1. Alive &Thrive IYCF Outcome Evaluation in Ethiopia
Yared Mekonnen, PhD
Mela Research PLC
November 20, 2012
Addis Ababa

2. Presentation outline Evaluation objectives Study design Methodology
Coverage and frequency of Timed & Targeted Counseling (TTC)
Program impact on key outcome indicators
Summary
Conclusion
Study teams
Acknowledgments

3. Evaluation Objective
The overall objective of this endline survey is to assess the impact of the A&T program intervention in the implementation Woredas in SNNPR primarily concerning on Infant and Young Child Feeding Practices (IYCF).

4. Focus Indicators
Infant and young child feeding practices of children 0 to 5 and 6 to 23 months that include:
Knowledge of IYCF
Early initiation of BF,
Colostrum feeding
Exclusive breastfeeding,
Timely introduction of complementary feeding,
Minimum Meal Frequency
Minimum Dietary Diversity
Minimum Acceptable Diet
Continuation of breastfeeding
Nutritional status of children
Other indicators of interest include utilization of ANC, immunization of children, among others

5. Study design (Non-equivalent control group design)
HEP
Intervention area
4 Woredas
Intervention area
4 Woredas +
A&T intervention
[Peer Mothers /TTC]
Control area
4 Woredas
Control area
4 Woredas
HEP
No A&T intervention
Aug.-Sept
(Baseline)
Aug.-Sept
(Endline)

6. Methodology A two-stage cluster sampling method A cluster is a Kebele
A 40 by 40 factorial design was implemented (40 respondents in 40 Kebeles).
20 in the intervention & 20 in the control
Target respondents per Kebele:
20 women with children 0-5 months
20 women with children 6-23 months

7. Selection of Kebeles
Two reporting domains (1) Intervention area & (2) Control area
Kebeles were selected separately for the intervention and control area
All Kebeles in the respective areas were used as sampling frame
A total of 40 Kebeles (20 in the intervention and 20 in the control area) were selected using probability proportion to size (PPS)
The same Kebeles were surveyed at baseline and endline

8. Household selection procedure
The selection of households was based on systematic sampling with a random start.
We anticipated to find children age 0-23 months in every tenth household (DHS).
The number of households and women in the Kebele were obtained from the HEWs to serve as sampling frame.
Households with children 0-23 months were eligible for the interview

9. Sampling procedure Intervention Control 4 Woredas 4 Woredas 20 Kebeles
20 children:
0-5 months
(per Kebele)
20 children:
6-23 months
(per Kebele)
20 children:
0-5 months
(per Kebele)
20 children:
6-23 months
(per Kebele)
800 children
800 children

10. Questionnaire
It is a structured and pre-coded questionnaire containing 44 pages.
It collected information on various issues:
Background information
Household food security and economic status
Household water supply and sanitation
IYCF knowledge and practice
Childhood illness and treatment, antenatal care, vaccination status, types and frequency of foods consumed, iron and vitamin A supplementation status.

11. Anthropometric measurements for children and women
Weight of the children were measured with minimum clothing and without any ornaments on a digital scale to the nearest 0.1 kg (WHO recommendation).
Laying length of under two children measured on a wooden board to the nearest 0.1 cm.
Standing height of children older than two years was measured without shoes or anything on the head on a wooden board to the nearest 0.1 cm,
Women' nutritional status was assessed using Body mass index (BMI).
Women's height was measured on a wooden board to the nearest 0.1 cm with a minimum clothing.
Weight will be measured using digital scale.
Data collection – 30 days (September)

12. Method of analysis Difference-in-difference (DID)
Binary Logit Model with dummy-by-dummy interaction effect (Multivariate)
DID estimate (%)
Visualizing interaction effect (graphical presentation)
Static Group Comparison
Exposed vs. unexposed to TTC in the intervention area
Data entry & analysis software
EPI-INFO for data entry
STATA 11 for data nalysis (developed Syntax and do files)

13. Difference-in-Difference (DID) Estimate Indicator XP3
(P3-P1)
DID=(P3-P1) - (P4-2) P1
(P4-P2) P4 P2
DID= (C-A) - (D-B)

14. Difference-in-Difference (DID) Estimate Indicator XP3
(P3-P1)
DID=(P3- P1)-(P4-P2)
P1=P2
DID=P3 – P4 P4 P1
(P4-P2) P2

15. Difference-in-Difference (DID) Estimate Indicator XP3 P4
DID=(P3-P1) - (P4-P2)
(P4-P2)
(P3-P1) P2 P1

16. Coverage and frequency of Timed & Targeted Counseling (TTC)

17. % of women visited by peer mothers according to number of visits (In the intervention area) – n=800

18. % women visited by peer mothers (for their most recent child age 0-23 months) – in the intervention areas

19. Type of information received during the TTC visit (during 3rd trimester & at delivery)
Intervention area
At the Third Trimester:
Putting baby on the breast immediately within 1st hr
Giving colostrums to the baby
Pre-lacteal feeding is not necessary
The benefit of feeding only breast milk first 6 months
At the day of birth :
86.7
87.3
78.4
74.2
79.7
86.1

20. Type of information received during the TTC visit (at the 4th and 6 months)
Intervention area
At the 4th month after birth:
Feed only breast milk up to six months
Consulting health professional if any problem
Monitoring Infant weight gain
Waiting up to six month to start supplementary feeding
At the 6th month after birth:
Introducing complementary feeding
Continuing breastfeeding
88.4
75.8
60.0
83.7
96.9
82.2

21. Type of information received
Type of information received during the TTC visit (at the 8th and 12 months)
Type of information received
Intervention area
At the 8th month after birth:
Introducing complementary feeding
Continuing breastfeeding
Monitoring Infant weight gain
At the 12th month after birth:
87.2
92.8
73.4
98.6
79.2

22. Program impact on key outcome indicators

23. The intervention has a net positive effect on women’s knowledge of key breastfeeding practices……

24. Multivariate Logistic Regression coefficient (β) -Interaction term (DID)
Knowledge of breastfeeding practices
Breastfeeding should start within an hour β
Colostrums should be fed
Fluid should be started at age 6th month
Food should be started at age 6th month
Study time
Baseline (2010)-ref
Endline (2012)
Study arm
Control -ref
Intervention
Interaction/DID
(time X arm)
0.00
1.64***
0.23*
0.36
0.80***
-0.28*
0.61***
0.42***
0.13
0.59***
0.05
0.21
0.49*
*p<0.05, ***p<0.0001; MV adjusted for several factors

25. % who said BF should be started immediately after birth
DID=1.8 %
(Not significant)
DID=1.8 % (Not significant)

26. % who said colostrum should be fed
DID= 12.3%
DID estimate= 12%

27. % who said fluid should be started at 6 months
DID= 10%

28. % who said food should be started at 6 months
DID=8 %
DID=8 %

29. The intervention has a net positive effect on key breastfeeding practices ….. -Early initiation of BF -Colostrum feeding -Pre-lacteal Feeding -Exclusive BF

30. Multivariate Logistic Regression Coefficient (β) -Interaction term (DID)
Breastfeeding practices
Initiation of breastfeeding within an hour
(0-23 months) β
Colostrums feeding
Pre-lacteal feeding
Exclusive breastfeeding up to age 6 months
(0-5 months)
Study time
Baseline (2010)-ref
Endline (2012)
Study arm
Control -ref
Intervention
Interaction/DID
(time X arm)
0.00
0.22
-0.03
0.38*
0.05
0.17
0.67***
-0.83***
-0..14
-0.75***
0.81***
-0.28
0.47*
*p<0.05, ***p<0.0001; MV adjusted for several factors

31. % who initiated BF within 1 hr
DID=6%
DID=6%

32. % who fed colostrum
DID=11.3%
DID=11.3%

33. % who gave pre-lacteal feeding
DID=3.1%
DID=(-)3.1%

34. % with exclusive BF (0-5 months)
DID=9.8%
DID=9.8%

35. No evidence of program impact on meal Frequency, food diversity and acceptable diet…..

36. % Minimum Meal Frequency (6-23 months)

37. % Minimum Dietary Diversity (6-23 months)
DID=3.3%
DID=3.3%
Not significant

38. % Minimum Acceptable Diet (6-23 months)

39. No evidence of decline in the prevalence of stunting among children 6-23 months….. Significant declining trend in the prevalence of wasting and underweight in the intervention area…

40. Nutrition status (6-23 months)
Multivariate Logistic Regression Coefficient (β) -Interaction term (DID)
Nutrition status (6-23 months)
Stunting
(6-23 months) β
Wasting
Underweight
Study time
Baseline (2010)-ref
Endline (2012)
Study arm
Control -ref
Intervention
Interaction/DID
(time X arm)
0.00
0.41*
-0.02
0.29
-0.25
-0.69*
0.30
0.10
-0.63*
*p<0.05, MV adjusted for several factors

41. Prevalence of stunting (among children 6-23 months) did not change significantly in both the intervention and control area

42. Net significant decline in wasting in the intervention area
DID= -3 %
DID= (-)3 %

43. Net significant decline in underweight in the intervention area
DID=(-)5.2 %

44. Net positive gain in child immunization and ANC coverage in the intervention area…..

45. Net positive increase in the proportion of children fully vaccinated in the intervention area
DID=17.8%
DID=16%

46. Net positive increase in ANC uptake in the intervention area
DID=7.8%
DID=6%

47. High exposure to TTC is associated with better outcome…..

48. Exposure to TTC by peer mothers & knowledge of BF practices

49. Visit at the 3rd trimester or at delivery (by peer mother) and initiation of BF within 1 hr, Colostrum feeding and pre-lacteal feeding

50. Visit before 6 months and exclusive BF

51. MMF, MDD and MAD by exposure to TTC

52. Summary The intervention has a net positive effect on the following …
knowledge of IYCF
breastfeeding practices
early initiation of breastfeeding,
colostrum feeding,
pre-lacteal feeding
exclusive breastfeeding
use of maternal and child health services (e.g. ANC and child immunization)
Wasting and underweight (among 6-23 months) declined in the intervention area ????

53. Summary
No evidence of program impact on dietary diversity and meal frequency
Exposure to the TTC positively and significantly associated with better outcome
Women who received TTC visit have significantly better IYCF knowledge, IYCF practices and use of other maternal; and child health services.

54. Summary Coverage with at least one TTC visit is only 46%
Missed opportunity for TTC visit is high (~54%)
Only 32% of the mothers were visited by PMs when their children were 6 months old.

55. Conclusion
The findings of this evaluation suggest that when rural mothers are exposed to a timed and targeted counselling on IYCF by volunteer peer mothers, it is likely that their knowledge and behaviour regarding IYCF will improve.
To achieve the maximum possible impact of the intervention…
peer mothers should be able to reach out to more women and maintain scheduled visits
program should find ways to improve the staggeringly low dietary diversity for children in the study area. Counseling alone may not be adequate to improve dietary diversity.

56. Ethical Clearance SNNP regional Health bureau
Participation was based on Informed Consent

57. Mela study team 1 Lead Researcher (PhD) 1 Senior Nutritionist (PhD)
2 Field coordinators (1 for 4 Woredas)
4 Field supervisors (1 per team)
16 Interviewers
8 Anthro. Measurers
5 Land cruisers
1 Data Manager
2 Data Coders
4 Data entry clerks
Data collection – 30 days (September)

58. Acknowledgments World Vision Ethiopia
The SNNP regional health bureaus and the Woredas
World Vision A&T team in SNNPR
The HEWs, peer mothers in the study Kebeles
The Women and their children who participated in the study
Data collection teams
Data entry clerks and coders