Analysis of Baseline Data:Ethiopia

Nutrition at the Center

May 2014

Objectives of the Session

• 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

What Can We Learn from Baseline Data?

• 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

Description of the Population

Variable Intervention ControlMaternal age 20-34 73% 75%

Married 85% 88%

Female headed HH 13% 9%

Able to read 10% 15%

Own agricultural land 73% 91%

Own animals 82% 85%

Food from social transfers 9% 43%

Participation in Safety Net Programs

Program Intervention N=1277

ControlN=855

Food for work 21% 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%

Defining Poverty

• 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

Lowest Low middle High middleMiddle Highest

Female Headed HH are More Likely to be Poor

Low Low mid Middle High mid High0

5

10

15

20

25

30

35

Female headed HH

Poverty Quintile

Per

cent

Poor Families are Less Likely to Participate in PNSP

Low Low mid Middle High mid High05

1015202530354045

Participation in PNSP

Poverty Quintile

Per

cent

Poor Families are Less Likely to Own Land or Animals

Low Low mid Middle High mid High0

20

40

60

80

100

120

Land (black) & Animal (red) Ownership

Poverty Quintile

Per

cent

Child Anthropometry

Intervention ControlStunting (6-35 mo) 50% 52%Wasting (6-35 mo) 32% 29%

Height-for-age compared with WHO standard (boys/girls)

Maternal Undernutrition

Intervention ControlLow 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

Description of Feeding Practices

Indicator Intervention ControlFeeding 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?

Analytic Results

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

?

Testing for Statistical Significance

http://www.openepi.com/v37/TwobyTwo/TwobyTwo.htm

Assess whether the potential predictor is significantly associatedwith an outcome usinga 2 x 2 table

Statistical Testing: Environmental Enteropathy (EE) Risk Score and Diarrhea

130(30%)

391(23%) 1301

310

EE RiskScore*

High

Med/Low

Diarrhea in Past 2 WeeksYes No

P <0.01

*Score includes animal ownership, keeping animals in the house at night,eating soil or chicken feces, and open defecation

What are Risk Factors for HH Hunger?Variable Levels Hunger – YesHead of household (HH) Female 19%

Male 6%Agricultural land ownership No 16%

Yes 6%Animal ownership No 15%

Yes 6%Poverty Poorest 40% 12%

Richer 60% 5%Home garden No 8%

Yes 6%

All differences are statistically significant

Complementary Feeding

Variable Adequate Not adequateMeal frequency 53% 47%

Dietary diversity 5% 95%

Children 6-23 months old

Variable Levels PercentAdequate meal frequency

Hunger – no 58%

Hunger - yes 35%

Minimum dietary diversity

Hunger – no 5%

Hunger - yes 1%

Who Eats What Food in the Family?

Mother Child InterpretationEats Eats Food in HH – no food insecurity

Does not eat Does not eat No food in HH – food insecurity*

Eats Does not eat Family choice who eats

Does not Eat Eats Family choice who eats

If a child does not eat a food group, it is because of foodinsecurity (not available or not affordable) or because thefamily 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

Food Group Eaten by Mothers andChildren 6-23 months

Both eat

Motheronly eats Neither eats

Childonly eats

Child EatsFood Group

Yes

No

Mother Eats Food GroupYes No

Food Insecurity or Feeding Behaviors?

Food group

Both eat

Neither eats

Mother only eats

Child only eats

Grains 85% 0 15% 0

Vit A rich 4% 85% 9% 2%

Other F & V 5% 58% 36% 2%

Legumes 54% 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

Sanitation Facilities & Behaviors

• 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)

Environmental Enteropathy Risk?

• 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

Participation in Safety Net Programs

Program Intervention N=1277

ControlN=855

Food for work 21% 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%

Participation in Women’s Empowerment Program and HH Hunger

24(5%)

61(9%) 610

425Participation

in CommunityWE Program

Yes

No

HH HungerYes No

P =0.02

Risk Factors for Child Stunting

Independent variables Odds Ratio P-value

Male (ref female)

1.4 0.03

Age of marriage <18 yrs(ref >18rs)

1.6 0.01

Low maternal BMI(ref normal BMI)

1.4 0.04

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

What Are Some Important Things We’ve Learned from the Baseline Survey?

• 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

Triangulation with Other Ethiopia Data

• N@C formative research

• 2011 Demographic and Health Survey

• Alive and Thrive (A & T) baseline survey

Are Survey Data Consistent with the Formative Research? (1)

• 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

Are Survey Data Consistent with the Formative Research? (2)

• 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

Are Survey Data Consistent with the 2011 DHS?

• 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%

Are Survey Data Consistent with A & T?

• 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”

What Additional Information Would be Useful? What Questions Remain?

• 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?

What Are the Implications for Program Design and Implementation?

• 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)?