1. Nutrition at the Center May 2014

2. Understand findings of the baseline survey Describe and discuss analyses for programmatically important questions Consider implications for program design and implementation Build capability in using data for decision-making

3. People’s situation at the beginning of the program – Allows program to set targets for indicators – Provides a comparison with endline data – Approach is descriptive Who is at risk for poor outcomes and who is most likely to have poor health behaviors – Allows the program to target those at higher risk – Identifies what interventions the program should focus on to have the greatest impact – Approach is analytic

4. VariableInterventionControl Maternal age 20-3473%75% Married85%88% Female headed HH13% 9% Able to read10%15% Own agricultural land73%91% Own animals82%85% Food from social transfers 9%43%

5. Program Intervention N=1277 Control N=855 Food for work21%46% School feeding program 8%10% Plot to grow food for HH consumption 7%14% Seeds 9%18% Ag tools/implements 3% 5% Livestock 3% 7% Poultry 2% 7% Latrine (new or renovated) 9%21% Water pump for irrigation 2% 4%

6. Poverty defined by quintiles – each 20% of the population – as used in the DHS Calculation based on composition of house, WASH facilities and ownership of assets Often differences between lowest quintiles is small – other categories such as “below poverty line” may be useful to analyze LowestLow middleHigh middleMiddleHighest

7. Poverty Quintile Percent

8. Poverty Quintile Percent

9. Poverty Quintile Percent

10. InterventionControl Stunting (6-35 mo)50%52% Wasting (6-35 mo)32%29% Height-for-age compared with WHO standard (boys/girls)

11. InterventionControl Low BMI (<18.5)28%24% Low MUAC (<22.5)31%33% Anemia (Hb <12) 8%10% 2011 Ethiopia DHS reports 17% of women anemic in Amhara About half of women reported taking iron tablets during pregnancy

12. IndicatorInterventionControl Feeding for 0 – 5 month olds Early breastfeeding Exclusive breastfeeding 72% 75% 78% 80% Feeding for 6 – 23 month olds Intro of food by 6-8 mo Minimum dietary diversity 99% 10% 87% 9% Is poor complementary feeding a result of knowledge and behavior or a consequence of food insecurity?

13. Examples of questions to answer Who is at risk for poor nutritional outcomes? Is poor complementary feeding due to poor feeding behaviors or to food insecurity? Does poor sanitation increase the risk of diarrhea or stunting? Potential Predictor Outcome ?

14. http://www.openepi.com/v37/ TwobyTwo/TwobyTwo.htm Assess whether the potential predictor is significantly associated with an outcome using a 2 x 2 table

15. 130 (30%) 391 (23%) 1301 310 EE Risk Score* High Med/ Low Diarrhea in Past 2 Weeks YesNo P <0.01 *Score includes animal ownership, keeping animals in the house at night, eating soil or chicken feces, and open defecation

16. VariableLevelsHunger – Yes Head of household (HH)Female19% Male 6% Agricultural land ownershipNo16% Yes 6% Animal ownershipNo15% Yes 6% PovertyPoorest 40%12% Richer 60% 5% Home gardenNo 8% Yes 6% All differences are statistically significant

17. VariableAdequateNot adequate Meal frequency53%47% Dietary diversity 5%95% Children 6-23 months old VariableLevelsPercent Adequate meal frequency Hunger – no58% Hunger - yes35% Minimum dietary diversity Hunger – no 5% Hunger - yes 1%

18. MotherChildInterpretation Eats Food in HH – no food insecurity Does not eat No food in HH – food insecurity* EatsDoes not eatFamily choice who eats Does not EatEatsFamily choice who eats If a child does not eat a food group, it is because of food insecurity (not available or not affordable) or because the family chooses not to give the child that food (behavior)? *May also represent family choice not to eat a food group or possibly the father eats the food but the mother and child do not

19. Both eat Mother only eats Neither eats Child only eats Child Eats Food Group Yes No Mother Eats Food Group YesNo

20. Food group Both eat Neither eats Mother only eats Child only eats Grains85%015%0 Vit A rich 4%85% 9%2% Other F & V 5%58%36%2% Legumes54%10%30%6% Meat 3%86% 9%2% Eggs 3%89% 2%6% Dairy 3%89% 4%5% Families with children 6-23 months old

21. Sanitation facilities – Improved toilet – 30% – Open defecation – 31% (Intervention 38%, Control 20%) Child behaviors – Eat soil – 33% (In last 30 days 14%) – Eat chicken feces – 6% (In last 30 days 3%) – Open defecation – 71% (In or outside of house & yard)

22. Risk score = 1 point each for owning animals, keeping animals in the house at night, child eating soil or chicken feces, and open defecation High score (3 or 4) significantly associated with diarrhea in the past 2 weeks and low maternal BMI High score not associated with child stunting or anemia

23. Program Intervention N=1277 Control N=855 Food for work21%46% School feeding program 8%10% Plot to grow food for household consumption 7%14% Seeds 9%18% Ag tools/implements 3% 5% Livestock 3% 7% Poultry 2% 7% Latrine (new or renovated) 9%21% Water pump for irrigation 2% 4%

24. 24 (5%) 61 (9%) 610 425 Participation in Community WE Program Yes No HH Hunger YesNo P =0.02

25. Independent variablesOdds RatioP-value Male (ref female) 1.40.03 Age of marriage <18 yrs (ref >18rs) 1.60.01 Low maternal BMI (ref normal BMI) 1.40.04 No association with poverty, head of household, women dietary diversity, PSNP enrollment, household hunger scale, access to unshared improved water, EE risk score, and mother’s or child’s minimum dietary diversity Contractor Report – Multivariate Analysis

26. There are some differences between the intervention and control areas that will make comparison difficult There is a high rate of EBF and continued BF Female headed HHs are a high risk group Children’s dietary diversity is very poor – The only foods eaten by a majority of children are grains and legumes – Fewer than 1 child in 10 eats meat, eggs, dairy, vitamin A rich foods and other fruits and vegetables – From comparing with mothers’ diets, most of this is due to food insecurity

27. N@C formative research 2011 Demographic and Health Survey Alive and Thrive (A & T) baseline survey

28. Exclusive BF – Some pre-lacteals; some encouragement to feed at ~4 mo Complementary feeding & dietary diversity – Some foods not acceptable for children – greens, cabbage, chick peas, possibly mango & papaya (young women are more likely to say these are okay than older women) – Greens, Vit A rich foods, meat & animal products seldom eaten due to seasonal availability and cost – Fruit and eggs are sold to but other foods – Husbands have priority for meat when it is available

29. Limitations to HH food production for own consumption – Lack of water, cost of inputs – food often grown to sell Handwashing – Baseline survey – most respondents reported handwashing at recommended times – Observation in FR – “Handwashing is rare” Sanitation – Latrines are common but not sure whether they are being used – No open defecation was observed – Animal feces common around houses and animals often kept in the house at night

30. Stunting in Amhara – 52% – Relatively similar nationally in lowest 4 wealth quintiles (45- 49%) and only lower in wealthiest quintile (30%) – Significantly associated with mothers’ low BMI Exclusive BF – 52% (with predominant BF 75%); and high rates of continued BF (96% at 1 yr) Complementary feeding is very poor; 6-23 mo diets: – Grains – 66%; Vit A rich – 15%; Other F & V – 3%; Legumes – 20%; Animal foods – 5%; Eggs – 8%; Dairy 13% – Adequate frequency – 49%; adequate diversity – 5% Anemia in Amhara (children) – 35% Open defecation – 45%

31. A & T in Tigre and SNNPR Exclusive BF – 70% and continuation “universal” – Problems breastfeeding only 7% “Half” adequate CF meal frequency but only 6% adequate dietary diversity – CF knowledge poor on when to introduce foods “Two-thirds” of HH experienced some food insecurity and 15% “extremely food insecure”

32. Given low consumption of iron rich foods (animals, greens), why aren’t more women and children anemic? When neither children nor mothers eat a food, is this because the food isn’t available, is too expensive, or is eaten by the man? When women eat a food but the child doesn’t, why not? What are the barriers? What dietary factors and other exposures are linked with stunting?

33. Identification and targeting of those at greatest risk? Approaches to increase availability of nutritious foods? Approaches to increase giving nutritious foods to infants and young children? Importance of maternal nutrition before and during pregnancy (and during lactation)?