : 0.89- 1.97] ; 2= 1.9 ; p= 0.08 (Yates corrected : 2= 1.6 ; p= 0.1) RR =1.7 [95% CI : 0.6- 4.2] ; 2= 1.1 ; p= 0.15 (Yates corrected : 2= 0.6 ; p= 0.2)

38

the reference population. The standard deviation is 0.98 which is within the acceptable range of 0.8-1.2. The design effect is 1.38. Figure 4.2: Distribution of weight-for-height z-scores (muncipality of President Roxas, October/November 2010)

The population of under five year old children in the municipality of President Roxas is approximately 4663. According to the results shown in table 4.3 it can be estimated that a total 387 and 93 children are currently suffering from MAM and SAM, respectively, in President Roxas.

4.1.3. ACUTE MALNUTRITION ACCORDING TO MUAC MEASUREMENTS Among the 872 children for which the height was measured 16 were excluded from MUAC analysis because they had a height of less than 65cm. For five children MUAC measurements were missing leading to a total sample size of 851 children. Table 4.6: MUAC distribution (municipality of President Roxas, October/November 2010)
Height (cm) n MUAC < 115 n % 2 1.3 0 0 0 0 2 0.2 MUAC >115 & <125 n % 8 5.1 1 0.2 0 0 9 1.1 MUAC >125 & <135 n % 26 16.5 21 4.7 3 1.2 50 5.9 MUAC >135 n % 121 77.1 421 9.5 247 98.4 789 92.7% Total

>65 and <75 >75 and <90 > 90 Total

157 443 251 851

According to MUAC measurements 0.2% of children suffer from SAM and 1.1% from moderate malnutrition. A further 5.9% are at risk of malnutrition.

39

The two children with a MUAC of less than 115mm are also classified as severely malnourished according to weight for height measurements. Among the 9 children classified as moderately malnourished according to MUAC measurements: - 4 have a z-score of less than -3, - 3 have a z-score between -2 and -3, - 2 have a z-score of between -1 and -2. Among the 50 children considered to be at risk of malnutrition according to MUAC measurements: - 3 have a z-score of less than -3, - 12 have a z-score between -2 and -3, - 35 have a z-score greater than -2. Of the 89 acutely malnourished children according to weight for height measurements: - 1 had a MUAC of less than 115 - 6 had a MUAC between 115 and 125mm - 13 had a MUAC between 125 and 135mm

4.1.4 CHRONIC MALNUTRITION Of the 872 children measured 12 SMART flags were excluded from height-for-age analysis, leading to a total sample size of 860 children. In the municipality of President Roxas parents generally knew the age of their children and proof of age was provided for 610 children (70%). Prevalence of stunting in the sample by sex and by age is presented in table 4.7 and 4.8, respectively. Table 4.7: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of President Roxas, October/November 2010)
All n = 860 51.3 % (n=441) (46.9 - 55.6 95% C.I.) 35.1 % (n=302) (32.1 - 38.3 95% C.I.) 16.2 % (n=139) (12.8 - 20.2 95% C.I.) Boys n = 443 53.0% (n=235) (47.6 - 58.5 95% C.I.) 37.2% (n=165) (32.6 - 42.1 95% C.I.) 15. % (n=70) (11.4 - 21.4 95% C.I.) Girls n = 417 49.4% (n=206) (43.7 - 55.1 95% C.I.) 32.9 % (n=137) (28.3 - 37.7 95% C.I.) 16.5% (n=69) (13.0 - 20.8 95% C.I.)

Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) Prevalence of severe stunting (<-3 z-score)

Table 4.8: Prevalence of stunting by age based on height-for-age z-scores(municipality of President Roxas, October/November 2010)
Age (months) Total number of children Severe stunting (<-3 z-score) n % Moderate stunting (>= -3 and <-2 z-score ) n % Normal (> = -2 z score) n %
40

6-17 18-29 30-41 42-53 54-59 Total

185 208 213 187 67 860

17 38 38 37 9 139

9.2 18.3 17.8 19.8 13.4 16.2

50 72 79 72 29 302

27.0 34.6 37.1 38.5 43.3 35.1

118 98 96 78 29 419

63.8 47.1 45.1 41.7 43.3 48.7

Prevalence of stunting is 51.3%. Table 4.7, shows that is slightly higher in boys than girls, this difference is however not statistically significant (p>0.05)35. Prevalence of moderate and severe stunting is 35.1% and 16.2%, respectively. Moderate and severe stunting is lowest in the 6-17 months age group. There is no significant difference between the older age groups. The figure below shows the distribution of height-for-age z-scores compared to the reference population (WHO standards). The mean of the curve is shifted to the left by -1.99 z-scores, which shows that the nutritional status of the survey population is worse than that of the reference population. The standard deviation is 1.03 which is within the acceptable range of 0.8-1.2. The design effect was 1.65. Figure 4.3: Distribution of height-for-age z-scores (municipality of President Roxas, October/November 2010)

4.1.5 UNDERWEIGHT Of the 872 children measured 6 SMART flags were excluded from height-for-age analysis, leading to a total sample size of 868 children. Prevalence of underweight in the sample by sex and by age is presented in table 4.9 and 4.10, respectively.
35

RR =1.07 [95% CI : 0.94- 1.22] ; 2= 1.1; p= 0.14 (Yates corrected : 2= 1.0 ; p= 0.15) 41

Table 4.9: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of President Roxas, October/November 2010)
All n = 868 36.8% (n=319) (33.3 - 40.4 95% C.I.) 27.6% (n=240) (24.7 - 30.8 95% C.I.) 9.1% (n=79) (7.0 - 11.7 95% C.I.) Boys n = 448 33.7% (n=151) (29.0 - 38.7 95% C.I.) 25.2% (n=113) (21.4 - 29.4 95% C.I.) 8.5 % (n=38) (5.9 - 12.0 95% C.I.) Girls n = 420 40.0% (n=168) (35.8 - 44.4 95% C.I.) 30.2% (n=127) (26.0 - 34.9 95% C.I.) 9.8% (n=41) (7.1 - 13.2 95% C.I.)

Prevalence of underweight (<-2 z-score) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) Prevalence of severe underweight (<-3 z-score)

Table 4.10: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of President Roxas, October/November 2010)
Age (mo) Total no. Severe underweight (<-3 z-score) n % 14 7.3 20 9.5 19 9.0 19 10.1 7 10.6 79 9.1 Moderate underweight (>= -3 and <-2 z-score ) n % 43 22.5 58 27.5 55 25.9 64 34.0 20 30.3 240 27.6 Normal (> = -2 z score) n 134 133 138 105 39 549 % 70.2 63.0 65.1 55.9 59.1 63.2 Oedema

6-17 18-29 30-41 42-53 54-59 Total

191 211 212 188 66 868

n 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Prevalence of underweight is 36.8%. Underweight rates are significantly higher in boys than girls (p>0.05)36. Prevalence of moderate and severe underweight is 27.6% and 9.1%, respectively. Moderate and severe underweight is lowest in the 6-17 months age group and increases with age. 4.1.6 DIARRHEA A total of 887 children were included in the analysis for diarrhea. 14.2% (n=126) of children had diarrhea in the two weeks preceding the survey, 82.3% (n=126) did not suffer from diarrhea and parents were unsure about the remaining 3% (n=27). The relationship between diarrhea and malnutrition is shown in table 4.11. Analysis of the association between diarrhea and acute malnutrition included a total 856 children37. There is no statistically significant association between diarrhea and malnutrition (p>0.05)38. Table 4.11: Association between diarrhea and malnutrition (municipality of President Roxas, October/November 2010)
Diarrhea Yes
36 37

Weight-for-height <-2 z- Weight-for-height >-2 z- Total scores scores 13 (10.7%) 109 (89.3%) 122 (100%)

RR =0.84 [95% CI : 0.7- 1.0] ; 2= 3.7 ; p= 0.03 (Yates corrected : 2= 3.4 ; p= 0.03) All SMART flags, children whose height could not be measured and for whom Diarrhea information was missing were excluded. 38 RR =0.9 [95% CI : 0.5- 1.6] ; 2= 0.05 ; p= 0.41 (Yates corrected : 2= 0.01 ; p= 0.47)

42

No Dont know Total

81 (11.4%) 0 (0%) 94 (11%)

631 (88.6%) 22 (100%) 762 (89%)

712 (100%) 22 (100%) 856 (%)

4.1.7. MEASLES VACCINATION COVERAGE 87.6% of children aged 9-59 months received measles vaccination, 47.3% were confirmed by a vaccination booklet (see table 4.12). 10% of children who had received the measles vaccination were malnourished and 17% of those who did not. This difference was statistically significant (p<0.05)39.

Table 4.12: Measles Vaccination Coverage (municipality of President Roxas, October/November 2010)
Measles vaccination Yes (according to mother) Yes (confirmed by vaccination booklet) No Dont know Total n 339 398 66 38 841 Percentage (%) 40.3% 47.3% 7.9% 4.5% 100%

4.1.8. DEWORMING COVERAGE 33.8% of children aged 12-59 months received deworming medication in the municipality of President Roxas. 6.7% of children who received deworming medication were malnourished compared to 10.9% of those that did not receive deworming medication. This difference was statistically significant (p<0.05)40. Table 4.13: Deworming Coverage (municipality of President Roxas, October/November 2010)
Deworming Yes No Dont know Total n 266 491 31 788 Percentage (%) 33.8% 62.3% 3.9% 100%

4.1.9. VITAMIN A SUPPLEMENTATION COVERAGE 70.7% of children aged 6-59 months received Vitamin A supplements in the last 6 months. 9% of children who received vitamin A supplements in the last six months were malnourished,
39

RR =0.59 [95% CI : 0.3- 1.1] ; 2= 3.0 ; p= 0.04 (Yates corrected : 2= 2.3 ; p= 0.06) RR =0.6 [95% CI : 0.3- 1.0] ; 2= 3.5 ; p= 0.03 (Yates corrected : 2= 3.1 ; p= 0.04)

40

43

compared to 15% of those that did not receive supplements. This difference was found to be statistically significant (p<0.05)41. 4.14: Vitamin A supplementation (municipality of President Roxas, October/November 2010)
Vitamin A supplementation Yes No Dont know Total n 627 229 31 887 Percentage (%) 70.7% 25.8% 3.5% 100%

4.1.10. MORTALITY RATES The 14th of June (Independence Day) was chosen as the start of the recall period, leading to a recall period of 145 days (calculated from the 14th of June until the midpoint of the survey which was the 5th of November). A total of 16 deaths were reported to have occured during the recall period, 3 of these were in children under 5. In addition 100 babies were born, 120 people left their households and 206 people joined the households. Causes of deaths included diarrhea (n=2), violence (n=1), difficulty breathing (n=1), kidney failure (n=2), tuberculosis (n=1), schistosomiasis (n=1), colon cancer (n=1), liver disease (n=1) and unidentified infection (n=1). 5 causes of death were unknown. 2 people died in hospital, the others in their home. The crude mortality rate is 0.15 deaths/10000 people/day. The under-five mortality rate is 0.21/10000people/day. The mortality rates are below alert level42. The design effect was 1.04. Table 4.15 Births and deaths by age groups (municipality of President Roxas, October/November 2010)
Age groups 0-4 5-11 12-17 18-49 50-64 65-120 Total Total Population 974 1300 1041 3442.5 649 290.5 7697 Male 527 660 557 1811 316 149 4020 female 506 650 492 1645 333 136 3762 joined 32 30 28 109 5 2 206 left 11 10 12 78 3 6 120 Births 100 0 0 0 0 0 100 Deaths 3 0 0 4 2 7 16

4.2

ANTHROPOMETRIC AND MORTALITY SURVEY OF THE MUNICIPALITY OF ARAKAN

4.2.1. DESCRIPTION OF THE SAMPLE

41

RR =0.6 [95% CI : 0.4- 0.9] ; 2= 4.7 ; p= 0.01 (Yates corrected : 2= 4.4 ; p= 0.01)

Crude Mortality Rate: 1death/10000/day is considered to be the alert level, 2 deaths/10000/day is considered as emergency level. For under five mortality 2 deaths/10000/day is believed to be alert level and emergency level is 4 deaths/10000/day (Sphere standards 2004). 44

42

The household list provided by the LGU turned out to be more out of inaccurate than first expected. Out of the 784 HH initially chosen 101 (12.8%) either moved away or were not found. In addition there was high absentee rate for children: out of the 367 children included in the sample 55 (14.9%) were absent and one could not be measured. It was therefore decided to visit the replacement HHs chosen before the start of the survey. This lead to a total sample of 756 HH and 398 children to be included in analysis. Of these weight-for-height could not be computed for 60. 59 were absent (14.8%) and 1 refused to be measured. In addition 1 SMART flag had to be excluded leading to a total 338 children included for weight-for-height analysis under NCHS and WHO standards. 5 SMART flags had to be excluded for height-for-age and 3 for underweight leading to a sample size of 334 and 337, respectively. The total sample size required
for this survey was 354 children (see table 3.1.) the number of children included in the analysis was therefore slightly less than needed.

Since MUAC measurements were only taken for children of a minimum height of 65 cm, the sample for MUAC measurements was smaller than for weight-for-height, namely 329 children. 359 children were included for diarrhea and coverage of vitamin A supplementation, 341 for measles vaccination and 322 for deworming coverage.

Table 4.16: Characteristics of the sample (municipality of Arakan, November 2010) 4.16a: Anthropometric nutrition survey
Total number of children Children aged 6-29 months Children aged 30-59 months Girls Boys Ratio m/f n 398 168 230 206 192 0.9 Percentage (%) 100% 42.2% 57.8% 51.8% 48.2% -

4.16b. Mortality survey

n Total Number of households Total Number of people Total Number of Children under five Average Number of people per household Average Number of under five year olds per household 756 3707 463 4.9 0.6 Percentage (%) 12.5% -

4.2.2. AGE AND SEX DISTRIBUTION Table 4.17 below shows the age and sex distribution of the sample. The sample consists of 42.2% of children aged 6-29 (n=168) months and 57.8% of children aged 30-59 months (n=230). With 78.5% the 54-59 months age group is slightly underrepresented. The boy/girl ratio is 0.9 and therefore within the norm43. The age and sex distribution of the total population included in the mortality survey is shown in Figure 4.4 below.
43

Acceptable range is from 08-1.2 45

Table 4.17: Distribution of age and sex of the anthropometric sample (municipality of Arakan, November 2010)
Boys Age (months) 6-17 18-29 30-41 42-53 54-59 Total n 36 50 42 46 18 192 % 42.9 56.2 45.2 46.9 52.9 48.2 n 48 39 51 52 16 206 Girls % 57.1 43.8 54.8 53.1 47.1 51.8 n 84 89 93 98 34 398 Total % 21.1 22.4 23.4 24.6 8.5 100.0 Ratio Boy:girl 0.8 1.3 0.8 0.9 1.1 0.9

Figure 4.4:. Population age and sex pyramid (municipality of Arakan, November 2010)

Error! No se encuentra el origen de la referencia.

4.2.3 ACUTE MALNUTRITION

A total 338 children were included for calculation of acute malnutrition rates under WHO standards and 866 under NCHS standards. All results are according to WHO standards. Results according to NCHS growth standards are shown in Annex 15. GAM prevalence is 5.9% and 0.9% of children were found to suffer from SAM (see table 4.18). No cases of oedema were found during the survey. GAM was found to be significantly higher in boys that girls (p<0.05)44. The difference SAM prevalence between boys and girls was found to be insignificant (p<0.05)45.

Table 4.18: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of Arakan, November 2010)
All n = 338
44 45

Boys n = 165

Girls n = 173

RR =2.4 [95% CI : 0.96- 6.2] ; 2= 3.8 ; p= 0.025 (Yates corrected : 2= 2.9 ; p= 0.04) RR =2.1 [95% CI : 0.19- 22.9] ; 2= 0.4 ; p= 0.27 (Yates corrected : 2= 0.00 ; p= 0.48)

46

Prevalence of GAM (<-2 z-score and/or oedema) Prevalence of MAM (<-2 z-score and >=-3 z-score, no oedema) Prevalence of SAM (<-3 z-score and/or oedema)

5.9 %(n=20) (3.9 - 9.0 95% C.I.) 5.0 % (n=17) (3.2 - 7.9 95% C.I.) 0.9 % (n=3) (0.3 - 2.6 95% C.I.)

8.5 % (n=14) (5.1 - 13.7 95% C.I.) 7.3 % (n=12) (4.2 - 12.3 95% C.I.) (n=2) 1.2 % (0.3 - 4.3 95% C.I.)

3.5 % (n=6) (1.6 - 7.4 95% C.I.) 2.9 % (n=5) (1.2 - 6.6 95% C.I.) 0.6 % (n=1) (0.1 - 3.2 95% C.I.)

Table 4.19 shows the prevalence of acute malnutrition by age group. Prevalence of moderate malnutrition appears to be higher in the younger age groups while prevalence of SAM is higher in the older age groups. Table 4.19: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of Arakan, November 2010)
Severe wasting (<-3 z-score) n % Moderate wasting (>= -3 and <-2 z-score ) n % Normal (> = -2 z score) n % Oedema n %

Age (months) 6-17 18-29 30-41 42-53 54-59 Total

Total Number of Children 189 208 210 188 66 861

0 0 1 1 1 3

0.0 0.0 1.3 1.2 3.3 0.9

5 6 2 4 0 17

7.1 7.5 2.6 4.9 0.0 5.0

65 74 74 76 29 318

92.9 92.5 96.1 93.8 96.7 94.1

0 0 0 0 0 0

0.0 0.0 0.0 0.0 0.0 0.0

In line with other surveys carried out in the region the children were further divided into 6-23 months and 24-59 months age groups. GAM was 6.3% (n=7) in the 6-23 months age group and 5.7% (n=13) in the 24-59 months age group. The difference in GAM prevalence was statistically insignificant46. SAM was 0% (n=0) in the 6-23 months olds and 1.1% (n=3) in the older age group. Similarly to GAM rates this difference was statistically insignificant47. Table 4.20: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of Arakan November 2010)
Oedema present Oedema absent <-3 z-score Marasmic kwashiorkor n= 0 (0.0 %) Marasmic n=3(0.9 %) >=-3 z-score Kwashiorkor n=0 (0.0 %) Not severely malnourished n= 335 (99.9 %)

The figure below shows the distribution of weight-for-height z-scores compared to the reference population (WHO standards). The mean of the curve is shifted to the left by -0.78 which
shows that the nutritional status of the survey population is worse than that of the reference population. The standard deviation is 0.82 which is within the acceptable range of 0.8-1.2. The design effect was 1, as expected.
46 47

RR =1.1 [95% CI : 0.4- 2.6] ; 2= 0.0 ; p= 0.42 (Yates corrected : 2= 0.00 ; p= 0.48) RR =0 [95% CI : 0-0] ; p= 0.59 (Fishers Exact Test)

47

Figure 4.5: Distribution of weight-for-height z-scores (muncipality of Arakan, November 2010)

The Population of under-five year old children in the muncipality of Arakan is approximately 4430. According to the results shown in table 4.18 it can be estimated that a total 261 and 40 children are currently suffering from MAM and SAM, respectively, in Arakan. 4.2.4. ACUTE MALNUTRITION ACCORDING TO MUAC MEASUREMENTS Among the 338 children for whom the height was measured 9 were excluded from MUAC analysis because they had a height of less than 65 cm leading to a total sample size of 851 children. Table 4.21: MUAC distribution (municipality of Arakan, November 2010)
Height (cm) n MUAC < 115 n % 1 1.5 0 0 0 0 1 0.3 MUAC >115 & <125 n % 3 4.5 1 0.06 0 0 4 1.2 MUAC >125 & <135 n % 17 25.4 8 0.5 0 0 25 7.6 MUAC >135 n % 46 68.6 151 94.4 102 100 299 90.89 Total

>65 and <75 >75 and <90 > 90 Total

67 160 102 329

According to MUAC measurements 0.3% of children suffer from SAM and 1.2% from moderate malnutrition. A further 7.6% are at risk of malnutrition. The child with a MUAC of less than 115 mm was classified as moderately malnourished according to weight-for-height measurements.

48

Among the 4 children classified as moderately malnourished according to MUAC measurements 2 had a z-score between -2 and -3 and 2 had a z-score greater than -2. Among the 25 children classified as being at risk of malnutrition 2 were classified as being moderately malnourished according to weight-for-height measurements, the remaining 23 had a z-score greater than -2. Of the 20 acutely malnourished children according to weight for height measurements: - 1 had a MUAC of less than 115. - 2 had a MUAC between 115 and 125mm - 2 had a MUAC between 125 and 135mm

4.2.5 CHRONIC MALNUTRITION Of the 339 children measured 5 SMART flags were excluded for height-for-age analysis, leading to a total sample size of 334 children. In the municipality of Arakan parents generally knew the age of their children and proof of age was provided for 222 children (65.5%). Prevalence of stunting in the sample by sex and by age is presented in table 4.23 and 4.24, respectively. Table 4.22: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of Arakan, November 2010)
All n = 334 (204) 61.1 % (55.8 - 66.2 95% C.I.) (118) 35.3 % (30.4 - 40.6 95% C.I.) (86) 25.7 % (21.4 - 30.7 95% C.I.) Boys n =165 (104) 63.0 % (55.4 - 70.0 95% C.I.) (56) 33.9 % (27.2 - 41.5 95% C.I.) (48) 29.1 % (22.7 - 36.4 95% C.I.) Girls n = 169 (100) 59.2 % (51.6 - 66.3 95% C.I.) (62) 36.7 % (29.8 - 44.2 95% C.I.) (38) 22.5 % (16.8 - 29.4 95% C.I.)

Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) Prevalence of severe stunting (<-3 z-score)

Table 4.23: Prevalence of stunting by age based on height-for-age z-scores (municipality of Arakan, November 2010)
Age (months) Total number of children 69 77 77 81 30 334 Severe stunting (<-3 z-score) n % 6 8.7 24 31.2 23 29.9 25 30.9 8 26.7 86 25.7 Moderate stunting (>= -3 and <-2 z-score ) n % 27 39.1 25 32.5 30 39.0 24 29.6 12 40.0 118 35.3 Normal (> = -2 z score) n % 36 52.2 28 36.4 24 31.2 32 39.5 10 33.3 130 38.9

6-17 18-29 30-41 42-53 54-59 Total

Prevalence of stunting is 61.1%. Table 4.22 shows that is slightly higher in boys than girls, this difference is, however, statistically insignificant (p>0.05)48. Prevalence of moderate and severe stunting is 35.3% and 25.7%, respectively. Severe stunting is lowest in the 6-17 months age group. There is only a small difference between the different age groups for moderate stunting.
48

RR =1.1 [95% CI : 0.96- 6.2] ; 2=0.5 ; p= 0.23 (Yates corrected : 2= 0.5 ; p= 0.27)

49

The figure below shows the distribution of height-for-age z-scores compared to the reference population (WHO standards). The mean of the curve is shifted to the left at -2.37 which shows that
the nutritional status of the survey population is worse than that of the reference population. The standard deviation is 1.07 which is within the acceptable range of 0.8-1.2. The design effect is 1, as expected.

Figure 4.6: Distribution of height-for-age z-scores (municipality of Arakan, November 2010)

4.2.6. UNDERWEIGHT Of the 339 children measured, 3 SMART flags were excluded from weight-for-age analysis, leading to a total sample size of 336 children. Prevalence of underweight in the sample by sex and by age is presented in table 4.24 and 4.25, respectively. Table 4.24: Prevalence of underweight based on WFA z-scores by sex (Arakan November 2010)
All n = 336 (134) 39.8 % (34.7 - 45.1 95% C.I.) (101) 30.0 % (25.3 - 35.1 95% C.I.) (33) 9.8 % (7.1 - 13.4 95% C.I.) Boys n = 166 (65) 39.2 % (32.1 - 46.7 95% C.I.) (46) 27.7 % (21.5 - 35.0 95% C.I.) (19) 11.4 % (7.5 - 17.2 95% C.I.) Girls n = 170 (69) 40.4 % (33.3 - 47.8 95% C.I.) (55) 32.2 % (25.6 - 39.5 95% C.I.) (14) 8.2 % (4.9 - 13.3 95% C.I.)

Prevalence of underweight (<-2 z-score) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) Prevalence of severe underweight (<-3 z-score)

Table 4.25: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of Arakan 2010)
Age (months) 6-17 18-29 Total no. 70 80 Severe underweight (<-3 z-score) n % 4 5.7 8 10.0 Moderate underweight (>= -3 and <-2 z-score ) n % 15 21.4 21 26.3 Normal (> = -2 z score) n % 51 72.9 51 63.8 Oedema n 0 0 % 0.0 0.0
50

30-41 42-53 54-59 Total

76 81 30 337

8 12 1 33

10.5 14.8 3.3 9.8

30 20 15 101

39.5 24.7 50.0 30.0

38 49 14 203

50.0 60.5 46.7 60.2

0 0 0 0

0.0 0.0 0.0 0.0

Prevalence of underweight is 39.8%. Table 4.24, shows that underweight is slightly higher in boys than girls but this difference is NOT statistically significant (p>0.05)49. Prevalence of moderate and severe underweight is 30% and 9.8%, respectively. Moderate underweight is highest in the 54-59 months age group and severe underweight is lowest in the 6-17 months and 54-59 months age group. 4.2.7 DIARRHEA A total of 359 children were included in the analysis for diarrhea. 14.2% (n=51) of children had diarrhea in the two weeks preceding the survey, 83.6% (n=300) did not suffer from diarrhea and parents were unsure about the remaining 2.2% (n=8). The relationship between diarrhea and malnutrition is shown in table 4.26. Analysis for association between diarrhea and acute malnutrition included a total 337 children, after exclusion of SMART flags and all children for whom height could not be measured. There was no statistically significant association between diarrhea and malnutrition rates (p>0.05)50. Table 4.26: Association between diarrhea and malnutrition (municipality of Arakan, November 2010)
Diarrhea Yes No Dont know Total Weight-for-height <-2 z- Weight-for-height >-2 z- Total scores scores 7.8% (n=4) 92.2% (n=47) 100% (n=51) 5.7% (n=16) 94.3% (n=266) 100% (n=282) 0% (n=0) 100% (n=4) 100% (n=4) 5.9% (n=20) 94.1% (n=317) 100% (n=337)

4.2.8. MEASLES VACCINATION COVERAGE A total of 87.4% of children received measles vaccination, 46% of these were confirmed by a vaccination booklet. 4.6% of the children that received the measles vaccination were malnourished compared 13.3% of those that did not receive the vaccination. This difference was found to be statistically significant (p<0.05)51.

Table 4.27: Measles vaccination coverage (municipality of Arakan, November 2010)

Measles vaccination Yes (according to mother) Yes (confirmed by vaccination booklet) No Dont know n 141 157 31 12 Percentage (%) 41.4% 46.0% 9.1% 3.5%

49 50 51

RR =0.8 [95% CI : 0.6- 1.2] ; 2= 0.6 ; p= 0.2 (Yates corrected : 2= 0.6 ; p= 0.24) RR =1.38 [95% CI : 0.48- 3.9] ; 2= 0.36 ; p= 0.27 (Yates corrected : 2= 0.7 ; p= 0.38) RR =0.3 [95% CI : 0.1- 0.9] ; 2= 4.0 ; p= 0.02 (Yates corrected : 2=2.5 ; p= 0.06)

51

Total

341

100%

4.2.9. DEWORMING COVERAGE 73.3% of 12-59 months old children received deworming medication. Nearly a quarter of children (23.9%) did not receive deworming treatment and parents were unsure about 2.7%. 4.8% of children that received deworming treatment were malnourished compared to 8.6% of those that did not receive a deworming treatment. This difference was found to be statistically insignificant (p>0.05)52. Table 4.28: Deworming (municipality of Arakan, November 2010)
Deworming Yes No Dont know Total n 236 77 9 322 Percentage (%) 73.3% 23.9% 2.7% 100%

4.2.10. VITAMIN A SUPPLEMENTATION COVERAGE Coverage of vitamin A supplementation was 80.2% in 6-59 months old child. 4.8% of children that received vitamin A supplements were malnourished compared to 11.7% of those that did not receive supplements. This difference was found to be statistically significant (p<0.05)53. Table 4.29: Vitamin A supplementation (municipality of Arakan, November 2010)
Vitamin A supplementation Yes No Dont know Total n 288 62 9 359 Percentage (%) 80.2 17.3 2.5 100

4.2.11. MORTALITY RATES The 14th of June (Independence Day) was chosen as the start of the recall period leading to a recall period of 152 days (calculated from the 14th of June until the midpoint of the survey which was the 13th of November). A total of 7 deaths were reported to have occurred during the recall period, no deaths in underfive year old children were reported. Causes of death included difficulty breathing, tuberculosis, and cirrhosis of the liver, liver cancer, cardiovascular disease and diabetes. 6 people died in their home and 1 in the hospital. In addition 36 babies were born, 71 people left their households and 57 people joined the households. These results are shown in more detail in table 4.30.

52 53

RR =0.5 [95% CI : 0.2- 1.5] ; 2= 1.4 ; p= 0.1 (Yates corrected : 2= 0.7 ; p= 0.19) RR =0.6 [95% CI : 0.2- 1.0] ; 2= 4.1 ; p= 0.02 (Yates corrected : 2= 2.9 ; p= 0.04)

52

The crude mortality rate was 0.12 deaths/10000 people/day (95%CI=0.06-0.26). The under five mortality rate is 0/10000people/day (95% CI=0-0.54). The mortality rates are below alert level54. The design effect was 1.04. Table 4.30: Births and deaths by age groups (municipality of Arakan, November2010)
Age groups 0-4 5-11 12-17 18-49 50-64 Total Total Population 463 674.5 569 1591 289.5 3706.5 male 237 357 303 872 152 1990 female 248 318 263 713 134 1724 joined 12 10 5 29 0 57 left 4 9 11 39 5 71 Births 36 0 0 0 0 36 Deaths 0 0 0 2 2 7

4.3 ANTHROPOMETRIC AND MORTALITY SURVEY OF THE MUNICIPALITY OF KAPATAGAN

4.3.1. DESCRIPTION OF THE SAMPLE
Six clusters became inaccessible during the survey due to security reasons (6, 7, 50, 51, 52, 53). Since this was less than 10% of all clusters it was not necessary to visit the replacement clusters. The total sample consisted of a total of 1112 households and 903 children. Of the 903 children, 67 were absent (7.4%). In addition 7 and 5 SMART flags were excluded from weightfor-height analysis under WHO and NCHS standards, respectively leading to a total 829 children included for analysis under WHO standards and 831 under NCHS standards. Of the 836 children measured 30

SMART flags (3.6%) were excluded for height-for-age analysis, leading to a total sample size of 806 children. The total sample size required for this survey was 560 children (see table 3.3.) the
number of children included in the analysis was therefore more than enough.

Since MUAC measurements were only taken for children of a minimum height of 65 cm, the sample for MUAC measurements were less than those included for weight-for-height, namely 807 children. 809 children were included for diarrhea, coverage of vitamin A supplementation, 793 for measles vaccination and 742 for deworming.

Table 4.31: Characteristics of the sample (municipality of Kapatagan, November/December 2010) 4.31a. Anthropometric nutrition survey
Total number of children Children aged 6-29 months Children aged 30-59 months n 903 370 533 Percentage (%) 100% 40.9% 59.0%

54

Crude Mortality Rate: 1death/10000/day is considered to be the alert level, 2 deaths/10000/day is considered as emergency level. For under five mortality 2 deaths/10000/day is believed to be alert level and emergency level is 4 deaths/10000/day (Sphere standards 2004).

53

Girls Boys Ratio m/f

426 477 1.1

47.2% 52.8% -

4.31b. Mortality survey

n Total Number of households Total Number of people Total Number of Children under five Average Number of people per household Average Number of under five year olds per household 1112 5225 1001 4.7 0.9 Percentage (%) 19.2% -

4.3.2. AGE AND SEX DISTRIBUTION The sample consists of 40.9% of children aged 6-29 (n=370) months and 59% of children aged 30-39 months (n=533). 47.2% (n=426) are girls and 52.8% (n=477) are boys. The boy/girl ratio is 1.1 and therefore within the norm55. Table 4.32 below shows the age and sex distribution of the sample in more detail. The sample is evenly distributed across age groups. The age and sex distribution of the total population included in the mortality survey is shown in Figure 4.7, below. Table 4.32: Distribution of age and sex of the anthropometric sample (municipality of Kapatagan, November/December 2010)
Boys AGE (months) 6-17 18-29 30-41 42-53 54-59 Total n 118 108 99 101 50 476 % 56.2 57.1 48.8 50.5 50.0 52.8 n 92 81 104 99 50 426 Girls % 43.8 42.9 51.2 49.5 50.0 47.2 n 210 189 203 200 100 902 Total % 23.3 21.0 22.5 22.2 11.1 100.0 Ratio Boy:girl 1.3 1.3 1.0 1.0 1.0 1.1

Figure 4.7. Population age and sex pyramid (municipality of Kapatagan, November/December 2010)

55

Acceptable range is from 08-1.2 54

Error! No se encuentra el origen de la referencia.

4.3.3 ACUTE MALNUTRITION

A total of 829 children were included for calculation of acute malnutrition rates under WHO standards and 831 under NCHS standards. All results are according to WHO standards. Results according to NCHS growth standards are shown in Annex 16. GAM prevalence is 6.9%, and 1% of children were found to suffer from SAM. No cases of oedema were found during the survey. Table 4.33 shows that both GAM and SAM are slightly higher in boys than in girls, this difference was however shown to be statistically insignificant (p>0.05)56.

Table 4.33: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of Kapatagan, November/December 2010)
All n = 829 (57) 6.9 % (5.2 - 9.0 95% C.I.) (49) 5.9 % (4.5 - 7.8 95% C.I.) (8) 1.0 % (0.5 - 2.0 95% C.I.) Boys n = 433 (34) 7.9 % (5.5 - 11.1 95% C.I.) (30) 6.9 % (4.8 - 9.9 95% C.I.) (4) 0.9 % (0.3 - 2.4 95% C.I.) Girls n = 396 (23) 5.8 % (4.1 - 8.1 95% C.I.) (19) 4.8 % (3.3 - 6.9 95% C.I.) (4) 1.0 % (0.4 - 2.6 95% C.I.)

Prevalence of GAM (<-2 z-score and/or oedema) Prevalence of MAM (<-2 z-score and >=-3 z-score, no oedema) Prevalence of SAM (<-3 z-score and/or oedema)

Table 4.34: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of Kapatagan, November/December 2010)
Severe wasting (<-3 z-score) n % Moderate wasting (>= -3 and <-2 z-score ) n % Normal (> = -2 z score) n % Oedema n %

Age (months)

Total Number of Children

56

RR =1.35 [95% CI : 0.8- 2.3] ; 2= 1.35 ; p= 0.12 (Yates corrected : 2= 1.0 ; p= 0.15) 55

6-17 18-29 30-41 42-53 54-59 Total

189 179 188 183 90 829

2 4 1 1 0 8

1.1 2.2 0.5 0.5 0.0 1.0

25 9 5 6 4 49

13.2 5.0 2.7 3.3 4.4 5.9

162 166 182 176 86 772

85.7 92.7 96.8 96.2 95.6 93.1

0 0 0 0 0 0

0 0 0 0 0 0

In line with other surveys carried out in the region the children were further divided into 6-23 months and 24-59 months age groups. GAM was 11.8% (n=31) in the 6-23 months age group and 4.6% (n=26) in the 24-59 months age group. Malnutrition is significantly higher in the younger age group (p<0.05). 57 Children in the younger age group have 2.6 times the risk of being malnourished . SAM was 1.5% (n=4 ) in the 6-23 months olds and 0.7% (n=4) in the older age group. This difference is however statistically insignificant58. Table 4.35 below show the types of SAM encountered during the survey.

Table 4.35: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of Kapatagan November/December 2010)
Oedema present Oedema absent <-3 z-score Marasmic kwashiorkor 0 (0.0 %) Marasmic 12 (1.4 %) >=-3 z-score Kwashiorkor 0 (0.0 %) Not severely malnourished 824 (98.6 %)

The figure below shows the distribution of weightfor-height z-scores compared to the reference population (WHO standards). The curve is shifted to the left by a mean z-score of 0.42 which shows that the nutritional status of the survey population is worse than that of the reference population. The standard deviation is 0.98 which is within the acceptable range of 0.8-1.2. The design effect was 1.14.

Figure 4.8. Distribution of weight-for-height z-scores (municipality of Kapatagan, November/December 2010)

57 58

RR =2.6 [95% CI : 1.5- 4.2] ; 2= 14.5 ; p= 0.00 (Yates corrected : 2= 13.4 ; p= 0.0) RR =2.1 [95% CI : 0.5- 8.5] ; 2= 1.2 ; p= 0.13 (Yates corrected : 2= 0.54 ; p= 0.23)

56

The population of 6-59 months old children in the muncipality of Kapatagan is approximately 2058. According to the results shown in table 4.33 it can be estimated that a total 121 and 21 children are currently suffering from MAM and SAM, respectively, in Kapatagan. 4.3.4. ACUTE MALNUTRITION ACCORDING TO MUAC MEASUREMENTS The sample size for MUAC analysis was 807 children. According to MUAC measurements 0% of children suffer from SAM and 1.1% from moderate malnutrition. A further 7.3% are at risk of malnutrition (see table 4.36.). Table 4.36: MUAC distribution (municipality of Kapatagan, November/December 2010)
Height (cm) MUAC < 115 n % 0 0 0 0 0 0 0 0 MUAC >115 & <125 n % 8 4.8 1 0.3 0 0 9 1.1 MUAC >125 & <135 n % 43 25.9 15 3.9 1 0.4 59 7.3 MUAC >135 n % 115 69.3 368 95.8 256 99.4 739 91.6 Total

>65 and <75 >75 and <90 > 90 Total

166 384 257 807

Among the 9 children classified as moderately malnourished according to MUAC measurements: - 3 had a z-score of less than -3, - 5 have a z-score between -2 and -3, - 1 have a z-score of between -1 and -2. Among the 59 children considered to be at risk of malnutrition according to MUAC measurements: - 2 had a z-score of less than -3, but weight-for-height data for these children was flagged, - 19 have a z-score between -2 and -3, - 38 have a z-score greater than -2.
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Of the 57 acutely malnourished children according to weight for height measurements: - 8 had a MUAC between 115 and 125mm - 19 had a MUAC between 125 and 135mm. - MUAC measurements were unavailable 4.3.4 CHRONIC MALNUTRITION Of the 836 children measured 30 SMART flags were excluded for height-for-age analysis, leading to a total sample size of 806 children. In the municipality of Kapatagan it was difficult to get the exact date of birth. Proof of age was provided for 336 children (40.2%). Prevalence of stunting in the sample by sex and by age is presented in table 4.37 and 4.38, respectively. Table 4.37: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of Kapatagan, November/December 2010)
All n = 806 Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) Prevalence of severe stunting (<-3 z-score) (440) 54.6 % (49.8 - 59.3 95% C.I.) (230) 28.5 % (25.3 - 32.0 95% C.I.) (210) 26.1 % (22.0 - 30.6 95% C.I.) Boys n = 420 (225) 53.6 % (47.5 - 59.5 95% C.I.) (107) 25.5 % (21.3 - 30.2 95% C.I.) (118) 28.1 % (22.8 - 34.1 95% C.I.) Girls n = 386 (215) 55.7 % (49.3 - 61.9 95% C.I.) (123) 31.9 % (27.2 - 36.9 95% C.I.) (92) 23.8 % (19.4 - 28.9 95% C.I.)

Table 4.38: Prevalence of stunting by age based on height-for-age z-scores (municipality of Kapatagan, November/December 2010)
Age (months) Total number of children 184 174 182 176 90 806 Severe stunting (<-3 z-score) n % 31 16.8 53 30.5 57 31.3 51 29.0 18 20.0 210 26.1 Moderate stunting (>= -3 and <-2 z-score ) n % 40 21.7 51 29.3 58 31.9 51 29.0 30 33.3 230 28.5 Normal (> = -2 z score) n % 113 61.4 70 40.2 67 36.8 74 42.0 42 46.7 366 45.4

6-17 18-29 30-41 42-53 54-59 Total

Prevalence of stunting is 54.6%. Table 4.37 shows that it is slightly higher in girls than boys but this is not significant59. Prevalence of moderate and severe stunting is 28.5% and 26.1%, respectively. Moderate and severe stunting is lowest in the 6-17 months age group and higher in the older age groups. The figure below shows the distribution of height-for-age z-scores compared to the reference population (WHO standards). The mean of the curve is shifted to the left by -2.16 z-scores which show that the nutritional status of the survey population is significantly worse than that

59

RR =0.96 [95% CI : 0.85- 1.1] ; 2= 0.37 ; p= 0.27 (Yates corrected : 2= 0.29 ; p= 0.29) 58

of the reference population. The standard deviation is 1.17 which is within the acceptable range of 0.8-1.2. The design effect was 1.86. Figure 4.9: Distribution November/December 2010) of height-for-age z-scores (muncipality of Kapatagan,

4.3.5 UNDERWEIGHT Of the 836 children measured, 11 SMART flags were excluded from height-for-age analysis, leading to a total sample size of 825 children. Prevalence of underweight in the sample by sex and by age is presented in table 4.39 and 4.40, respectively. Table 4.39: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of Kapatagan November/December 2010)
All n = 825 Prevalence of underweight (<-2 z-score) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) Prevalence of severe underweight (<-3 z-score) (256) 31.0 % (27.6 - 34.6 95% C.I.) (204) 24.7 % (21.5 - 28.2 95% C.I.) (52) 6.3 % (4.6 - 8.5 95% C.I.) Boys n = 432 (132) 30.6 % (26.1 - 35.4 95% C.I.) (102) 23.6 % (19.7 - 28.0 95% C.I.) (30) 6.9 % (4.6 - 10.3 95% C.I.) Girls n = 393 (124) 31.6 % (27.6 - 35.8 95% C.I.) (102) 26.0 % (22.0 - 30.4 95% C.I.) (22) 5.6 % (3.8 - 8.2 95% C.I.)

Table 4.40: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of Kapatagan November/December 2010)
Age (mo) Total no. Severe underweight Moderate underweight Normal (> = -2 z score) Oedema

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6-17 18-29 30-41 42-53 54-59 Total

189 178 186 182 90 825

(<-3 z-score) n % 12 6.3 10 5.6 15 8.1 12 6.6 3 3.3 52 6.3

(>= -3 and <-2 z-score ) n % 50 26.5 42 23.6 45 24.2 42 23.1 25 27.8 204 24.7

n 127 126 126 128 62 569

% 67.2 70.8 67.7 70.3 68.9 69.0

n 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Prevalence of underweight is 31.0%. Table 4.39., shows that it is slightly higher in girls than in boys but this difference is not significant60. Prevalence of moderate and severe underweight is 24.7% and 6.3%, respectively. Severe underweight is lowest in the 54-59 months age group while moderate underweight does not differ much according to the different age groups. 4.3.6 DIARRHEA A total of 859 children were included in the analysis for diarrhea. 7.2% (n=62) of children had diarrhea in the two weeks preceding the survey, 91.5% (n=785) did not suffer from diarrhea and parents were unsure about the remaining 1.3% (n=12). The relationship between diarrhea and malnutrition is shown in table 4.41. Analysis for association between diarrhea and acute malnutrition included a total 826 children after exclusion of SMART flags all children for whom height could not be measured and diarrhea information was missing. A significant association between diarrhea and malnutrition rates was found (p<0.05)61. Children who suffered from diarrhea were 2.6 times more at risk of malnutrition. Table 4.41: Association between diarrhea and malnutrition (municipality of Kapatagan, November/December 2010)
Diarrhea Yes No Dont know Total Weight-for-height <-2 z- Weight-for-height >-2 z- Total scores scores 9 ( 15%) 51 (85%) 60 (100%) 44 (5.8%) 710 (94.2%) 754 (100%) 2 (16.70%) 10 (83.3%) 12 (100%) 55 (6.7%) 771(93.3%) 826 (100%)

4.3.7. MEASLES VACCINATION COVERAGE A total of 61.2% of 9-59 months old children received a measles vaccination, 26.1% of these were confirmed by a vaccination booklet. 6.5% of children that received measles vaccination were malnourished compared to 6.1% of those that did not receive the vaccination. This difference was statistically insignificant (p>0.05)62. Table 4.42: Measles vaccination coverage (municipality of Kapatagan, November/December 2010)
Measles vaccination n Percentage (%)

60 61

RR =0.97 [95% CI : 0.8- 1.2] ; 2= 0.09 ; p= 0.38 (Yates corrected : 2= 0.05 ; p= 0.41) RR =2.6 [95% CI : 1.3- 5.0] ; 2= 7.6 ; p= 0.0 (Yates corrected : 2= 6.2 ; p= 0.0 ) RR =1.1 [95% CI : 0.6- 1.9] ; 2= 0.06 ; p= 0.4 (Yates corrected : 2= 0.009 ; p= 0.5) 60

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Yes (according to mother) Yes (confirmed by vaccination booklet) No Dont know Total

278 207 293 15 793

35.1% 26.1% 36.9% 1.9% 100%

4.3.8. DEWORMING COVERAGE 34.8% of 12-59 months old children received deworming medication in the municipality of Kapatagan. 5.2% of children that received deworming medication were malnourished, compared to 6.1% of those that did not. This difference was statistically insignificant (p>0.05)63. Table 4.43: Deworming coverage (municipality of Kapatagan, November/December 2010)
Deworming Yes No Dont know Total n 258 464 20 742 Percentage (%) 34.8% 62.5% 2.7% 100%

4.3.9. VITAMIN A SUPPLEMENTATION COVERAGE 46% of 6-59 months old children received vitamin A supplements in the last 6 months before the survey. 7.8% of children that received vitamin A supplements in the last 6 months were found to be malnourished compared to 5.2% of children that did not receive vitamin A supplements. This difference was statistically insignificant (p>0.05)64.

Table 4.44: Vitamin A supplementation (municipality Kapatagan, November/December 2010)

Vitamin A supplementation Yes No Dont know Total n 395 443 21 859 Percentage (%) 46% 51.6% 2.4% 100%

4.3.10. MORTALITY RATES The 30th of August (National Heroes Day) was chosen as the start of the recall period leading to a recall period of 88 days (calculated from the 30th of August until the midpoint of the survey which was the 25th of November). A total of 15 deaths were reported to have occured during the recall period. Deaths per age groups are shown in table 4.45. Two deaths were caused by fever, 3 by breathing difficulties, 1 by a gunshot wound wound, two by dengue amd 1 by stroke. 10 people died in their house, 1 in place of last residence and 3 in hospital. For one the location of death was unknown. All four deaths in the under fives are caused by measles. 53 babies were born, 75 people left their
63 64

RR =0.8 [95% CI : 0.4- 1.6] ; 2= 0.3 ; p= 0.3 (Yates corrected : 2= 0.1 ; p= 0.4) RR =1.5 [95% CI : 0.9- 2.6] ; 2= 2.3 ; p= 0.06 (Yates corrected : 2= 1.9 ; p= 0.08) 61

households and 46 people joined the households. These results are shown in more detail in table 4.45. The crude mortality rate was 0.27 deaths/10000 people/day (95%CI=0.15-0.51). The under five mortality rate is 0.45/10000people/day (95% CI=0.14-1.52). The mortality rates are below alert level65. The design effect for the overall mortality rate was 1.44. Table 4.45; Births and Deaths by age groups (Municipality of Kapatagan, November/December 2007)
Age groups '0-4 '5-11 '12-17 '18-49 '50-64 '65-120 Total Total Population 1000.5 1392.5 953.5 2491 271 116 6224.5 male 531 694 442 1208 149 63 3087 female 494 693 508 1273 122 52 3142 joined 7 2 11 21 3 2 46 left 7 12 16 36 3 1 75 53 Births 53 Deaths 4 1 2 5 3 15

5. DISCUSSION
5.1. ACUTE MALNUTRITION
Acute malnutrition rates were 10.3%, 5.9% and 6.9% in President Roxas, Arakan and Kapatagan respectively. These results are in line with those of previous surveys in the region (see section 1.2.). SAM rates were 2%, 0.9% and 1% in President Roxas, Arakan and Kapatagan. While SAM rates were as expected in Arakan and Kapatagan they were higher in President Roxas. GAM rates in Arakan are significantly higher in boys than in girls. It is not clear why such a difference occured. In the other two municipalities there was no significant difference between GAM rates in boys and girls. As mentioned in section 1.5., previous reports have shown that malnutrition is higher the 6-23 age group than in the older age group which was believed to be due to inadequate infant and young child feeding practices. While in all three surveys GAM was higher in the younger age group, this difference was significant in Kapatagan but insignificant in Arakan and President Roxas. In Kapatagan GAM was 11.8% in the 6-23 months olds and 4.6% in the 24-59 month olds. Younger children were 2.6 times more at risk of being malnourished. In addition to inadequate infant feeding practices this is probably due to an unsanitary environment. Unsanitary environments make children more susceptible to disease and thus malnutrition. In Kapatagan children were 2.6 more likely to be malnourished if they were suffering from diarrhea. No association between diarrhea and malnutrition was found in the other two municipalities. Vitamin A supplementation reduces risk of disease. It is therefore not suprising that in the municipalities of President Roxas and Arakan children were significantly less likely to be malnourished if they had received vitamin A supplements. In line with this in both these
Crude Mortality Rate: 1death/10000/day is considered to be the alert level, 2 deaths/10000/day is considered as emergency level. For under five mortality 2 deaths/10000/day is believed to be alert level and emergency level is 4 deaths/10000/day (Sphere standards 2004). 62
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municipalities the proportion of malnourished children was significantly less in those children that had previously received a measles vaccination than in their unvaccinated peers. It can therefore be argued that improving basic health services for children in the 3 municipalities is crucial to preventing malnutrition. In Kapatagan no significant difference in prevalence of malnutrition was found between children that were vaccinated, received vitamin A supplements or deworming medication and those that did not. It has to added, that many parents in Kapatagan did not have vaccination or health cards and were often unable to recall their childs birthdate. It is therefore uncertain how accurate these results are. In contrast, the percentage of acutely malnourished children was much lower when MUAC measurements were used. In President Roxas 0.2% suffered from SAM, 1.1% from MAM and 5.9% were at risk of malnutrition. In Arakan 0.3% suffered from SAM, 1.2% from MAM and 7.6% were at risk of malnutrition. In Kapatagan no cases of SAM were found according to MUAC measurements, 1.1% of children suffered from MAM and 7.3% were at risk of malnutrition. Overall only a small proportion of children classified as malnourished according to weight-forheight were also classified as malnourished according MUAC measurements. Out of the 89 acutely malnourished children in the muncipality of President Roxas only 7.8% had a MUAC of less than 125mm. Among the 17 SAM cases in President Roxas none had a MUAC of less than 115mm and only 3 (17.6%) had a MUAC between 115 and 125mm. Out of he 20 acutely malnourished in Arakan 3 (15%) had a MUAC of less than 125mm and 2 between 125 and 135mm. Out of the 3 SAM cases none were classified as malnourished according to MUAC. Of the 57 acutely malnourished children in Kapatagan 8 (14%) had a MUAC between 115 and 125mm and none had a MUAC of less than 115 mm. On the contrary a large proportion of children classified as malnourished using MUAC were also identified as malnourished according to weight-for-height. Of the children classified as severely malnourished according MUAC in President Roxas 100% were also classified as being severely malnourished according to weight-for-height z-scores. 77.5% of children with a MUAC between 115 and 125mm also had a z-score of less than -2. In Arakan, 60% of children with a MUAC of less than 125mm also had a z-score of less than -2. In Kapatagan 8 out 9 children (89%) with a MUAC of less than 125mm also had a weight-for-height z-score of less than -2. In contrast, the survey carried out by Save the Children in March 2010 found similar rates of SAM according MUAC and weight-for-height, and double the amount of MAM according to MUAC measurements. A study that investigated the relationship between MUAC and weight-for-height in 31 countries showed that prevalence of acute malnutrition according to weight-for-height and MUAC was very similar. They did however state that and only 40% of all children selected by one indicator were also selected by the other [19]. In these particular surveys 7-15% of children with a weight-for-height of less than -2 z-scores were also classified as malnourished while 60-89% of those classified as being acutely malnourished according to MUAC were also identified as acutely malnourished according to weight-for-height. It is unclear why there is such a big difference between MUAC and weight-for-height and this topic deserves further investigation. The high difference between acute malnutrition rates according to MUAC and weight-for-height was noticed by the survey manager early on in the survey and quality of MUAC measurements were double checked. In addition both measurers within each team were asked to take MUAC measurements on each eligible child in order to

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avoid errors. While MUAC measurements were accurate when supervised, it is unclear whether correct methodology was followed when the survey manager was not present. It was planned to use MUAC for active case finding during the programme. The results of these surveys however indicate that this will mean missing a lot of malnourished children and other possibilities should be discussed. No cases of oedema were found during the survey, this in line with the Save the Children survey in March 2010 that did not find any cases of oedema either. While prevalence of oedema is certainly low in the Philippines it does exist. There was one case of nutritional oedema at the German Doctors hospital in Buda at the time of the survey and 3 cases were found in ACFs rapid assessment in April 2010. There is no clearly defined hungry season in Mindanao. A number of different crops are planted and harvested at different times of the year. Corn the main crop in all three municipalities is harvested twice a year. In Arakan and President Roxas rice is the second most common crop, which can also be harvested twice a year but is rarely done. Vegetables and fruit are harvested more often. Initial results from the food security assessment carried out ACF at the same time as this survey have shown that income for agricultural workers fluctuates during the year and it is likely that this has an impact on quality and quantity of food consumed and therefore malnutrition rates. While in Kapatagan 30% of respondents mentioned that they encountered difficulties in getting enough food, in the muncicipality of President Roxas all respondents had difficulties getting enough food in the last 12 months. This finding might explain the higher malnutrition rates found in the municipality of President Roxas. Respondents in Kapatagan mentioned that they usually experience food shortage in February, March and June and in President Roxas food shortage was higher during the months of January, March and April. It is therefore possible that malnutrition rates increase slightly in first three months of year compared to the ones measured ones measured in this survey [21]. This is in line with the observation from a nurse at the German Doctors hospital that SAM admissions increased in January last year.

5.2. STUNTING
Stunting prevalence was found to be 51% in President Roxas, 61% in Arakan and 55% in Kapatagan. According to the WHO classification a prevalence of stunting of 40% is very high. Stunting is therefore a serious public health problem in all 3 municipalities [20]. Stunting rates in the three municipalities are slightly higher than rates found in previous surveys (see section 1.3). Since the three municipalities were partly chosen because malnutrition in these areas was believed to be higher than in others in the region this is not unexpected. In Arakan and President Roxas, parents generally know the age of their children and proof of age was provided for 70% and 65.5% of children in President Roxas and Arakan, respectively. As a result the number of flagged height-for-age data was low and stunting data are believed to be reliable. In Kapatagan it was more difficult to find out the exact age of children and proof of age was provided only for 40%. This leads to a larger number of flagged data (3.6%) than in the other two municipalities.

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Stunting has an adverse impact on physical and mental development of children and has been linked to lower school performance. Preventing malnutrition and its consequences is therefore a crucial element in improving quality of life of the population and achieving the project goal: improving socio-economic development. FS and WASH activities as well as education campaigns and community workshops will all help to prevent malnutrition in the three municipalities. Initially PD/Hearth will focus on underweight children. However, because malnutrition often starts in early life and even before birth, it should be investigated whether over the course of the programme these community workshops can be expanded to adolescents and pregnant mothers to enable a better prevention of malnutrition. Since micronutrients play a crucial role in stunting, consumption of micronutrient rich foods, especially those rich in iron and zinc, should be promoted through community workshops, nutrition education and campaigns.

5.3. UNDERWEIGHT
Underweight data were presented in this report since this is still the main indicator used by the government in the Philippines. Prevalence of underweight was found to be 37%, 40% and 31% in President Roxas, Arakan and Kapatagan, respectively. According to the WHO classification a prevalence of underweight of 30% is very high. Underweight rates indicate that malnutrition must be addressed in the area. No significant differences between boys and girls were found in all three municipalties. This is slightly higher than data from the 2006 survey that found a prevalence of 28.5% in Lanao del Sur and 27% in North Cotabato [8] and much higher than municipal data provided by RHUs (see section 1.2). However RHU staff mentioned that they often have to use faulty equipment and non representative sampling, which explains these differences.

5.4. HEALTH
Prevalence of diarrhea in President Roxas and Arakan was 14.2%. In Kapatagan 7.2% of children were suffering from diarrhea. Whereas in President Roxas and Arakan there was no significant association between diarrhea and malnutrition, in Kapatagan children were significantly more likely to be malnourished if they suffered from diarrhea. These results are similar to those found in the DHS survey [13] and the WFP survey [10]66. Although no data is available it is likely that diarrhea prevalence is higher during the rains than at other times of the year. Measles vaccination in President Roxas, Arakan and Kapatagan was 88%, 87% and 61% respectively. 47%, 46% and 26% were confirmed by a vaccination card in President Roxas, Arakan and Kapatagan respectively. As mentioned in section 1.6., health services are less accessible in Kapatagan than in the other 2 municipalities. While in some barangays parents complained about the lack of vaccination coverage others mentioned that they did not want their children to be immunized. As mentioned above, children that received the measles vaccination were significantly less likely to malnourished in President Roxas and Arakan. While no statistically significant association was found between measles vaccination and malnutrition in Kapatagan, all reported deaths in children under five were due to measles. It is therefore important that vaccination coverage is improved.
66

The DHS survey showed 9% and the WFP assessment 16%. 65

Deworming coverage was 34%, 73% and 35% in President Roxas, Arakan and Kapatagan, respectively. This is similar to results from the DHS survey which showed deworming coverage 29% in ARMM and 43% in RegionXII. Vitamin A supplementation coverage is 71%, 80% and 36% in President Roxas, Arakan and Kapatagan. Again, these results are similar to those of the DHS survey results which showed 48% of children received vitamin A supplements in ARMM and 73% in Region XII. As previously mentioned children in Arakan and President Roxas were significantly less likely to be malnourished if they had received vitamin A supplements in the last six months, once again demonstrating the importance of basic health services. Crude Mortality rates was 0.15/10,000/day, 0.12/10,000/day and 0.27/10,000/day and underfive-mortality rate was 0.21/10000/day, 0/10,000/day, 0.45/10,000/day in President Roxas, Arakan and Kapatagan, respectively. Mortality rates in all three municipalities were under alert level. As mentioned above, the fact that all under five deaths in Kapatagan were due to measles, is a big concern.

6. RECOMMENDATIONS
Set up OTPs as soon as possible in all three municipalities. Since rates are highest in President Roxas this municipality should be the priority. During the survey it emerged that cost of public transport is very high and many can not afford it. The issue of transport cost should be discussed with the municipal governments in order to ensure that the population can access the OTPs once they are set up. Discuss and investigate the possibility of using weight-for-height in active case finding instead of MUAC to avoid missing many of the severe cases. If possible collect both data at the beginning to see if the difference persists. If the difference persists investigate which indicator is more appropriate for admission into feeding programmes. Substantial effort should be made towards reducing stunting over the next four years. Stunting should be addressed through the community based component of the programme (PD/Hearth, nutrition education and campaigns). Since malnutrition can start before birth, diet of women and girls before and during pregnancy needs to be improved. While the initial target of the PD/Hearth are mothers of underweight children the possibility of expanding it to pregnant women and adolescents should be considere. Foods rich in iron (such as kangkong), vitamin A and zinc should be promoted during community workshops, nutrition education and campaigns. Work closely with the foodsecurity team to enable setting up back yard gardening in households affected by malnutrition. Seeds should be provided for fruits and vegetables rich in iron and vitamin A. This will enable a diversification of diet and improvement of micronutrient status. Advocate for improved coverage of basic health services, such as immunizations, in particular in the municipality of Kapatagan. Since part of the population in Kapatagan stated that do not want their children to immunised, key messages should be included in the media campaigns. Since prevalence of acute malnutrition is not alarming, funds limited and the main focus of the programme should be prevention of malnutrition, in particular stunting, the option
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of reducing the frequency and of SMART surveys and carrying out a coverage survey instead should be considered. In the next round of SMART surveys a cluster surveys should be carried out in Arakan as well, because household lists were so inadequate.

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7. REFERENCES
1. National Statistical Coordination Board [homepage on the internet]. List of Regions in the Philippines. Available at: http://www.nscb.gov.ph/activestats/psgc/listreg.asp 2. National Statics Office [homepage on the internet]. Mindanao Comprised about 24% of Philippines Population. A Special Release on New Mindanao Groupings Based on the Results of Census 2000. Available at: http://www.census.gov.ph/data/sectordata/sr05173tx.html 3. National Statistical Coordination Board, World Bank. Estimation of local poverty in the Philippines. Manila: November 2005. Available at: http://siteresources.worldbank.org/INTPGI/Resources/3426741092157888460/Local_Estimation_of_Poverty_Philippines.pdf 4. AusAID [homepage on the internet]. Philippines Country Profile. Available at: http://www.ausaid.gov.au/country/country.cfm?CountryID=31 5. Municipality of Arakan. Socio-Economic Profile. Arakan: 2008. 6. Municiplaity of President Roxas. Municipal profile. President Roxas: 2009. 7. Municipality of Lanao del Sur. Socioeconomic Profile 2007. 8. Food and Nutrition Research Institute, WFP, UNICEF. Baseline Nutrition and Food Security Assessment in Mindanao. 2006. 9. Food and Nutrition Research Institute. National Nutrition Survey. 2008. 10. UNICEF, WFP. Joint emergency nutrition and food security Assessment of the conflict-affected Persons in Central Mindanao. January- March 2009. 11. Save the Children, UNICEF, DoH ARMM, DoH Region XII, MERN. Follow-up Emergency Nutrition Assessment in the Conflict Affected Communities in Central Mindanao. Philippines. March-April 2010. 12. Food and Nutrition Research Institue. National Nutrition Survey. 2003 13. National Statistics Office of the Philippines/ ICF Macro. Demographic and health survey of the Philippines. 2008. Available at: www.measuredhs.org. 14. WFP. Emergency Food Security Assessment. 2007. 15. ACF. Convenio Rapid Assessment. April 2010. 16. Division of Public Health Surveillance and Informatics Division, National Epidemiology Center, Department of Health Manila, Philippines. Field Health Services Information System. Annual Report 2008. 17. ACF. Mindanao Vulnerability Observatory: Broken Lives, Fragile Dreams. A vulnerability Study of Five Ethnic Communities in Maguindanao and Lanao del Sur. 2005. 18. Provincial Government of North Cotabato. Socio Economic profile. 19. WHO, UNICEF. WHO child growth standards and the identification of severe acute malnutrition in infants and children. A joint statement by the World Health Organisation and the United Nations Childrens Fund. 2009. 20. WHO. WHO Global Database on child growth and malnutrition. Available at: http://whqlibdoc.who.int/hq/1997/WHO_NUT_97.4.pdf. 21. ACF. Food security and livelihoods assessment municipalities of Arakan, President Roxas and Kapatagan. Initial Results. December 2010.

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8. ANNEXES ANNEX 1: MAP OF MINDANAO

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ANNEX 2. MAP OF REGION XII (INDICATING LOCATION OF THE MUNICIPALITIES OF ARAKAN AND PRESIDENT ROXAS)

ANNEX 3. MAP OF ARMM (INDICATING LOCATION OF THE MUNICIPALITY OF KAPATAGAN)

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ANNEX 4: MAP OF THE MUNICIPALITY OF ARAKAN

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ANNEX 5: MAP OF THE MUNICIPALITY OF PRESIDENT ROXAS

72

ANNEX 6: MAP OF THE MUNICIPALITY OF KAPATAGAN

73

ANNEX 7. ANTHROPOMETRIC SURVEY DATA FORM

Municipality: __________ Barangay:_________ Date: _____________ Cluster number: _______ Team number: _______ Number of absent children :_____ Child no. HH no. Sex (f/m) Birthday Age in months Proof of age (y/n) Weight (kg) 100g Height (cm) 0.1cm Oedema (y/n) zscore MUAC (mm) Measles Vaccination 1. Yes/mother 2.Yes/card 3.No 4.Dont know Did the child suffer from diarrhea in the last 15 days? 1.yes 2. no 3. dont know Vitamin A supplementation in the last 6 months 1. yes 2. no 3. dont know Did the child receive any deworming medication in the last 6 months? (show the pill to the mother) 1.yes 2. no 3. dont know

Mother w/ child

Mother only

Child only

1 2 3 4 5 6 7 8 9 10 11 12 13

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Annex 8. Household enumeration data collection form for a death rate calculation survey (ONE SHEET/HOUSEHOLD)
Municipality: Cluster number: Barangay: Team number: Age in years or date of birth Joined during recall period Left during recall period Date: HH number: Born during recall period Died during the recall period

No

Name (optional)

Sex (m or f)

Cause for death

Location of death

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Codes for Cause of Death 1 Diarrhea 2 Fever 3 Measles 4 Difficulty Breathing

5 Malnutrition 6 Violence/ conflict related 7 Other (fill)

Codes for Location of Death 1 In current location 2 During migration 3 In place of last residence 4 Other (fill)

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ANNEX 9. CLUSTER SELECTION FOR THE MUNICIPALITY OF PRESIDENT ROXAS

Geographical unit Alegria Bato-Bato Cabangbangan Camasi Datu Inda Datu-Sundongan Del Carmen F. Cajelo Greenhill Idaoman Ilustre Kamarahan Kimahuring Kisupaan La Esperanza Labu-o Lama-Lama Lomonay Mabuhay New Cebu Poblacion Sagcungan Sarayan Tuael Population size 1615.9075 1274.375 1156.113 1218.3025 1039.89 1310.0575 3023.837 1027.656 1715.8185 1811.6515 1718.877 1594.498 453.6775 2031.8635 387.41 3107.436 1168.347 907.355 1391.6175 2931.0625 7330.205 1141.84 1474.197 1858.5485 Cluster RC, RC, 1 2 3, 4 5, 6, 7 8 9 10, 11, 12, 13, 14, 15 RC 16, 17 18, 19, 20, 21 RC, 22, 23 24 25 26, 27 28, 29, 30, 31 32, 33, 34 RC, 35 36 RC, 37, 38 39, 40, 41, 42, 43, 44, 45, 46, 47 48, 49 50, 51, 52, 53 54

ANNEX 10. CLUSTER SELECTION FOR KAPATAGAN

Geographical unit Bakikis Barao Bongabong Daguan Inudaran Kabaniakawan Kapatagan Lusain Minimao Pinantao Salaman Sigayan Tabuan Upper Igabay Population size 1253.563779 952.6237002 1409.332059 2663.955486 1087.199017 812.7501425 1820.475547 580.6871944 1728.286157 2143.668238 1973.064883 1239.788353 1050.111331 997.1289231 RC, 34, 35, 36, 37 38, 39, 40, 41, 42, 43, 44, 45 46, 47, 48, 49 RC, 50, 51, 52, 53 54, 55, 56, 57, 58 59, 60, 61, 62 Cluster RC, 1, 2, 3, 4 5, 6, 7 8, 9, 10, 11, 12, 13, 14 RC, 15, 16, RC, 17, 18, 19, 20, 21 RC, 22, 23, 24 RC, 25, 26 27, 28, 29, 30, 31, 32, 33

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ANNEX 11. PLAUSIBILITY REPORT MUNICIPALITY OF PRESIDENT ROXAS

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 Missing/Flagged data (% of in-range subjects) Overall Sex ratio (Significant chi square) Overall Age distrib (Significant chi square) Dig pref score - weight Dig pref score - height Standard Dev WHZ Skewness Kurtosis WHZ WHZ Flags* Unit Incl Incl Incl Incl Incl Excl Excl Excl Excl Excl % Good Accept Poor Unacceptable >10 20 <0.000 10 <0.000 10 > 20 10 > 20 10 >1.20 20 >3.0 5 >3.0 5 <0.000 5 5 >15 Score

Poisson dist WHZ-2 Timing OVERALL SCORE WHZ =

0-2.5 >2.5-5.0 0 5 p >0.1 >0.05 0 2 p >0.1 >0.05 0 2 # 0-5 5-10 0 2 # 0-5 5-10 0 2 SD <1.1 <1.15 0 2 # <1.0 <2.0 0 1 # <1.0 <2.0 0 1 p >0.05 >0.01 0 1 Not determined yet 0 1 0-5 5-10

>5.0-10 10 >0.001 4 >0.001 4 10-20 4 10-20 4 <1.20 6 <3.0 3 <3.0 3 >0.001 3 3 10-15

0 (1.3 %) 0 (p=0.231) 4 (p=0.033) 0 (3) 4 (16) 0 (0.98) 0 (-0.17) 0 (0.16) 0 (p=0.079)

8 %

At the moment the overall score of this survey is 8 %, this is acceptable.

There were no duplicate entries detected.

Missing data: SEX: Line=195/ID=75, Line=680/ID=31, Line=823/ID=324 MONTHS: Line=195/ID=75, Line=680/ID=31, Line=823/ID=324 WEIGHT: Line=9/ID=741, Line=53/ID=852, Line=57/ID=832, Line=58/ID=833, Line=74/ID=660, Line=75/ID=659, Line=95/ID=662, Line=96/ID=669, Line=97/ID=670, Line=101/ID=806, Line=110/ID=815, Line=112/ID=817, Line=115/ID=810, Line=127/ID=760, Line=132/ID=755, Line=133/ID=754, Line=134/ID=753, Line=147/ID=770, Line=160/ID=938, Line=173/ID=93, Line=181/ID=101, Line=182/ID=100, Line=184/ID=94, Line=189/ID=73, Line=190/ID=64, Line=191/ID=65, Line=192/ID=71, Line=195/ID=75, Line=196/ID=74, Line=205/ID=68, Line=208/ID=42, Line=217/ID=46, Line=225/ID=40, Line=233/ID=147, Line=243/ID=169, Line=248/ID=177, Line=251/ID=178, Line=264/ID=212, Line=309/ID=509, Line=388/ID=932, Line=391/ID=935, Line=398/ID=928, Line=403/ID=348, Line=416/ID=359, Line=493/ID=438, Line=533/ID=473, Line=538/ID=482, Line=540/ID=484, Line=561/ID=582, Line=562/ID=581, Line=567/ID=580, Line=573/ID=558, Line=574/ID=559, Line=585/ID=595, Line=587/ID=596, Line=589/ID=598, Line=596/ID=645, Line=605/ID=641, Line=606/ID=644, Line=607/ID=643, Line=633/ID=325, Line=647/ID=7, Line=650/ID=2, Line=666/ID=17, Line=675/ID=24, Line=680/ID=31, Line=685/ID=163, Line=716/ID=207, Line=717/ID=206, Line=720/ID=203, Line=725/ID=198, Line=741/ID=124, Line=754/ID=251, Line=799/ID=296, Line=802/ID=298, Line=805/ID=307, Line=807/ID=303, Line=810/ID=299, Line=823/ID=324, Line=864/ID=387, Line=929/ID=796, Line=934/ID=795 HEIGHT: Line=9/ID=741, Line=53/ID=852, Line=57/ID=832, Line=58/ID=833, Line=74/ID=660, Line=75/ID=659, Line=78/ID=653, Line=95/ID=662, Line=96/ID=669, Line=97/ID=670, Line=101/ID=806, Line=110/ID=815, Line=112/ID=817, Line=115/ID=810, Line=127/ID=760, Line=132/ID=755, Line=133/ID=754, Line=134/ID=753, Line=147/ID=770, Line=160/ID=938, Line=173/ID=93, Line=181/ID=101, Line=182/ID=100, Line=184/ID=94, Line=186/ID=96, Line=189/ID=73, Line=190/ID=64, Line=191/ID=65, Line=192/ID=71, Line=195/ID=75, Line=196/ID=74, Line=205/ID=68, Line=208/ID=42, Line=217/ID=46, Line=225/ID=40, Line=233/ID=147, Line=243/ID=169, Line=248/ID=177, Line=251/ID=178, Line=264/ID=212, Line=309/ID=509, Line=388/ID=932, Line=391/ID=935, Line=398/ID=928, Line=403/ID=348,

77

Line=416/ID=359, Line=493/ID=438, Line=533/ID=473, Line=538/ID=482, Line=540/ID=484, Line=562/ID=581, Line=567/ID=580, Line=573/ID=558, Line=574/ID=559, Line=585/ID=595, Line=589/ID=598, Line=596/ID=645, Line=605/ID=641, Line=606/ID=644, Line=607/ID=643, Line=647/ID=7, Line=650/ID=2, Line=666/ID=17, Line=675/ID=24, Line=680/ID=31, Line=685/ID=163, Line=717/ID=206, Line=720/ID=203, Line=725/ID=198, Line=741/ID=124, Line=754/ID=251, Line=802/ID=298, Line=805/ID=307, Line=807/ID=303, Line=810/ID=299, Line=823/ID=324, Line=929/ID=796, Line=934/ID=795

Line=561/ID=582, Line=587/ID=596, Line=633/ID=325, Line=716/ID=207, Line=799/ID=296, Line=864/ID=387,

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=17/ID=744: HAZ (1.522), Height may be incorrect Line=46/ID=845: WHZ (3.321), WAZ (2.434), Weight may be incorrect Line=136/ID=757: HAZ (-5.282), Height may be incorrect Line=214/ID=49: WHZ (2.958), Weight may be incorrect Line=218/ID=41: WHZ (2.671), Weight may be incorrect Line=239/ID=167: WHZ (-4.580), Weight may be incorrect Line=292/ID=248: HAZ (-5.060), Age may be incorrect Line=333/ID=535: HAZ (4.708), Age may be incorrect Line=436/ID=907: WHZ (3.821), Weight may be incorrect Line=475/ID=894: WHZ (-4.132), Weight may be incorrect Line=495/ID=432: HAZ (1.436), Height may be incorrect Line=515/ID=451: WAZ (1.431), Weight may be incorrect Line=575/ID=566: WHZ (-4.978), WAZ (-4.675), Weight may be incorrect Line=579/ID=564: WHZ (-4.406), WAZ (-5.178), Weight may be incorrect Line=594/ID=589: HAZ (-5.282), Age may be incorrect Line=595/ID=588: HAZ (-5.163), Age may be incorrect Line=635/ID=330: HAZ (1.879), Age may be incorrect Line=641/ID=336: HAZ (1.671), Age may be incorrect Line=730/ID=193: HAZ (1.107), Age may be incorrect Line=760/ID=257: HAZ (-5.603), Age may be incorrect Line=914/ID=715: WHZ (-5.310), HAZ (5.361), Height may be incorrect Line=916/ID=721: WHZ (-5.149), WAZ (-5.692), Weight may be incorrect Line=939/ID=614: WHZ (4.883), WAZ (2.357), Weight may be incorrect Percentage of values flagged with SMART flags:WHZ: 1.3 %, HAZ: 1.4 %, WAZ: 0.7 %

Age distribution: Month 6 : ######### Month 7 : ############### Month 8 : ################### Month 9 : ################ Month 10 : ################### Month 11 : ##################### Month 12 : ################### Month 13 : ################# Month 14 : ################# Month 15 : ############ Month 16 : ################ Month 17 : ###################### Month 18 : ############################# Month 19 : ################## Month 20 : ##################

78

Month 21 : ################### Month 22 : ############## Month 23 : ########################## Month 24 : ####################### Month 25 : ################# Month 26 : ############### Month 27 : ############ Month 28 : ######################## Month 29 : ################## Month 30 : ####################### Month 31 : #################### Month 32 : ############## Month 33 : ################# Month 34 : #################### Month 35 : ################### Month 36 : ############################## Month 37 : ######################## Month 38 : ###################### Month 39 : ############# Month 40 : #################### Month 41 : ########### Month 42 : ############### Month 43 : ############# Month 44 : ############### Month 45 : ############## Month 46 : ################## Month 47 : ####################### Month 48 : ########################## Month 49 : ################ Month 50 : ############## Month 51 : ############ Month 52 : ################ Month 53 : ################## Month 54 : ############# Month 55 : ############### Month 56 : ################# Month 57 : ############### Month 58 : ######### Month 59 : ########### Month 60 : ##### Age ratio of 6-29 months to 30-59 months: 0.87 (The value should be around 1.0). Statistical evaluation of sex and age ratios (using Chi squared statistic):
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 104/114.8 (0.9) 112/106.3 (1.1) 216/221.1 (1.0) 0.93 18 to 29 12 119/112.0 (1.1) 109/103.6 (1.1) 228/215.6 (1.1) 1.09 30 to 41 12 123/108.5 (1.1) 107/100.4 (1.1) 230/209.0 (1.1) 1.15 42 to 53 12 110/106.8 (1.0) 95/98.8 (1.0) 205/205.6 (1.0) 1.16 54 to 59 6 39/52.8 (0.7) 35/48.9 (0.7) 74/101.7 (0.7) 1.11 ------------------------------------------------------------------------------------6 to 59 54 495/476.5 (1.0) 458/476.5 (1.0) 1.08

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.231 (boys and girls equally represented) Overall age distribution: p = 0.033 (significant difference) Overall age distribution for boys: p = 0.130 (as expected)

79

Overall age distribution for girls: p = 0.276 (as expected) Overall sex/age distribution: p = 0.008 (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 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Digit preference Height: Digit .0 Digit .1 Digit .2 Digit .3 Digit .4 Digit .5 Digit .6 Digit .7 Digit .8 Digit .9 : #################### : ############################ : ############################################################# : ####################### : ########################################### : ############ : ###################################### : ############ : ############################## : #######################

Digit Preference Score: 16 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Digit preference MUAC: Digit .0 Digit .1 Digit .2 Digit .3 Digit .4 Digit .5 Digit .6 Digit .7 Digit .8 Digit .9 : ################# : ############################################## : ################################################ : ######################################### : ################################################ : ###################################### : ################################################ : ############################################## : ########################################## : ######################################################

Digit Preference Score: 8 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures
. no exclusion . . WHZ Standard Deviation SD: 1.08 (The SD should be between 0.8 and 1.2) exclusion from reference mean (EPI Info 6 flags) 1.06 exclusion from observed mean (SMART flags) 0.98

80

Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1: HAZ Standard Deviation SD: (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1: WAZ Standard Deviation SD: (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1:

10.9% 13.1% 11.3%

10.7% 12.4% 11.1%

1.14

1.14

1.03

51.1% 49.0% 48.8%

51.1% 49.0% 48.8%

51.3% 49.5% 49.5%

1.03

1.03

0.99

36.8% 37.0% 36.6%

36.8% 37.0% 36.6%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.031 HAZ p= 0.000 p= 0.000 p= 0.201 WAZ p= 0.006 p= 0.006 p= 0.388 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed) Skewness WHZ -0.07 0.07 -0.17 HAZ 0.53 0.53 0.00 WAZ 0.01 0.01 -0.02 If the value is: -below minus 2 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 2 and minus 1, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 1 and plus 1, the distribution can be considered as symmetrical. -between 1 and 2, there may be an excess of obese/tall/overweight subjects in the sample. -above 2, there is an excess of obese/tall/overweight subjects in the sample Kurtosis WHZ 2.27 1.97 0.16 HAZ 3.22 3.22 -0.06 WAZ 0.76 0.76 0.12 (Kurtosis characterizes the relative peakedness or flatness compared with the normal distribution, positive kurtosis indicates a relatively peaked distribution, negative kurtosis indicates a relatively flat distribution) If the value is: -above 2 it indicates a problem. There might have been a problem with data collection or sampling. -between 1 and 2, the data may be affected with a problem. -less than an absolute value of 1 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 < WHZ < GAM: SAM: HAZ < HAZ < WAZ < WAZ < -2: ID=1.29 (p=0.079) -3: ID=0.94 (p=0.603) ID=1.29 (p=0.079) ID=0.94 (p=0.603) -2: ID=1.70 (p=0.001) -3: ID=2.40 (p=0.000) -2: ID=1.34 (p=0.048) -3: ID=1.44 (p=0.020)

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 < 0.05 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p value is higher than 0.05 the cases appear to be randomly distributed among the clusters, if 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

81

but not for WHZ then aggregation of GAM and SAM cases is 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 point 01: 0.95 02: 1.33 03: 1.07 04: 1.13 05: 1.08 06: 0.97 07: 0.89 08: 1.21 09: 1.03 10: 1.12 11: 1.25 12: 0.89 13: 1.22 14: 0.96 15: 1.27 16: 0.74 17: 0.82 18: 1.16 19: 1.22 20: 1.01 21: 1.17 22: 1.44 23: 0.83 24: 0.75 25: 0.50 26: 1.12 27: 1.12 28: 0.21 SD for WHZ 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 ###### ###################### ########### ############## ############ ####### #### ################# ########## ############# ################### #### ################# ####### #################### # ############### OOOOOOOOOOOOOOOOOO OOOOOOOOO OOOOOOOOOOOOOOOO ~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~

(n=52, (n=47, (n=49, (n=52, (n=50, (n=50, (n=49, (n=51, (n=47, (n=45, (n=42, (n=42, (n=42, (n=39, (n=38, (n=32, (n=29, (n=26, (n=21, (n=19, (n=14, (n=09, (n=07, (n=05, (n=02, (n=03, (n=04, (n=03,

f=0) f=2) f=0) f=0) f=1) f=0) f=0) f=2) f=0) f=1) f=1) f=0) f=1) f=0) f=1) f=0) f=0) f=1) f=1) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) 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 2 3 4 n= 225 196 138 198 Percentage of values flagged with SMART flags: WHZ: 11.6 4.8 16.5 13.1 HAZ: 9.2 4.8 17.4 13.1 WAZ: 10.1 4.2 13.9 13.1 Age ratio of 6-29 months to 30-59 months: 0.94 0.96 0.80 0.77 Sex ratio (male/female): 1.10 1.04 0.90 1.02 Digit preference Weight (%): .0 : 12 12 10 12 .1 : 14 8 7 9 .2 : 7 6 10 12 .3 : 8 10 2 14 .4 : 6 13 6 9 .5 : 11 12 14 9 .6 : 13 8 13 13 .7 : 11 10 12 6 .8 : 12 10 14 6 5 87 10.1 11.4 10.1 0.67 1.13 11 14 9 9 15 10 9 11 4 6 56 19.1 23.4 19.1 1.15 1.07 11 6 15 19 6 11 4 11 11 7 56 3.7 7.4 3.7 1.00 2.11 9 4 9 15 9 17 11 9 7

82

.9 : 8 11 11 10 DPS: 9 6 12 8 acceptable, 10-20 poor and > 20 unacceptable) Digit preference Height (%): .0 : 19 2 1 2 .1 : 13 6 7 10 .2 : 21 25 13 24 .3 : 9 5 11 7 .4 : 13 17 15 18 .5 : 5 4 7 2 .6 : 6 16 13 14 .7 : 2 2 7 5 .8 : 4 16 12 10 .9 : 7 7 12 9 DPS: 20 25 13 22 acceptable, 10-20 poor and > 20 unacceptable) Digit preference MUAC (%): .0 : 10 1 2 2 .1 : 6 11 11 19 .2 : 12 10 14 11 .3 : 6 12 9 11 .4 : 9 12 6 10 .5 : 12 12 4 6 .6 : 14 9 10 11 .7 : 9 11 12 11 .8 : 10 12 13 8 .9 : 11 11 19 11 DPS: 8 11 16 14 acceptable, 10-20 poor and > 20 unacceptable) Standard deviation of WHZ: SD 1.22 1.08 1.13 0.89 Prevalence (< -2) observed: % 13.0 9.0 15.7 Prevalence (< -2) calculated with current SD: % 16.2 12.2 18.0 Prevalence (< -2) calculated with a SD of 1: % 11.5 10.4 15.0 Standard deviation of HAZ: SD 1.13 1.15 1.22 1.05 observed: % 51.7 47.6 48.8 51.4 calculated with current SD: % 44.7 49.5 51.1 50.9 calculated with a SD of 1: % 44.0 49.4 51.4 51.0

8 10

6 14

9 11

Digit preference score (0-5 good, 5-10

8 8 20 8 14 5 13 8 10 8 14

9 11 23 6 15 2 19 2 11 2 23

2 19 15 11 7 4 22 7 7 6 21

Digit preference score (0-5 good, 5-10

1 8 13 8 21 8 14 14 4 10 18

11 4 4 13 17 7 7 4 13 20 18

2 9 13 11 15 6 11 13 7 13 13

Digit preference score (0-5 good, 5-10

1.10 15.2 14.9 12.5 1.19 50.6 49.4 49.3

0.93

0.94

1.24 61.7 55.4 56.7

1.09 57.4 45.8 45.4

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 19/27.4 (0.7) 28/24.8 (1.1) 47/52.2 (0.9) 0.68 18 to 29 12 37/26.7 (1.4) 25/24.2 (1.0) 62/50.9 (1.2) 1.48 30 to 41 12 30/25.9 (1.2) 26/23.5 (1.1) 56/49.3 (1.1) 1.15 42 to 53 12 25/25.5 (1.0) 22/23.1 (1.0) 47/48.5 (1.0) 1.14 54 to 59 6 7/12.6 (0.6) 6/11.4 (0.5) 13/24.0 (0.5) 1.17 ------------------------------------------------------------------------------------6 to 59 54 118/112.5 (1.0) 107/112.5 (1.0) 1.10

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The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.463 (boys and girls equally represented) Overall age distribution: p = 0.063 (as expected) Overall age distribution for boys: p = 0.046 (significant difference) Overall age distribution for girls: p = 0.504 (as expected) Overall sex/age distribution: p = 0.008 (significant difference) Team 2:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 27/23.2 (1.2) 22/22.3 (1.0) 49/45.5 (1.1) 1.23 18 to 29 12 21/22.6 (0.9) 26/21.7 (1.2) 47/44.3 (1.1) 0.81 30 to 41 12 23/21.9 (1.0) 18/21.0 (0.9) 41/43.0 (1.0) 1.28 42 to 53 12 18/21.6 (0.8) 21/20.7 (1.0) 39/42.3 (0.9) 0.86 54 to 59 6 11/10.7 (1.0) 9/10.2 (0.9) 20/20.9 (1.0) 1.22 ------------------------------------------------------------------------------------6 to 59 54 100/98.0 (1.0) 96/98.0 (1.0) 1.04

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.775 (boys and girls equally represented) Overall age distribution: p = 0.936 (as expected) Overall age distribution for boys: p = 0.845 (as expected) Overall age distribution for girls: p = 0.836 (as expected) Overall sex/age distribution: p = 0.571 (as expected) Team 3:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 14/15.1 (0.9) 13/16.7 (0.8) 27/31.8 (0.8) 1.08 18 to 29 12 12/14.7 (0.8) 22/16.3 (1.4) 34/31.0 (1.1) 0.55 30 to 41 12 19/14.3 (1.3) 20/15.8 (1.3) 39/30.0 (1.3) 0.95 42 to 53 12 16/14.0 (1.1) 12/15.5 (0.8) 28/29.6 (0.9) 1.33 54 to 59 6 4/6.9 (0.6) 5/7.7 (0.7) 9/14.6 (0.6) 0.80 ------------------------------------------------------------------------------------6 to 59 54 65/68.5 (0.9) 72/68.5 (1.1) 0.90

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.550 (boys and girls equally represented) Overall age distribution: p = 0.204 (as expected) Overall age distribution for boys: p = 0.451 (as expected) Overall age distribution for girls: p = 0.223 (as expected) Overall sex/age distribution: p = 0.043 (significant difference) Team 4:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 21/23.2 (0.9) 23/22.7 (1.0) 44/45.9 (1.0) 0.91 18 to 29 12 23/22.6 (1.0) 19/22.2 (0.9) 42/44.8 (0.9) 1.21 30 to 41 12 28/21.9 (1.3) 27/21.5 (1.3) 55/43.4 (1.3) 1.04 42 to 53 12 20/21.6 (0.9) 22/21.1 (1.0) 42/42.7 (1.0) 0.91 54 to 59 6 8/10.7 (0.7) 7/10.5 (0.7) 15/21.1 (0.7) 1.14 ------------------------------------------------------------------------------------6 to 59 54 100/99.0 (1.0) 98/99.0 (1.0) 1.02

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.887 (boys and girls equally represented) Overall age distribution: p = 0.273 (as expected)

84

Overall age distribution for boys: p = 0.612 (as expected) Overall age distribution for girls: p = 0.550 (as expected) Overall sex/age distribution: p = 0.219 (as expected) Team 5:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 6/10.4 (0.6) 14/9.3 (1.5) 20/19.7 (1.0) 0.43 18 to 29 12 8/10.2 (0.8) 6/9.0 (0.7) 14/19.2 (0.7) 1.33 30 to 41 12 14/9.9 (1.4) 7/8.8 (0.8) 21/18.6 (1.1) 2.00 42 to 53 12 13/9.7 (1.3) 9/8.6 (1.0) 22/18.3 (1.2) 1.44 54 to 59 6 4/4.8 (0.8) 4/4.3 (0.9) 8/9.1 (0.9) 1.00 ------------------------------------------------------------------------------------6 to 59 54 45/42.5 (1.1) 40/42.5 (0.9) 1.13

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.588 (boys and girls equally represented) Overall age distribution: p = 0.630 (as expected) Overall age distribution for boys: p = 0.255 (as expected) Overall age distribution for girls: p = 0.431 (as expected) Overall sex/age distribution: p = 0.049 (significant difference) Team 6:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 7/6.7 (1.0) 7/6.3 (1.1) 14/13.0 (1.1) 1.00 18 to 29 12 8/6.6 (1.2) 8/6.1 (1.3) 16/12.7 (1.3) 1.00 30 to 41 12 5/6.4 (0.8) 6/5.9 (1.0) 11/12.3 (0.9) 0.83 42 to 53 12 7/6.3 (1.1) 4/5.8 (0.7) 11/12.1 (0.9) 1.75 54 to 59 6 2/3.1 (0.6) 2/2.9 (0.7) 4/6.0 (0.7) 1.00 ------------------------------------------------------------------------------------6 to 59 54 29/28.0 (1.0) 27/28.0 (1.0) 1.07

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.789 (boys and girls equally represented) Overall age distribution: p = 0.765 (as expected) Overall age distribution for boys: p = 0.895 (as expected) Overall age distribution for girls: p = 0.824 (as expected) Overall sex/age distribution: p = 0.615 (as expected) Team 7:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 10/8.8 (1.1) 5/4.2 (1.2) 15/13.0 (1.2) 2.00 18 to 29 12 10/8.6 (1.2) 3/4.1 (0.7) 13/12.7 (1.0) 3.33 30 to 41 12 4/8.3 (0.5) 3/3.9 (0.8) 7/12.3 (0.6) 1.33 42 to 53 12 11/8.2 (1.3) 5/3.9 (1.3) 16/12.1 (1.3) 2.20 54 to 59 6 3/4.1 (0.7) 2/1.9 (1.0) 5/6.0 (0.8) 1.50 ------------------------------------------------------------------------------------6 to 59 54 38/28.0 (1.4) 18/28.0 (0.6) 2.11

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.008 (significant excess of boys) Overall age distribution: p = 0.404 (as expected) Overall age distribution for boys: p = 0.424 (as expected) Overall age distribution for girls: p = 0.910 (as expected) Overall sex/age distribution: p = 0.011 (significant difference)

85

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 point 01: 0.77 02: 1.25 03: 1.18 04: 1.53 05: 1.37 06: 1.10 07: 1.00 08: 1.36 09: 0.98 10: 1.82 11: 1.88 12: 1.10 13: 1.73 14: 0.86 15: 0.88 16: 1.22 17: 0.92 18: 1.64 19: 0.89 20: 1.25 21: 1.30 22: 1.12 23: 0.45 24: 0.31 26: 1.56 27: 0.59 28: 0.28 SD for WHZ 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 (n=11, (n=09, (n=10, (n=10, (n=10, (n=08, (n=10, (n=11, (n=11, (n=10, (n=11, (n=10, (n=10, (n=10, (n=10, (n=08, (n=07, (n=07, (n=06, (n=06, (n=04, (n=04, (n=03, (n=03, (n=02, (n=03, (n=02, f=0) f=0) f=0) f=0) f=1) f=0) f=0) f=1) f=0) f=1) f=1) f=0) f=1) f=0) f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) ################### ################ ############################### ######################## ############# ######## ####################### ######## ########################################### ############################################# ############# ####################################### ### #### ################## ##### ################################### #### ################### OOOOOOOOOOOOOOOOOOOOO OOOOOOOOOOOOO

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

(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)

Team: 2
Time point 01: 0.82 02: 1.22 03: 1.19 04: 1.13 05: 1.10 06: 0.83 07: 0.57 08: 0.97 09: 1.21 10: 0.94 11: 0.96 12: 0.73 13: 1.24 14: 0.72 15: 2.31 16: 0.44 17: 0.94 18: 1.04 19: 1.87 20: 0.89 21: 1.30 SD for WHZ 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 # ################## ################ ############## ############ # ####### ################# ###### ####### ################## ################################################################ ###### ########## OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO OOOO OOOOOOOOOOOOOOOOOOOOO

(n=11, (n=11, (n=11, (n=11, (n=10, (n=11, (n=11, (n=10, (n=10, (n=10, (n=09, (n=10, (n=10, (n=08, (n=07, (n=07, (n=07, (n=07, (n=05, (n=05, (n=05,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=1) f=0) 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)

Team: 3
Time point 01: 1.07 (n=08, f=0) 02: 2.03 (n=07, f=2) SD for WHZ 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 ########### ####################################################

86

03: 04: 05: 06: 07: 08: 09: 10: 11: 12: 13: 14: 15: 16: 17: 18: 19: 20:

1.11 0.97 1.07 0.98 1.05 1.84 1.21 1.10 1.02 0.48 0.93 1.12 0.49 0.54 0.91 0.39 0.84 0.28

(n=07, (n=07, (n=08, (n=08, (n=08, (n=08, (n=07, (n=06, (n=05, (n=04, (n=05, (n=04, (n=06, (n=05, (n=04, (n=05, (n=04, (n=02,

f=0) f=0) f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0)

############# ####### ########### ####### ########### ############################################ ################# ############# ######### ###### OOOOOOOOOOOOO

OOOOO OO

(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)

Team: 4
Time point 01: 0.93 02: 0.83 03: 0.72 04: 0.88 05: 1.19 06: 0.93 07: 0.75 08: 1.03 09: 1.02 10: 0.56 11: 0.94 12: 1.02 13: 0.65 14: 0.96 15: 0.88 16: 0.66 17: 0.84 18: 1.09 19: 0.22 20: 1.84 21: 1.82 SD for WHZ 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 ###### # ### ################# ##### ########## ######### ###### ######### ####### ### OO ~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

(n=13, (n=12, (n=11, (n=13, (n=11, (n=12, (n=09, (n=13, (n=10, (n=10, (n=08, (n=08, (n=08, (n=08, (n=08, (n=05, (n=05, (n=03, (n=02, (n=02, (n=02,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) 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)

Team: 5
Time point 01: 1.45 02: 1.03 03: 1.52 04: 1.50 05: 0.39 06: 0.84 07: 0.50 08: 1.06 09: 0.77 10: 0.67 11: 1.23 12: 0.96 13: 1.69 14: 0.33 15: 0.68 16: 0.34 17: 0.16 18: 1.41 19: 0.50 20: 0.11 SD for WHZ 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 ########################### ########## ############################## ############################# ## ###########

(n=05, (n=04, (n=06, (n=06, (n=06, (n=05, (n=04, (n=05, (n=02, (n=04, (n=04, (n=04, (n=04, (n=04, (n=04, (n=03, (n=02, (n=02, (n=02, (n=02,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0)

################## ####### #####################################

OOOOOOOOOOOOOOOOOOOOOOOOOO

87

(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)

Team: 6
Time point 01: 0.12 02: 0.10 04: 0.91 05: 1.15 06: 0.27 07: 1.54 08: 0.88 09: 0.45 10: 1.59 11: 0.35 12: 0.04 13: 0.66 14: 0.82 16: 0.37 17: 1.46 SD for WHZ 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 (n=02, (n=02, (n=02, (n=03, (n=03, (n=02, (n=02, (n=02, (n=02, (n=02, (n=02, (n=02, (n=02, (n=02, (n=02, f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) 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)

Team: 7
Time point 01: 0.86 02: 1.65 03: 0.68 04: 0.83 05: 0.72 06: 1.71 07: 1.12 08: 0.58 09: 1.63 10: 0.92 11: 0.07 12: 0.13 13: 0.64 14: 0.15 SD for WHZ 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 ## #################################### # ###################################### ############# ################################### #####

(n=05, (n=04, (n=05, (n=04, (n=04, (n=04, (n=04, (n=03, (n=04, (n=03, (n=02, (n=03, (n=02, (n=03,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) 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)

(for better comparison it can be helpful to copy/paste part of this report into Excel

ANNEX 12. PLAUSIBILITY REPORT MUNICIPALITY OF ARAKAN

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 Missing/Flagged data (% of in-range subjects) Overall Sex ratio (Significant chi square) Overall Age distrib (Significant chi square) Dig pref score - weight Flags* Unit Incl Incl Incl Incl % p p # Good 0-2.5 0 >0.1 0 >0.1 0 0-5 Accept >2.5-5.0 5 >0.05 2 >0.05 2 5-10 Poor Unacceptable >10 20 <0.000 10 <0.000 10 > 20 Score

>5.0-10 10 >0.001 4 >0.001 4 10-20

0 (0.3 %) 0 (p=0.483) 0 (p=0.337)

88

Dig pref score - height Standard Dev WHZ Skewness Kurtosis WHZ WHZ

Incl Excl Excl Excl Excl Excl

Poisson dist WHZ-2 Timing OVERALL SCORE WHZ =

0 2 0-5 5-10 0 2 SD <1.1 <1.15 0 2 # <1.0 <2.0 0 1 # <1.0 <2.0 0 1 p >0.05 >0.01 0 1 Not determined yet 0 1 0-5 5-10 #

4 10-20 4 <1.20 6 <3.0 3 <3.0 3 >0.001 3 3 10-15

10 > 20 10 >1.20 20 >3.0 5 >3.0 5 <0.000 5 5 >15

0 (5) 4 (18) 0 (0.93) 0 (-0.14) 0 (0.26) 0 (p=)

4 %

At the moment the overall score of this survey is 4 %, this is good.

There were no duplicate entries detected.

Missing data: SEX: Line=23/ID=68, Line=43/ID=513, Line=336/ID=107 MONTHS: Line=23/ID=68, Line=43/ID=513, Line=336/ID=107 WEIGHT: Line=2/ID=47, Line=7/ID=48, Line=18/ID=63, Line=21/ID=62, Line=23/ID=68, Line=35/ID=29, Line=43/ID=513, Line=51/ID=505, Line=52/ID=504, Line=53/ID=503, Line=58/ID=498, Line=59/ID=497, Line=60/ID=496, Line=85/ID=471, Line=87/ID=469, Line=97/ID=459, Line=102/ID=454, Line=106/ID=450, Line=124/ID=432, Line=126/ID=430, Line=127/ID=429, Line=129/ID=427, Line=131/ID=425, Line=135/ID=248, Line=147/ID=236, Line=153/ID=230, Line=155/ID=228, Line=170/ID=213, Line=171/ID=212, Line=172/ID=161, Line=174/ID=173, Line=177/ID=156, Line=178/ID=155, Line=188/ID=187, Line=191/ID=188, Line=200/ID=20, Line=205/ID=172, Line=217/ID=154, Line=219/ID=124, Line=220/ID=123, Line=229/ID=142, Line=242/ID=182, Line=245/ID=134, Line=250/ID=125, Line=253/ID=133, Line=270/ID=110, Line=296/ID=211, Line=309/ID=11, Line=310/ID=75, Line=313/ID=76, Line=319/ID=74, Line=327/ID=115, Line=332/ID=4, Line=336/ID=107, Line=353/ID=353, Line=373/ID=373, Line=375/ID=375, Line=376/ID=376, Line=386/ID=386, Line=389/ID=389, Line=390/ID=390 HEIGHT: Line=2/ID=47, Line=7/ID=48, Line=18/ID=63, Line=21/ID=62, Line=23/ID=68, Line=35/ID=29, Line=43/ID=513, Line=51/ID=505, Line=52/ID=504, Line=53/ID=503, Line=58/ID=498, Line=59/ID=497, Line=60/ID=496, Line=85/ID=471, Line=87/ID=469, Line=97/ID=459, Line=102/ID=454, Line=106/ID=450, Line=124/ID=432, Line=126/ID=430, Line=127/ID=429, Line=129/ID=427, Line=131/ID=425, Line=135/ID=248, Line=147/ID=236, Line=152/ID=231, Line=153/ID=230, Line=155/ID=228, Line=170/ID=213, Line=171/ID=212, Line=172/ID=161, Line=174/ID=173, Line=177/ID=156, Line=178/ID=155, Line=188/ID=187, Line=191/ID=188, Line=200/ID=20, Line=205/ID=172, Line=217/ID=154, Line=219/ID=124, Line=220/ID=123, Line=229/ID=142, Line=242/ID=182, Line=245/ID=134, Line=250/ID=125, Line=253/ID=133, Line=270/ID=110, Line=296/ID=211, Line=309/ID=11, Line=310/ID=75, Line=313/ID=76, Line=319/ID=74, Line=327/ID=115, Line=332/ID=4, Line=336/ID=107, Line=353/ID=353, Line=373/ID=373, Line=375/ID=375, Line=376/ID=376, Line=386/ID=386, Line=389/ID=389, Line=390/ID=390

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=173/ID=160: HAZ (1.275), Age may be incorrect Line=282/ID=196: HAZ (1.818), Age may be incorrect Line=306/ID=21: WAZ (1.949), Age may be incorrect Line=311/ID=72: WAZ (-4.729), Age may be incorrect Line=318/ID=71: HAZ (-5.415), Age may be incorrect Line=322/ID=102: WHZ (9.045), WAZ (5.201), Weight may be incorrect Line=368/ID=368: HAZ (1.276), Age may be incorrect Line=372/ID=372: HAZ (3.310), Age may be incorrect Percentage of values flagged with SMART flags:WHZ: 0.3 %, HAZ: 1.5 %, WAZ: 0.9 %

89

Age distribution: Month 6 : ####### Month 7 : ####### Month 8 : ### Month 9 : ######## Month 10 : ###### Month 11 : ######### Month 12 : ######## Month 13 : ######## Month 14 : ###### Month 15 : ######## Month 16 : ##### Month 17 : ####### Month 18 : ## Month 19 : ###### Month 20 : ####### Month 21 : ####### Month 22 : ####### Month 23 : ######### Month 24 : ################### Month 25 : ######### Month 26 : ###### Month 27 : ####### Month 28 : ###### Month 29 : ### Month 30 : ##### Month 31 : ####### Month 32 : ###### Month 33 : ############# Month 34 : ########### Month 35 : #### Month 36 : ############## Month 37 : ############# Month 38 : ##### Month 39 : ######### Month 40 : ### Month 41 : ##### Month 42 : ###### Month 43 : ##### Month 44 : ##### Month 45 : ############### Month 46 : ####### Month 47 : ######### Month 48 : ######### Month 49 : ########### Month 50 : ## Month 51 : ####### Month 52 : ############ Month 53 : ########## Month 54 : #### Month 55 : #### Month 56 : ###### Month 57 : ####### Month 58 : ####### Month 59 : ####

90

Age ratio of 6-29 months to 30-59 months: 0.77 (The value should be around 1.0). Statistical evaluation of sex and age ratios (using Chi squared statistic):
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 36/44.5 (0.8) 48/47.8 (1.0) 84/92.3 (0.9) 0.75 18 to 29 12 50/43.4 (1.2) 39/46.6 (0.8) 89/90.0 (1.0) 1.28 30 to 41 12 42/42.1 (1.0) 51/45.2 (1.1) 93/87.3 (1.1) 0.82 42 to 53 12 46/41.4 (1.1) 52/44.5 (1.2) 98/85.9 (1.1) 0.88 54 to 59 6 18/20.5 (0.9) 16/22.0 (0.7) 34/42.5 (0.8) 1.13 ------------------------------------------------------------------------------------6 to 59 54 192/199.0 (1.0) 206/199.0 (1.0) 0.93

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.483 (boys and girls equally represented) Overall age distribution: p = 0.337 (as expected) Overall age distribution for boys: p = 0.487 (as expected) Overall age distribution for girls: p = 0.297 (as expected) Overall sex/age distribution: p = 0.064 (as expected)

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: 5 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Digit preference Height: Digit .0 Digit .1 Digit .2 Digit .3 Digit .4 Digit .5 Digit .6 Digit .7 Digit .8 Digit .9 : ########## : ############### : ############################## : ############## : ################################# : ###### : ################## : ##### : ######################### : ##############

Digit Preference Score: 18 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Digit preference MUAC: Digit .0 : ####

91

Digit .1 Digit .2 Digit .3 Digit .4 Digit .5 Digit .6 Digit .7 Digit .8 Digit .9

: ################################ : ######################################## : ############################################ : ########################################## : ##################### : ########################################### : ############################# : ################################## : ########################################

Digit Preference Score: 12 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures
. no exclusion . . WHZ Standard Deviation SD: 1.07 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 5.9% calculated with current SD: 8.6% calculated with a SD of 1: 7.2% HAZ Standard Deviation SD: (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1: WAZ Standard Deviation SD: (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1: exclusion from reference mean (EPI Info 6 flags) 0.93 exclusion from observed mean (SMART flags) 0.93

1.17

1.17

1.07

60.5% 61.0% 62.9%

60.5% 61.0% 62.9%

61.1% 63.6% 64.5%

1.06

1.00

0.96

39.7% 38.9% 38.2%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.570 p= 0.570 HAZ p= 0.000 p= 0.000 p= 0.300 WAZ p= 0.000 p= 0.179 p= 0.484 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed) Skewness WHZ 1.99 -0.14 -0.14 HAZ 0.39 0.39 -0.14 WAZ 0.93 0.20 0.15 If the value is: -below minus 2 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 2 and minus 1, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 1 and plus 1, the distribution can be considered as symmetrical. -between 1 and 2, there may be an excess of obese/tall/overweight subjects in the sample. -above 2, there is an excess of obese/tall/overweight subjects in the sample Kurtosis WHZ 18.34 0.26 0.26 HAZ 1.64 1.64 -0.22 WAZ 5.10 0.61 0.21 (Kurtosis characterizes the relative peakedness or flatness compared with the normal distribution, positive kurtosis indicates a relatively peaked distribution, negative kurtosis indicates a relatively flat distribution) If the value is: -above 2 it indicates a problem. There might have been a problem with data collection or sampling. -between 1 and 2, the data may be affected with a problem. -less than an absolute value of 1 the distribution can be considered as normal.

92

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 point SD for WHZ 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

(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 2 3 4 n= 76 35 59 47 Percentage of values flagged with SMART flags: WHZ: 24.6 6.1 0.0 14.6 HAZ: 27.9 9.1 0.0 14.6 WAZ: 24.6 6.1 0.0 14.6 Age ratio of 6-29 months to 30-59 months: 0.73 0.70 0.59 0.81 Sex ratio (male/female): 1.81 1.00 0.69 0.52 Digit preference Weight (%): .0 : 11 12 5 17 .1 : 7 9 24 7 .2 : 10 6 12 17 .3 : 10 6 12 7 .4 : 5 15 12 0 .5 : 13 12 12 10 .6 : 13 9 12 10 .7 : 8 18 0 10 .8 : 10 9 5 7 .9 : 13 3 7 15 DPS: 9 14 20 16 acceptable, 10-20 poor and > 20 unacceptable) Digit preference Height (%): .0 : 10 6 5 0 .1 : 5 12 5 0 .2 : 23 12 12 15 .3 : 2 9 7 10 .4 : 26 6 20 39 .5 : 3 9 5 5 .6 : 5 12 12 12 .7 : 0 9 0 0 .8 : 15 12 20 20 .9 : 11 12 15 0 DPS: 28 8 21 39 acceptable, 10-20 poor and > 20 unacceptable) Digit preference MUAC (%): .0 : 3 0 0 0 .1 : 14 0 14 15 .2 : 7 12 12 13 .3 : 7 27 17 5 .4 : 10 12 14 13 .5 : 10 9 10 10 .6 : 17 0 17 10 5 58 18.4 18.4 20.4 0.66 0.87 12 10 0 10 12 14 16 6 8 10 14 6 73 10.4 11.9 11.9 1.18 1.00 10 7 15 3 13 16 6 12 4 12 14 7 53 12.8 12.8 12.8 0.73 0.79 6 6 17 9 11 9 6 15 11 11 11

Digit preference score (0-5 good, 5-10

6 14 12 8 18 2 16 2 12 8 18

7 12 19 7 15 1 12 6 19 0 21

2 13 23 15 11 2 9 4 4 17 22

Digit preference score (0-5 good, 5-10

0 6 17 17 19 0 9

3 6 19 11 8 6 16

0 11 4 15 15 0 17 93

.7 : 3 3 7 13 .8 : 12 12 2 5 .9 : 16 24 7 15 DPS: 15 31 18 16 acceptable, 10-20 poor and > 20 unacceptable) Standard deviation of WHZ: SD 1.05 0.84 1.07 0.79 Prevalence (< -2) observed: % 11.5 7.3 Prevalence (< -2) calculated with current SD: % 11.4 8.9 Prevalence (< -2) calculated with a SD of 1: % 10.3 7.5 Standard deviation of HAZ: SD 1.37 1.31 0.93 1.09 observed: % 57.4 51.5 63.4 calculated with current SD: % 55.0 60.9 60.7 calculated with a SD of 1: % 56.8 64.2 61.7

6 21 4 25

9 9 13 15

20 9 9 22

Digit preference score (0-5 good, 5-10

0.76

1.45 3.0 9.7 3.0

0.91

1.08 53.1 54.0 54.3

1.23 65.7 65.4 68.6

1.08 63.8 68.9 70.3

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 11/11.4 (1.0) 9/6.3 (1.4) 20/17.6 (1.1) 1.22 18 to 29 12 8/11.1 (0.7) 4/6.1 (0.7) 12/17.2 (0.7) 2.00 30 to 41 12 12/10.7 (1.1) 7/5.9 (1.2) 19/16.7 (1.1) 1.71 42 to 53 12 11/10.6 (1.0) 7/5.8 (1.2) 18/16.4 (1.1) 1.57 54 to 59 6 7/5.2 (1.3) 0/2.9 (0.0) 7/8.1 (0.9) ------------------------------------------------------------------------------------6 to 59 54 49/38.0 (1.3) 27/38.0 (0.7) 1.81

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.012 (significant excess of boys) Overall age distribution: p = 0.641 (as expected) Overall age distribution for boys: p = 0.803 (as expected) Overall age distribution for girls: p = 0.264 (as expected) Overall sex/age distribution: p = 0.016 (significant difference) Team 2:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 2/3.9 (0.5) 5/3.9 (1.3) 7/7.9 (0.9) 0.40 18 to 29 12 4/3.8 (1.0) 3/3.8 (0.8) 7/7.7 (0.9) 1.33 30 to 41 12 4/3.7 (1.1) 3/3.7 (0.8) 7/7.5 (0.9) 1.33 42 to 53 12 5/3.7 (1.4) 4/3.7 (1.1) 9/7.3 (1.2) 1.25 54 to 59 6 2/1.8 (1.1) 2/1.8 (1.1) 4/3.6 (1.1) 1.00 ------------------------------------------------------------------------------------6 to 59 54 17/17.0 (1.0) 17/17.0 (1.0) 1.00

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 1.000 (boys and girls equally represented) Overall age distribution: p = 0.962 (as expected) Overall age distribution for boys: p = 0.829 (as expected) Overall age distribution for girls: p = 0.956 (as expected)

94

Overall sex/age distribution: p = 0.709 (as expected) Team 3:

Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 3/5.6 (0.5) 7/8.1 (0.9) 10/13.7 (0.7) 0.43 18 to 29 12 5/5.4 (0.9) 7/7.9 (0.9) 12/13.3 (0.9) 0.71 30 to 41 12 6/5.3 (1.1) 12/7.7 (1.6) 18/12.9 (1.4) 0.50 42 to 53 12 6/5.2 (1.2) 5/7.6 (0.7) 11/12.7 (0.9) 1.20 54 to 59 6 4/2.6 (1.6) 4/3.7 (1.1) 8/6.3 (1.3) 1.00 ------------------------------------------------------------------------------------6 to 59 54 24/29.5 (0.8) 35/29.5 (1.2) 0.69

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.152 (boys and girls equally represented) Overall age distribution: p = 0.433 (as expected) Overall age distribution for boys: p = 0.688 (as expected) Overall age distribution for girls: p = 0.466 (as expected) Overall sex/age distribution: p = 0.087 (as expected) Team 4:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 5/3.7 (1.3) 7/7.2 (1.0) 12/10.9 (1.1) 0.71 18 to 29 12 4/3.6 (1.1) 5/7.0 (0.7) 9/10.6 (0.8) 0.80 30 to 41 12 4/3.5 (1.1) 10/6.8 (1.5) 14/10.3 (1.4) 0.40 42 to 53 12 3/3.5 (0.9) 6/6.7 (0.9) 9/10.1 (0.9) 0.50 54 to 59 6 0/1.7 (0.0) 3/3.3 (0.9) 3/5.0 (0.6) 0.00 ------------------------------------------------------------------------------------6 to 59 54 16/23.5 (0.7) 31/23.5 (1.3) 0.52

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.029 (significant excess of girls) Overall age distribution: p = 0.623 (as expected) Overall age distribution for boys: p = 0.677 (as expected) Overall age distribution for girls: p = 0.700 (as expected) Overall sex/age distribution: p = 0.055 (as expected) Team 5:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 3/6.3 (0.5) 5/7.2 (0.7) 8/13.5 (0.6) 0.60 18 to 29 12 9/6.1 (1.5) 6/7.0 (0.9) 15/13.1 (1.1) 1.50 30 to 41 12 5/5.9 (0.8) 8/6.8 (1.2) 13/12.7 (1.0) 0.63 42 to 53 12 9/5.8 (1.5) 10/6.7 (1.5) 19/12.5 (1.5) 0.90 54 to 59 6 1/2.9 (0.3) 2/3.3 (0.6) 3/6.2 (0.5) 0.50 ------------------------------------------------------------------------------------6 to 59 54 27/29.0 (0.9) 31/29.0 (1.1) 0.87

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.599 (boys and girls equally represented) Overall age distribution: p = 0.112 (as expected) Overall age distribution for boys: p = 0.187 (as expected) Overall age distribution for girls: p = 0.528 (as expected) Overall sex/age distribution: p = 0.051 (as expected) Team 6:
Age cat. mo. boys girls total ratio boys/girls -------------------------------------------------------------------------------------

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6 to 17 12 10/8.4 (1.2) 9/8.4 (1.1) 19/16.7 (1.1) 1.11 18 to 29 12 10/8.1 (1.2) 10/8.1 (1.2) 20/16.3 (1.2) 1.00 30 to 41 12 5/7.9 (0.6) 6/7.9 (0.8) 11/15.8 (0.7) 0.83 42 to 53 12 10/7.8 (1.3) 9/7.8 (1.2) 19/15.5 (1.2) 1.11 54 to 59 6 1/3.8 (0.3) 2/3.8 (0.5) 3/7.7 (0.4) 0.50 ------------------------------------------------------------------------------------6 to 59 54 36/36.0 (1.0) 36/36.0 (1.0) 1.00

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 1.000 (boys and girls equally represented) Overall age distribution: p = 0.182 (as expected) Overall age distribution for boys: p = 0.336 (as expected) Overall age distribution for girls: p = 0.735 (as expected) Overall sex/age distribution: p = 0.161 (as expected) Team 7:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 2/5.3 (0.4) 6/6.7 (0.9) 8/12.1 (0.7) 0.33 18 to 29 12 10/5.2 (1.9) 4/6.6 (0.6) 14/11.8 (1.2) 2.50 30 to 41 12 6/5.0 (1.2) 5/6.4 (0.8) 11/11.4 (1.0) 1.20 42 to 53 12 2/5.0 (0.4) 11/6.3 (1.8) 13/11.2 (1.2) 0.18 54 to 59 6 3/2.5 (1.2) 3/3.1 (1.0) 6/5.5 (1.1) 1.00 ------------------------------------------------------------------------------------6 to 59 54 23/26.0 (0.9) 29/26.0 (1.1) 0.79

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.405 (boys and girls equally represented) Overall age distribution: p = 0.712 (as expected) Overall age distribution for boys: p = 0.072 (as expected) Overall age distribution for girls: p = 0.291 (as expected) Overall sex/age distribution: p = 0.008 (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 point SD for WHZ 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

(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)

Team: 2
Time point SD for WHZ 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

(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)

Team: 3
Time point SD for WHZ 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

(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)

Team: 4

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Time point

SD for WHZ 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

(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)

Team: 5
Time point SD for WHZ 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

(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)

Team: 6
Time point SD for WHZ 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

(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)

Team: 7
Time point SD for WHZ 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

(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)

(for better comparison it can be helpful to copy/paste part of this report into Excel)

ANNEX 13. PLAUSIBILITY REPORT MUNICIPALITY OF KAPATAGAN

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 Missing/Flagged data (% of in-range subjects) Overall Sex ratio (Significant chi square) Overall Age distrib (Significant chi square) Dig pref score - weight Dig pref score - height Standard Dev WHZ Skewness Kurtosis WHZ WHZ Flags* Unit Incl Incl Incl Incl Incl Excl Excl Excl Excl Excl % Good Accept Poor Unacceptable >10 20 <0.000 10 <0.000 10 > 20 10 > 20 10 >1.20 20 >3.0 5 >3.0 5 <0.000 5 5 >15 Score

Poisson dist WHZ-2 Timing OVERALL SCORE WHZ =

0-2.5 >2.5-5.0 0 5 p >0.1 >0.05 0 2 p >0.1 >0.05 0 2 # 0-5 5-10 0 2 # 0-5 5-10 0 2 SD <1.1 <1.15 0 2 # <1.0 <2.0 0 1 # <1.0 <2.0 0 1 p >0.05 >0.01 0 1 Not determined yet 0 1 0-5 5-10

>5.0-10 10 >0.001 4 >0.001 4 10-20 4 10-20 4 <1.20 6 <3.0 3 <3.0 3 >0.001 3 3 10-15

0 (0.8 %) 2 (p=0.096) 0 (p=0.819) 0 (3) 4 (19) 0 (0.98) 0 (-0.21) 0 (0.12) 0 (p=0.194)

6 %

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At the moment the overall score of this survey is 6 %, this is acceptable.

There were no duplicate entries detected.

Missing data: SEX: Line=408/ID=25 WEIGHT: Line=72/ID=802, Line=76/ID=812, Line=77/ID=808, Line=78/ID=809, Line=114/ID=707, Line=150/ID=741, Line=168/ID=738, Line=182/ID=754, Line=187/ID=770, Line=226/ID=110, Line=233/ID=135, Line=239/ID=142, Line=242/ID=134, Line=258/ID=158, Line=260/ID=166, Line=261/ID=164, Line=263/ID=163, Line=265/ID=162, Line=275/ID=173, Line=285/ID=181, Line=290/ID=180, Line=329/ID=222, Line=392/ID=8, Line=393/ID=9, Line=400/ID=13, Line=402/ID=11, Line=408/ID=25, Line=425/ID=26, Line=445/ID=63, Line=447/ID=62, Line=455/ID=70, Line=457/ID=74, Line=464/ID=81, Line=491/ID=438, Line=498/ID=439, Line=510/ID=448, Line=523/ID=465, Line=527/ID=469, Line=555/ID=416, Line=560/ID=415, Line=605/ID=503, Line=615/ID=538, Line=625/ID=546, Line=626/ID=547, Line=639/ID=561, Line=653/ID=560, Line=708/ID=269, Line=714/ID=293, Line=721/ID=294, Line=723/ID=288, Line=726/ID=295, Line=728/ID=306, Line=740/ID=319, Line=744/ID=318, Line=747/ID=317, Line=765/ID=358, Line=770/ID=357, Line=777/ID=367, Line=789/ID=387, Line=803/ID=386, Line=831/ID=840, Line=833/ID=842, Line=844/ID=853, Line=853/ID=862, Line=873/ID=882, Line=881/ID=890, Line=903/ID=912 HEIGHT: Line=72/ID=802, Line=76/ID=812, Line=77/ID=808, Line=78/ID=809, Line=114/ID=707, Line=150/ID=741, Line=168/ID=738, Line=182/ID=754, Line=187/ID=770, Line=226/ID=110, Line=233/ID=135, Line=239/ID=142, Line=242/ID=134, Line=258/ID=158, Line=260/ID=166, Line=261/ID=164, Line=263/ID=163, Line=265/ID=162, Line=275/ID=173, Line=285/ID=181, Line=290/ID=180, Line=329/ID=222, Line=392/ID=8, Line=393/ID=9, Line=400/ID=13, Line=402/ID=11, Line=408/ID=25, Line=425/ID=26, Line=445/ID=63, Line=447/ID=62, Line=455/ID=70, Line=457/ID=74, Line=464/ID=81, Line=491/ID=438, Line=498/ID=439, Line=510/ID=448, Line=523/ID=465, Line=527/ID=469, Line=555/ID=416, Line=560/ID=415, Line=605/ID=503, Line=615/ID=538, Line=625/ID=546, Line=626/ID=547, Line=639/ID=561, Line=653/ID=560, Line=708/ID=269, Line=714/ID=293, Line=721/ID=294, Line=723/ID=288, Line=726/ID=295, Line=728/ID=306, Line=740/ID=319, Line=744/ID=318, Line=747/ID=317, Line=765/ID=358, Line=770/ID=357, Line=777/ID=367, Line=789/ID=387, Line=803/ID=386, Line=831/ID=840, Line=833/ID=842, Line=844/ID=853, Line=853/ID=862, Line=873/ID=882, Line=881/ID=890, Line=903/ID=912

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=13/ID=613: HAZ (-5.759), Age may be incorrect Line=15/ID=629: HAZ (4.504), Height may be incorrect Line=42/ID=643: HAZ (1.401), Age may be incorrect Line=132/ID=718: WHZ (-3.780), Weight may be incorrect Line=146/ID=720: HAZ (-7.144), WAZ (-4.524), Age may be incorrect Line=156/ID=729: HAZ (2.725), Age may be incorrect Line=195/ID=772: WAZ (-4.509), Age may be incorrect Line=236/ID=136: HAZ (3.221), WAZ (2.151), Age may be incorrect Line=283/ID=189: HAZ (-6.863), Age may be incorrect Line=291/ID=191: WAZ (-4.628), Weight may be incorrect Line=294/ID=190: WHZ (-4.073), HAZ (-5.667), WAZ (-5.691) Line=310/ID=203: HAZ (1.190), Age may be incorrect Line=312/ID=199: WHZ (2.841), Weight may be incorrect Line=335/ID=323: HAZ (-6.278), WAZ (-4.586), Age may be incorrect Line=373/ID=88: HAZ (2.401), Age may be incorrect Line=381/ID=104: HAZ (-5.799), Age may be incorrect Line=413/ID=46: HAZ (1.121), Age may be incorrect Line=437/ID=59: HAZ (2.800), Height may be incorrect Line=441/ID=66: HAZ (4.525), WAZ (1.563), Age may be incorrect Line=449/ID=61: HAZ (1.290), Age may be incorrect

98

Line=470/ID=83: HAZ (4.558), Age may be incorrect Line=486/ID=247: WHZ (-6.763), WAZ (-5.490), Weight may be incorrect Line=487/ID=246: WHZ (-5.771), WAZ (-5.139), Weight may be incorrect Line=503/ID=457: HAZ (-5.280), Age may be incorrect Line=550/ID=425: HAZ (-5.316), WAZ (-4.718), Age may be incorrect Line=559/ID=420: HAZ (1.666), Age may be incorrect Line=602/ID=501: HAZ (0.927), Age may be incorrect Line=632/ID=553: WHZ (3.514), Weight may be incorrect Line=682/ID=241: HAZ (-5.831), Height may be incorrect Line=710/ID=282: HAZ (1.145), Age may be incorrect Line=737/ID=303: HAZ (1.042), Age may be incorrect Line=763/ID=347: HAZ (1.617), Height may be incorrect Line=826/ID=835: HAZ (1.185), Height may be incorrect Line=838/ID=847: HAZ (-5.233), Age may be incorrect Line=877/ID=886: HAZ (-5.252), Age may be incorrect Line=891/ID=900: WHZ (4.458), HAZ (1.487), WAZ (3.808) Line=895/ID=904: HAZ (1.152), Age may be incorrect Percentage of values flagged with SMART flags:WHZ: 0.8 %, HAZ: 3.6 %, WAZ: 1.3 %

Age distribution: Month 6 : ############ Month 7 : ####################### Month 8 : ##################### Month 9 : ####################### Month 10 : ################## Month 11 : ########## Month 12 : ######################## Month 13 : ####################### Month 14 : ########### Month 15 : ############ Month 16 : ################ Month 17 : ########## Month 18 : ################# Month 19 : ######## Month 20 : ############ Month 21 : ########## Month 22 : ########### Month 23 : ################ Month 24 : ################ Month 25 : ################ Month 26 : ################ Month 27 : ############### Month 28 : #################### Month 29 : ######################## Month 30 : ######################### Month 31 : ################## Month 32 : ####################### Month 33 : ############## Month 34 : ###################### Month 35 : ################# Month 36 : ################ Month 37 : ########## Month 38 : ################ Month 39 : ################# Month 40 : ############

99

Month 41 : ###################### Month 42 : ######## Month 43 : ##################### Month 44 : ########################## Month 45 : ######### Month 46 : ################## Month 47 : ##################### Month 48 : ###################### Month 49 : ################ Month 50 : #################### Month 51 : ########### Month 52 : ############ Month 53 : ########## Month 54 : ####################### Month 55 : #################### Month 56 : ######################### Month 57 : ############ Month 58 : ############### Month 59 : ############## Month 60 : #### Age ratio of 6-29 months to 30-59 months: 0.79 (The value should be around 1.0). Statistical evaluation of sex and age ratios (using Chi squared statistic):
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 118/110.4 (1.1) 92/98.8 (0.9) 210/209.3 (1.0) 1.28 18 to 29 12 108/107.7 (1.0) 81/96.4 (0.8) 189/204.0 (0.9) 1.33 30 to 41 12 99/104.4 (0.9) 104/93.4 (1.1) 203/197.8 (1.0) 0.95 42 to 53 12 101/102.7 (1.0) 99/91.9 (1.1) 200/194.6 (1.0) 1.02 54 to 59 6 50/50.8 (1.0) 50/45.5 (1.1) 100/96.3 (1.0) 1.00 ------------------------------------------------------------------------------------6 to 59 54 476/451.0 (1.1) 426/451.0 (0.9) 1.12

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.096 (boys and girls equally represented) Overall age distribution: p = 0.819 (as expected) Overall age distribution for boys: p = 0.934 (as expected) Overall age distribution for girls: p = 0.275 (as expected) Overall sex/age distribution: p = 0.075 (as expected)

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 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

100

Digit preference Height: Digit .0 Digit .1 Digit .2 Digit .3 Digit .4 Digit .5 Digit .6 Digit .7 Digit .8 Digit .9 : ############## : #################### : ################################################# : ############ : ################################################### : ########### : ######################################## : ############## : ################################################# : ####################

Digit Preference Score: 19 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Digit preference MUAC: Digit .0 Digit .1 Digit .2 Digit .3 Digit .4 Digit .5 Digit .6 Digit .7 Digit .8 Digit .9 : ############# : ################################################ : ################################################ : ########################################## : ######################################################## : ######################### : ######################################## : ####################################### : ######################################### : ######################################################

Digit Preference Score: 10 (0-5 good, 5-10 acceptable, 10-20 poor and > 20 unacceptable)

Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures
. no exclusion . . WHZ Standard Deviation SD: 1.06 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 7.3% calculated with current SD: 6.9% calculated with a SD of 1: 5.8% HAZ Standard Deviation SD: (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1: WAZ Standard Deviation SD: (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1: exclusion from reference mean (EPI Info 6 flags) 1.02 exclusion from observed mean (SMART flags) 0.98

7.1% 6.0% 5.6%

1.40

1.37

1.17

53.9% 53.3% 54.6%

53.8% 52.9% 53.9%

54.6% 55.6% 56.5%

1.08

1.08

1.01

31.6% 32.4% 31.1%

31.6% 32.4% 31.1%

31.0% 30.5% 30.4%

Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.006 HAZ p= 0.000 p= 0.000 p= 0.032 WAZ p= 0.000 p= 0.000 p= 0.547 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)

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Skewness WHZ -0.43 -0.06 -0.21 HAZ 0.44 0.57 -0.03 WAZ -0.03 -0.03 0.03 If the value is: -below minus 2 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 2 and minus 1, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 1 and plus 1, the distribution can be considered as symmetrical. -between 1 and 2, there may be an excess of obese/tall/overweight subjects in the sample. -above 2, there is an excess of obese/tall/overweight subjects in the sample Kurtosis WHZ 2.73 0.97 0.12 HAZ 2.18 2.08 -0.29 WAZ 1.15 1.15 -0.03 (Kurtosis characterizes the relative peakedness or flatness compared with the normal distribution, positive kurtosis indicates a relatively peaked distribution, negative kurtosis indicates a relatively flat distribution) If the value is: -above 2 it indicates a problem. There might have been a problem with data collection or sampling. -between 1 and 2, the data may be affected with a problem. -less than an absolute value of 1 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 < WHZ < GAM: SAM: HAZ < HAZ < WAZ < WAZ < -2: ID=1.16 (p=0.194) -3: ID=1.13 (p=0.241) ID=1.16 (p=0.194) ID=1.13 (p=0.241) -2: ID=1.97 (p=0.000) -3: ID=2.07 (p=0.000) -2: ID=1.57 (p=0.004) -3: ID=1.40 (p=0.026)

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 < 0.05 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p value is higher than 0.05 the cases appear to be randomly distributed among the clusters, if 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 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 point 01: 0.82 02: 0.93 03: 0.98 04: 0.99 05: 1.09 06: 1.10 07: 0.93 08: 1.12 09: 1.13 10: 1.11 11: 1.20 12: 1.12 13: 0.85 14: 1.31 15: 1.59 SD for WHZ 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 # ##### ####### ######## ############ ############# ###### ############# ############## ############# ################# ############# ## ##################### #################################

(n=55, (n=54, (n=52, (n=52, (n=52, (n=51, (n=52, (n=52, (n=48, (n=49, (n=44, (n=40, (n=38, (n=34, (n=28,

f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=1) f=0) f=1) f=1) f=0) f=0) f=1) f=2)

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16: 17: 18: 19: 20: 21: 22: 23: 24: 25: 26: 27:

1.06 1.09 0.87 0.72 0.38 1.01 0.87 1.44 1.75 0.80 1.09 0.07

(n=26, (n=21, (n=20, (n=18, (n=10, (n=09, (n=08, (n=07, (n=04, (n=04, (n=03, (n=03,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0)

########### OOOOOOOOOOOO OOO

~~~~~~~~~ ~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~

(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 2 3 4 n= 188 189 166 207 Percentage of values flagged with SMART flags: WHZ: 6.8 6.1 7.6 16.2 HAZ: 10.7 7.8 10.2 17.9 WAZ: 6.8 6.1 8.9 16.2 Age ratio of 6-29 months to 30-59 months: 0.84 0.89 0.78 0.74 Sex ratio (male/female): 0.96 1.30 1.14 1.07 Digit preference Weight (%): .0 : 8 7 11 12 .1 : 13 14 8 8 .2 : 10 12 13 11 .3 : 11 8 10 7 .4 : 8 9 7 12 .5 : 7 15 5 10 .6 : 10 13 12 6 .7 : 10 6 11 12 .8 : 17 9 12 11 .9 : 7 6 10 13 DPS: 10 11 8 8 10-20 poor and > 20 unacceptable) Digit preference Height (%): .0 : 1 7 3 12 .1 : 7 9 8 6 .2 : 12 22 14 23 .3 : 5 3 2 4 .4 : 24 14 19 18 .5 : 5 3 3 4 .6 : 21 13 15 12 .7 : 5 6 3 3 .8 : 15 19 23 13 .9 : 5 5 11 3 DPS: 25 21 24 22 10-20 poor and > 20 unacceptable) Digit preference MUAC (%): .0 : 2 2 3 7 .1 : 14 6 20 7 .2 : 11 13 11 12 .3 : 11 11 11 6 5 75 10.3 16.2 11.8 0.83 0.97 9 6 13 12 7 12 7 12 9 13 8 6 78 4.0 6.7 5.3 0.59 1.36 7 17 9 12 9 5 9 11 7 13 11

Digit preference score (0-5 good, 5-10 acceptable,

0 4 21 6 21 1 6 4 26 10 29

1 5 12 9 11 5 15 16 9 16 16

Digit preference score (0-5 good, 5-10 acceptable,

0 12 20 17

3 13 7 9

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.4 : 15 15 15 9 .5 : 5 6 8 8 .6 : 10 7 11 14 .7 : 9 11 5 11 .8 : 10 13 4 13 .9 : 13 15 14 11 DPS: 13 13 17 9 10-20 poor and > 20 unacceptable) Standard deviation of WHZ: SD 1.01 1.22 1.04 1.01 Prevalence (< -2) observed: % 7.9 8.3 7.0 5.0 Prevalence (< -2) calculated with current SD: % 6.4 11.0 6.3 4.6 Prevalence (< -2) calculated with a SD of 1: % 6.3 6.8 5.5 4.5 Standard deviation of HAZ: SD 1.49 1.33 1.44 1.27 observed: % 56.5 50.0 53.5 54.7 calculated with current SD: % 55.4 48.1 54.3 55.9 calculated with a SD of 1: % 58.0 47.5 56.1 57.5

11 5 3 15 9 9 20

20 1 9 9 11 19 19

Digit preference score (0-5 good, 5-10 acceptable,

1.01 7.4 5.7 5.6 1.53 44.1 45.9 43.7

1.01 9.3 6.2 6.0 1.38 65.3 59.6 63.2

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 26/21.3 (1.2) 24/22.3 (1.1) 50/43.6 (1.1) 1.08 18 to 29 12 20/20.8 (1.0) 16/21.7 (0.7) 36/42.5 (0.8) 1.25 30 to 41 12 22/20.2 (1.1) 24/21.0 (1.1) 46/41.2 (1.1) 0.92 42 to 53 12 18/19.9 (0.9) 25/20.7 (1.2) 43/40.6 (1.1) 0.72 54 to 59 6 6/9.8 (0.6) 7/10.2 (0.7) 13/20.1 (0.6) 0.86 ------------------------------------------------------------------------------------6 to 59 54 92/94.0 (1.0) 96/94.0 (1.0) 0.96

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.770 (boys and girls equally represented) Overall age distribution: p = 0.275 (as expected) Overall age distribution for boys: p = 0.580 (as expected) Overall age distribution for girls: p = 0.410 (as expected) Overall sex/age distribution: p = 0.139 (as expected) Team 2:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 23/24.8 (0.9) 19/19.0 (1.0) 42/43.9 (1.0) 1.21 18 to 29 12 30/24.2 (1.2) 17/18.5 (0.9) 47/42.8 (1.1) 1.76 30 to 41 12 17/23.5 (0.7) 20/18.0 (1.1) 37/41.4 (0.9) 0.85 42 to 53 12 20/23.1 (0.9) 11/17.7 (0.6) 31/40.8 (0.8) 1.82 54 to 59 6 17/11.4 (1.5) 15/8.8 (1.7) 32/20.2 (1.6) 1.13 ------------------------------------------------------------------------------------6 to 59 54 107/94.5 (1.1) 82/94.5 (0.9) 1.30

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.069 (boys and girls equally represented)

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Overall age distribution: p = 0.036 (significant difference) Overall age distribution for boys: p = 0.169 (as expected) Overall age distribution for girls: p = 0.119 (as expected) Overall sex/age distribution: p = 0.002 (significant difference) Team 3:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 20/20.4 (1.0) 18/17.9 (1.0) 38/38.3 (1.0) 1.11 18 to 29 12 20/19.9 (1.0) 15/17.4 (0.9) 35/37.3 (0.9) 1.33 30 to 41 12 19/19.3 (1.0) 18/16.9 (1.1) 37/36.2 (1.0) 1.06 42 to 53 12 18/19.0 (0.9) 17/16.6 (1.0) 35/35.6 (1.0) 1.06 54 to 59 6 11/9.4 (1.2) 9/8.2 (1.1) 20/17.6 (1.1) 1.22 ------------------------------------------------------------------------------------6 to 59 54 88/82.5 (1.1) 77/82.5 (0.9) 1.14

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.392 (boys and girls equally represented) Overall age distribution: p = 0.973 (as expected) Overall age distribution for boys: p = 0.987 (as expected) Overall age distribution for girls: p = 0.974 (as expected) Overall sex/age distribution: p = 0.816 (as expected) Team 4:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 32/24.8 (1.3) 13/23.2 (0.6) 45/48.0 (0.9) 2.46 18 to 29 12 24/24.2 (1.0) 19/22.6 (0.8) 43/46.8 (0.9) 1.26 30 to 41 12 18/23.5 (0.8) 22/21.9 (1.0) 40/45.4 (0.9) 0.82 42 to 53 12 23/23.1 (1.0) 32/21.6 (1.5) 55/44.7 (1.2) 0.72 54 to 59 6 10/11.4 (0.9) 14/10.7 (1.3) 24/22.1 (1.1) 0.71 ------------------------------------------------------------------------------------6 to 59 54 107/103.5 (1.0) 100/103.5 (1.0) 1.07

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.627 (boys and girls equally represented) Overall age distribution: p = 0.448 (as expected) Overall age distribution for boys: p = 0.474 (as expected) Overall age distribution for girls: p = 0.025 (significant difference) Overall sex/age distribution: p = 0.006 (significant difference) Team 5:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 9/8.6 (1.0) 6/8.8 (0.7) 15/17.4 (0.9) 1.50 18 to 29 12 9/8.4 (1.1) 10/8.6 (1.2) 19/17.0 (1.1) 0.90 30 to 41 12 8/8.1 (1.0) 13/8.3 (1.6) 21/16.4 (1.3) 0.62 42 to 53 12 9/8.0 (1.1) 6/8.2 (0.7) 15/16.2 (0.9) 1.50 54 to 59 6 2/3.9 (0.5) 3/4.1 (0.7) 5/8.0 (0.6) 0.67 ------------------------------------------------------------------------------------6 to 59 54 37/37.5 (1.0) 38/37.5 (1.0) 0.97

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.908 (boys and girls equally represented) Overall age distribution: p = 0.549 (as expected) Overall age distribution for boys: p = 0.885 (as expected) Overall age distribution for girls: p = 0.330 (as expected) Overall sex/age distribution: p = 0.212 (as expected)

105

Team 6:
Age cat. mo. boys girls total ratio boys/girls ------------------------------------------------------------------------------------6 to 17 12 8/10.4 (0.8) 12/7.7 (1.6) 20/18.1 (1.1) 0.67 18 to 29 12 5/10.2 (0.5) 4/7.5 (0.5) 9/17.6 (0.5) 1.25 30 to 41 12 15/9.9 (1.5) 7/7.2 (1.0) 22/17.1 (1.3) 2.14 42 to 53 12 13/9.7 (1.3) 8/7.1 (1.1) 21/16.8 (1.2) 1.63 54 to 59 6 4/4.8 (0.8) 2/3.5 (0.6) 6/8.3 (0.7) 2.00 ------------------------------------------------------------------------------------6 to 59 54 45/39.0 (1.2) 33/39.0 (0.8) 1.36

The data are expressed as observed number/expected number (ratio of obs/expect) Overall sex ratio: p = 0.174 (boys and girls equally represented) Overall age distribution: p = 0.111 (as expected) Overall age distribution for boys: p = 0.129 (as expected) Overall age distribution for girls: p = 0.303 (as expected) Overall sex/age distribution: p = 0.007 (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 point 01: 0.55 02: 0.85 03: 1.08 04: 1.21 05: 0.89 06: 1.17 07: 1.06 08: 0.98 09: 1.22 10: 1.29 11: 1.23 12: 0.86 13: 0.92 14: 0.82 15: 0.97 16: 0.82 17: 0.99 18: 0.87 19: 0.51 20: 0.47 21: 1.06 22: 0.94 23: 0.86 SD for WHZ 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 (n=10, (n=09, (n=09, (n=09, (n=10, (n=09, (n=09, (n=10, (n=10, (n=10, (n=09, (n=09, (n=09, (n=08, (n=07, (n=08, (n=07, (n=07, (n=06, (n=03, (n=02, (n=02, (n=02, f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) 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)

Team: 2
Time point 01: 0.91 02: 1.24 03: 0.91 04: 0.73 05: 1.33 06: 1.37 07: 1.31 08: 1.01 09: 1.10 10: 0.69 11: 1.43 12: 1.25 SD for WHZ 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 #### ################### ##### ###################### ######################## ##################### ######### ############# ########################## ###################

(n=12, (n=12, (n=11, (n=12, (n=12, (n=12, (n=12, (n=10, (n=09, (n=10, (n=09, (n=08,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0)

106

13: 14: 15: 16: 17: 18: 19: 20: 21: 22: 23: 24: 25:

0.95 2.45 2.53 0.87 2.10 0.31 0.82 0.28 0.68 0.56 0.22 1.70 0.77

(n=07, (n=06, (n=07, (n=06, (n=03, (n=04, (n=04, (n=04, (n=02, (n=02, (n=02, (n=02, (n=02,

f=0) f=1) f=1) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0)

###### ################################################################ ################################################################ ### OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO O

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

(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)

Team: 3
Time point 01: 0.50 02: 0.54 03: 0.82 04: 0.98 05: 1.02 06: 1.10 07: 0.76 08: 1.71 09: 0.93 10: 0.85 11: 1.27 12: 0.99 13: 0.57 14: 1.18 15: 1.97 16: 1.27 17: 1.15 18: 0.08 19: 0.10 SD for WHZ 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 (n=12, (n=12, (n=12, (n=12, (n=10, (n=10, (n=12, (n=12, (n=12, (n=10, (n=09, (n=06, (n=07, (n=05, (n=05, (n=04, (n=03, (n=02, (n=02, f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=1) f=0) f=0) f=1) f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=0)

# ####### ######### ############# ###################################### ###### ## #################### OOOOOOOO OOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOO ~~~~~~~~~~~~~~~

(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)

Team: 4
Time point 01: 1.35 02: 0.86 03: 0.96 04: 1.07 05: 1.19 06: 0.98 07: 0.66 08: 0.59 09: 1.21 10: 1.49 11: 1.02 12: 0.75 13: 0.80 14: 0.80 15: 0.91 16: 1.17 17: 0.82 18: 1.38 19: 0.78 20: 0.34 21: 0.55 22: 0.83 23: 3.12 SD for WHZ 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 ####################### ## ####### ########### ################ ########

(n=10, (n=10, (n=10, (n=09, (n=10, (n=10, (n=10, (n=10, (n=10, (n=11, (n=10, (n=09, (n=09, (n=10, (n=06, (n=06, (n=06, (n=05, (n=04, (n=02, (n=04, (n=03, (n=02,

f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=1) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0)

################# ############################# #########

##### ############### # OOOOOOOOOOOOOOOOOOOOOOOO

O ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

(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)

107

Team: 5
Time point 01: 0.80 02: 0.82 03: 1.43 04: 1.28 05: 0.99 06: 0.95 07: 0.50 08: 0.80 09: 1.35 10: 0.77 11: 1.02 12: 1.41 13: 0.79 14: 1.13 SD for WHZ 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 (n=06, (n=06, (n=06, (n=06, (n=05, (n=05, (n=04, (n=06, (n=03, (n=04, (n=03, (n=04, (n=03, (n=02, f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) # ########################## #################### ######## ######

####################### ######### ########################## OOOOOOOOOOOOOO

(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)

Team: 6
Time point 01: 0.52 02: 1.05 03: 0.96 04: 0.77 05: 0.81 06: 0.76 07: 0.88 08: 0.82 09: 1.50 10: 1.26 11: 1.54 12: 1.45 13: 0.53 14: 1.03 15: 0.83 SD for WHZ 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 (n=05, (n=05, (n=04, (n=04, (n=05, (n=05, (n=05, (n=04, (n=04, (n=04, (n=04, (n=04, (n=03, (n=03, (n=02, f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) f=0) ########## ####### # #### # ############################# ################### ############################### ########################### ########## O

(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)

(for better comparison it can be helpful to copy/paste part of this report into Excel)

108

ANNEX 14. ANTHROPOMETRIC SURVEY RESULTS ACCORDING TO NCHS STANDARDS (MUNICIPALITY OF PRESIDENT ROXAS)
Table 8.1: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of President Roxas, October-November 2010).
All n = 866 (92) 10.6 % (8.4 - 13.3 95% C.I.) (78) 9.0 % (7.1 - 11.3 95% C.I.) (14) 1.6 % (1.0 - 2.7 95% C.I.) Boys n = 447 (45) 10.1 % (7.3 - 13.7 95% C.I.) (36) 8.1 % (5.8 - 11.2 95% C.I.) (9) 2.0 % (1.0 - 3.9 95% C.I.) Girls n = 419 (47) 11.2 % (8.5 - 14.7 95% C.I.) (42) 10.0 % (7.6 - 13.2 95% C.I.) (5) 1.2 % (0.5 - 2.7 95% C.I.)

Prevalence of global malnutrition (<2 z-score and/or oedema) Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema) The prevalence of oedema is 0.0 %

Table 8.2: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of President Roxas, October-November 2010).
Severe wasting (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 189 211 212 188 66 866 n 4 4 3 2 1 14 % 2.1 1.9 1.4 1.1 1.5 1.6 Moderate wasting (>= -3 and <-2 zscore ) n % 17 25 20 11 5 78 9.0 11.8 9.4 5.9 7.6 9.0 Normal (> = -2 z score) n 168 182 189 175 60 774 % 88.9 86.3 89.2 93.1 90.9 89.4 Oedema

n 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Table8.3: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of President Roxas, October-November 2010).
Oedema present Oedema absent <-3 z-score Marasmic kwashiorkor n=0 (0.0 %) Marasmic n= 15 (1.7 %) >=-3 z-score Kwashiorkor n= 0 (0.0 %) Not severely malnourished n=857 (98.3 %)

Table 8.4: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of President Roxas, October-November 2010).
All n = 870 (398) 45.7 % (41.8 - 49.8 95% C.I.) (316) 36.3 % (33.0 - 39.8 95% C.I.) (82) 9.4 % (7.2 - 12.3 95% C.I.) Boys n = 450 (187) 41.6 % (36.4 - 46.9 95% C.I.) (150) 33.3 % (28.8 - 38.2 95% C.I.) (37) 8.2 % (5.7 - 11.7 95% C.I.) Girls n = 420 (211) 50.2 % (45.4 - 55.1 95% C.I.) (166) 39.5 % (35.2 - 44.0 95% C.I.) (45) 10.7 % (8.1 - 14.0 95% C.I.)

Prevalence of underweight (<-2 z-score) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) Prevalence of severe underweight (<-3 z-score)

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Table 8.5: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of President Roxas, October-November 2010).
Severe underweight (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 192 211 213 188 66 870 No. 16 26 19 15 6 82 % 8.3 12.3 8.9 8.0 9.1 9.4 Moderate underweight (>= -3 and <-2 zscore ) No. % 60 78 76 78 24 316 31.3 37.0 35.7 41.5 36.4 36.3 Normal (> = -2 z score) Oedema

No. 116 107 118 95 36 472

% 60.4 50.7 55.4 50.5 54.5 54.3

No. 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Table 8.6: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of President Roxas, October-November 2010).
All n = 861 (361) 41.9 % (37.5 - 46.5 95% C.I.) (261) 30.3 % (27.5 - 33.2 95% C.I.) (100) 11.6 % (9.1 - 14.7 95% C.I.) Boys n = 444 (185) 41.7 % (36.0 - 47.5 95% C.I.) (141) 31.8 % (27.4 - 36.5 95% C.I.) (44) 9.9 % (7.0 - 13.9 95% C.I.) Girls n = 417 (176) 42.2 % (36.5 - 48.1 95% C.I.) (120) 28.8 % (24.5 - 33.4 95% C.I.) (56) 13.4 % (10.2 - 17.5 95% C.I.)

Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) Prevalence of severe stunting (<-3 z-score)

Table 8.7: Prevalence of stunting by age based on height-for-age z-scores (municipality of President Roxas, October-November 2010).
Severe stunting (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 186 208 214 186 67 861 No. 14 23 22 32 9 100 % 7.5 11.1 10.3 17.2 13.4 11.6 Moderate stunting (>= -3 and <-2 zscore ) No. % 43 60 63 68 27 261 23.1 28.8 29.4 36.6 40.3 30.3 Normal (> = -2 z score) No. 129 125 129 86 31 500 % 69.4 60.1 60.3 46.2 46.3 58.1

Table 8.8: Mean z-scores, Design Effects and excluded subjects (municipality of President Roxas, October-November 2010).
Indicator Mean z- Design Effect scores SD (z-score < -2) Weight-for-Height 866 -1.000.86 1.34 Weight-for-Age 870 -1.860.92 1.39 Height-for-Age 861 -1.791.01 1.78 * contains for WHZ and WAZ the children with edema. n z-scores not available* 81 79 81 z-scores out of range 6 4 11

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ANNEX 15. ANTHROPOMETRIC SURVEY RESULTS ACCORDING TO NCHS STANDARDS (MUNICIPALITY OF ARAKAN)
Table 8.9: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality of Arakan, November 2010)
All n = 338 Prevalence of global malnutrition (<2 z-score and/or oedema) Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema) The prevalence of oedema is 0.0 % (20) 5.9 % (3.9 - 9.0 95% C.I.) (20) 5.9 % (3.9 - 9.0 95% C.I.) (0) 0.0 % (0.0 - 1.1 95% C.I.) Boys n = 165 (12) 7.3 % (4.2 - 12.3 95% C.I.) (12) 7.3 % (4.2 - 12.3 95% C.I.) (0) 0.0 % (0.0 - 2.3 95% C.I.) Girls n = 173 (8) 4.6 % (2.4 - 8.9 95% C.I.) (8) 4.6 % (2.4 - 8.9 95% C.I.) (0) 0.0 % (0.0 - 2.2 95% C.I.)

Table 8.10: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality of Arakan, November 2010)
Severe wasting (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 70 80 77 81 30 338 n 0 0 0 0 0 0 % 0.0 0.0 0.0 0.0 0.0 0.0 Moderate wasting (>= -3 and <-2 zscore ) n % 3 6 5 5 1 20 4.3 7.5 6.5 6.2 3.3 5.9 Normal (> = -2 z score) n 67 74 72 76 29 318 % 95.7 92.5 93.5 93.8 96.7 94.1 Oedema

n 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Table 8.11: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality of Arakan, November 2010)
Oedema present Oedema absent <-3 z-score Marasmic kwashiorkor n=0 (0.0 %) Marasmic n= 0 (0 %) >=-3 z-score Kwashiorkor n= 0 (0.0 %) Not severely malnourished n=338 (100 %)

Table 8.12: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of Arakan, November 2010)
All n = 338 (157) 46.4 % (41.2 - 51.8 95% C.I.) (126) 37.3 % (32.3 - 42.5 95% C.I.) (31) 9.2 % Boys n = 166 (72) 43.4 % (36.1 - 51.0 95% C.I.) (57) 34.3 % (27.5 - 41.8 95% C.I.) (15) 9.0 % Girls n = 172 (85) 49.4 % (42.0 - 56.8 95% C.I.) (69) 40.1 % (33.1 - 47.6 95% C.I.) (16) 9.3 %

Prevalence of underweight (<-2 z-score) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) Prevalence of severe

111

underweight (<-3 z-score)

(6.5 - 12.7 95% C.I.)

(5.6 - 14.4 95% C.I.)

(5.8 - 14.6 95% C.I.)

Table 8.13: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality of Arakan, November 2010)
Severe underweight (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 70 81 76 81 30 338 No. 6 9 6 10 0 31 % 8.6 11.1 7.9 12.3 0.0 9.2 Moderate underweight (>= -3 and <-2 zscore ) No. % 19 30 35 24 18 126 27.1 37.0 46.1 29.6 60.0 37.3 Normal (> = -2 z score) Oedema

No. 45 42 35 47 12 181

% 64.3 51.9 46.1 58.0 40.0 53.6

No. 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Table 8.14: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of Arakan, November 2010)
All n = 334 (178) 53.3 % (47.9 - 58.6 95% C.I.) (107) 32.0 % (27.3 - 37.2 95% C.I.) (71) 21.3 % (17.2 - 26.0 95% C.I.) Boys n = 166 (86) 51.8 % (44.3 - 59.3 95% C.I.) (48) 28.9 % (22.6 - 36.2 95% C.I.) (38) 22.9 % (17.2 - 29.9 95% C.I.) Girls n = 168 (92) 54.8 % (47.2 - 62.1 95% C.I.) (59) 35.1 % (28.3 - 42.6 95% C.I.) (33) 19.6 % (14.3 - 26.3 95% C.I.)

Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) Prevalence of severe stunting (<-3 z-score)

Table 8.15: Prevalence of stunting by age based on height-for-age z-scores (municipality of Arakan, November 2010)
Severe stunting (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 69 78 77 80 30 334 No. 4 21 16 22 8 71 % 5.8 26.9 20.8 27.5 26.7 21.3 Moderate stunting (>= -3 and <-2 zscore ) No. % 26 21 26 23 11 107 37.7 26.9 33.8 28.8 36.7 32.0 Normal (> = -2 z score) No. 39 36 35 35 11 156 % 56.5 46.2 45.5 43.8 36.7 46.7

Table 8.16: Mean z-scores, Design Effects and excluded subjects (municipality of Arakan, November 2010)
Indicator Weight-for-Height Weight-for-Age Height-for-Age n 338 338 334 Mean z- Design Effect scores SD (z-score < -2) -0.780.82 1.00 -1.900.89 1.00 -2.161.06 1.00 z-scores not available* 59 58 59 z-scores out of range 1 2 5

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* contains for WHZ and WAZ the children with edema.

ANNEX 16. ANTHROPOMETRIC SURVEY RESULTS ACCORDING TO NCHS STANDARDS (MUNICIPALITY OF KAPATAGAN)
Table 8.17: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (municipality Kapatagan, November/December 2010)
All n = 831 (49) 5.9 % (4.4 - 7.9 95% C.I.) (46) 5.5 % (4.1 - 7.4 95% C.I.) (3) 0.4 % (0.1 - 1.1 95% C.I.) Boys n = 436 (30) 6.9 % (4.7 - 10.0 95% C.I.) (28) 6.4 % (4.4 - 9.3 95% C.I.) (2) 0.5 % (0.1 - 1.8 95% C.I.) Girls n = 395 (19) 4.8 % (3.1 - 7.5 95% C.I.) (18) 4.6 % (2.9 - 7.0 95% C.I.) (1) 0.3 % (0.0 - 1.8 95% C.I.)

Prevalence of global malnutrition (<2 z-score and/or oedema) Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema) The prevalence of oedema is 0.0 %

Table 8.18: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema (municipality Kapatagan, November/December 2010)
Severe wasting (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 190 180 188 183 90 831 No. % Moderate wasting (>= -3 and <-2 zscore ) No. % Normal (> = -2 z score) No. % Oedema

No.

1 2 0 0 0 3

0.5 1.1 0.0 0.0 0.0 0.4

18 10 8 7 3 46

9.5 5.6 4.3 3.8 3.3 5.5

171 168 180 176 87 782

90.0 93.3 95.7 96.2 96.7 94.1

0 0 0 0 0 0

0.0 0.0 0.0 0.0 0.0 0.0

Table 8.19: Distribution of acute malnutrition and oedema based on weight-for-height z-scores (municipality Kapatagan, November/December 2010)
Oedema present <-3 z-score Marasmic kwashiorkor No. 0 (0.0 %) Marasmic No. 5 (0.6 %) >=-3 z-score Kwashiorkor No. 0 (0.0 %) Not severely malnourished No. 831 (99.4 %)

Oedema absent

Table 8.20: Prevalence of underweight based on weight-for-age z-scores by sex (municipality Kapatagan, November/December 2010)
All n = 830 (301) 36.3 % Boys n = 435 (151) 34.7 % Girls n = 395 (150) 38.0 %

Prevalence of underweight

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(<-2 z-score) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) Prevalence of severe underweight (<-3 z-score)

(32.2 - 40.6 95% C.I.) (245) 29.5 % (25.7 - 33.6 95% C.I.) (56) 6.7 % (5.1 - 9.0 95% C.I.)

(29.2 - 40.7 95% C.I.) (120) 27.6 % (22.9 - 32.8 95% C.I.) (31) 7.1 % (4.7 - 10.6 95% C.I.)

(33.4 - 42.8 95% C.I.) (125) 31.6 % (27.1 - 36.6 95% C.I.) (25) 6.3 % (4.5 - 8.9 95% C.I.)

Table 8.21: Prevalence of underweight by age, based on weight-for-height z-scores and oedema (municipality Kapatagan, November/December 2010)
Severe underweight (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 190 180 187 183 90 830 No. 15 15 13 10 3 56 % 7.9 8.3 7.0 5.5 3.3 6.7 Moderate underweight (>= -3 and <-2 zscore ) No. % 54 56 55 51 29 245 28.4 31.1 29.4 27.9 32.2 29.5 Normal (> = -2 z score) Oedema

No. 121 109 119 122 58 529

% 63.7 60.6 63.6 66.7 64.4 63.7

No. 0 0 0 0 0 0

% 0.0 0.0 0.0 0.0 0.0 0.0

Table 8.22: Prevalence of stunting based on height-for-age z-scores and by sex (municipality Kapatagan, November/December 2010)
All n = 807 (383) 47.5 % (42.6 - 52.4 95% C.I.) (242) 30.0 % (26.6 - 33.6 95% C.I.) (141) 17.5 % (14.6 - 20.8 95% C.I.) Boys n = 423 (192) 45.4 % (39.6 - 51.3 95% C.I.) (118) 27.9 % (24.2 - 31.9 95% C.I.) (74) 17.5 % (13.7 - 22.0 95% C.I.) Girls n = 384 (191) 49.7 % (43.1 - 56.4 95% C.I.) (124) 32.3 % (26.8 - 38.3 95% C.I.) (67) 17.4 % (13.8 - 21.8 95% C.I.)

Prevalence of stunting (<-2 z-score) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) Prevalence of severe stunting (<-3 z-score)

Table 8.23: Prevalence of stunting by age based on height-for-age z-scores (municipality Kapatagan, November/December 2010)
Severe stunting (<-3 z-score) Age (mo) 6-17 18-29 30-41 42-53 54-59 Total Total no. 186 174 182 177 88 807 No. 20 30 33 43 15 141 % 10.8 17.2 18.1 24.3 17.0 17.5 Moderate stunting (>= -3 and <-2 zscore ) No. % 48 51 62 54 27 242 25.8 29.3 34.1 30.5 30.7 30.0 Normal (> = -2 z score) No. 118 93 87 80 46 424 % 63.4 53.4 47.8 45.2 52.3 52.5

Table 8.24: Mean z-scores, Design Effects and excluded subjects (municipality Kapatagan, November/December 2010)
Indicator n Mean z- Design Effect z-scores not z-scores out

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scores SD (z-score < -2) Weight-for-Height 831 -0.640.85 1.15 Weight-for-Age 830 -1.690.96 1.57 Height-for-Age 807 -1.951.14 1.96 * contains for WHZ and WAZ the children with edema.

available* 66 66 66

of range 5 6 29

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