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)?
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