GRADUATION WITH RESILIENCE TO ACHIEVE SUSTAINABLE DEVELOPMENT

Nutrition Baseline Report

By

Solomon Bogale

February 2014

Addis Ababa

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Table of Contents

ABBREVIATIONS V

ACKNOWLEDGMENTS VI

EXECUTIVE SUMMARY VII

1. Introduction 1

1.1 Background 1

1.2 National nutrition strategy: overview 2

1.3 GRAD project overview 3

1.4 GRAD nutrition component overview 3

2. METHODOLOGY 5

2.1 Research Question 5

2.2 Study location 5

2.3 Indicators selection 5

2.4 Sampling method and size 5

2.5 Data collection methods 6

2.6 Training and pre-testing 7

2.7 Data management and analysis 7

3. RESULTS 7

3.1 Description of the study samples 7

3.2 Breastfeeding of children less than 6 months 8

3.2.1 Initiation of breastfeeding 8

3.2.2 Exclusive Breastfeeding 9

3.2.3 Initiation of feeding of solids semi solids and soft foods 10

3.3 Feeding of children 6-23 months of age 11

3.3.1 Continued breastfeeding at 23 months of age 11

3.3.2 Complementary feeding practices 12

3.3.3 Minimum Acceptable Diet 15

3.4 Women dietary diversity scores (WDDS) 16

3.5 Nutritional knowledge attitude and practices 17

3.5.1 VESA and nutrition education 17

3.5.2 Maternal conditional dietary change 18

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3.5.3 Breastfeeding intensity 18

3.5.4 Hand washing practices 19

3.5.5 BCC and cooking awareness 20

3.5.6 GRAD Value Chain and Income Generating Activities 20

4. DISCUSSION 21

4.1 Methodological limitations 21

4.2 Breastfeed initiation and breastfeeding 22

4.3 Exclusive breastfeeding 23

4.4 Continued breastfeeding 24

4.5 Complementary feeding 24

4.6 Dietary diversity and meal frequency 25

4.7 Minimum acceptable diet 25

4.8 Maternal dietary diversity 26

4.9 Nutritional knowledge attitude and practices 27

CONCLUSIONS AND RECOMMENDATIONS 27

REFERENCE 28

ANNEX 32

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List of Tables

Table 1: Summary of sample by indicator ..................................................... 6

Table 2: Samples by sex and age ................................................................. 8

Table 3: Initiation of breastfeeding by location (%) ........................................ 8

Table 4: Exclusive breastfeeding by age group (%) ........................................ 9

Table 5: Percentage of children less than 6 months of age feeding on breast, liquids, SSS foods in the previous day and night .............................. 11

Table 6: Percentage of children 6-23 months of age who continued breastfeeding .............................................................................. 12

Table 7: Complementary feeding initiation by age category (%) .................... 12

Table 8: Proportion of children who consumed various food groups in the previous day and night ................................................................. 14

Table 9: Infant and young child feeding practices (%) .................................. 16

Table 10: Proportion of women in the studied areas consuming various food

groups ....................................................................................... 17

Table 11: Participation in VESA and nutrition education by location ................ 17

Table 12: Proportion of mothers with diet change and feeding practices

during pregnancy/lactation (%) ..................................................... 18

Table 13: Change in frequency of breastfeeding of children less than

23 months of age ....................................................................... 18

Table 14: Proportion of households with hand washing practices (%) ............. 19

Table 15: Behaviour change communication, cooking demonstration and garden vegetable production practices (%) .............................................. 20

Table 16: Participation in GRAD’s IGA or VC activities (%) ............................ 21

List of Figures

Figure 1: Duration for initiation of breastfeeding (%) ...................................... 9

Figure 2: Exclusive breastfeeding by location (%) .......................................... 9

Figure 3: Exclusive breastfeeding by age (%) .............................................. 10

Figure 4: Initiation of complementary feeding by age group (%) .................... 10

Figure 5: Continued breastfeeding by age category (%) ................................ 11

Figure 6: Complementary feeding initiation by age (%) ................................ 13

Figure 7: Proportion of children who consumed various food groups (15) during the preceding 24 hours. .................................................... 13

Figure 8: Percentage of breastfed children feed on various food groups in

the previous day and night .......................................................... 14

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Figure 9: Percentage of non-breastfed children feed on various food groups

in the previous day and night ....................................................... 15

Figure 10: Mininimum acceptable diet (%) for children aged 6-23 months ...... 15

Figure 11: Proportion of women consuming different food groups (14) during

the preceeding 24 h ................................................................. 16

Figure 12: Changes in breastfeeding intensity ............................................. 19

Abbreviations BCC Behaviour Change Communication

CARE Cooperative for Assistance and Relief Everywhere

CRS Catholic Relief Services

CSA Central Statistical Agency

DD Dietary Diversity

EDHS Ethiopian Demographic and Health Survey

EBF Exclusive Breastfeeding

ENA Essential Nutrition Actions

FANTA Food and Nutrition Technical Assistance

FtF Feed the Future

GRAD Graduation with Resilience to Achieve Sustainable Development

HDDS Household Dietary Diversity Score

HH Household

HHS Household Hunger Scale

HI Home Improvement (maintenance)

IGA Income Generating Activity

IYCF Infant and young child feeding

MAD Minimum Acceptable Diet

MCS Meki Catholic Secretariat

MOH Ministry of Health

MMF Minimum Meal Frequency

NNS National Nutrition Strategy

NNP National Nutrition Plan for Ethiopia

ORDA Organization for Rehabilitation and Development in Amhara

PSNP Productive Safety Net Program

REST Relief Society of Tigray

PSNP Productive Safety Net Program

SNNPR Southern Nations, Nationalities, and People’s Region

SNV Netherlands Development Organization

SSS Solid semi-solid and soft foods

USAID United States Agency for International Development

VESA Village Economic and Social Association

VC Value Chain

WDDS Women Dietary Diversity Score

WHO World Health Organization of the United Nations

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Acknowledgments

The GRAD Project “Graduation with Resilience to Achieve Sustainable

Development” is being funded by the United States Agency for International Development (USAID). The Program is led by CARE, and implemented by CARE,

Catholic Relief Services (CRS) and partners Meki Catholic Secretariat (MCS), the Organization for Rehabilitation and Development in Amhara (ORDA), the Relief Society of Tigray (REST) and Agri-Servie Ethiopia. Technical partners include the

Netherlands Development Organization (SNV) and the Feinstein International Center, Tufts University. This report presents the findings of a nutrition baseline

survey of the GRAD project. The content of this report is derived from this

baseline that was carried out by CARE with support from the Feinstein International Center, Tufts University and funded by USAID under the GRAD

project.

The author would like to thank Mr John Mayer, Chief of Party for GRAD project and Teferra Mekonen from CARE Ethiopia as well as Mr John Burns from Tufts

University for supporting this study from its inception. The author would also like

to thank Mr Girmay Abadi from CRS for leading the fieldwork in Hawasa Zuria and Zeway Dugda, and reviewing the manuscript. I also appreciate Mr Behailu

W/ Giorgis from ENGINE Project for his contribution during planning period and

manuscript review.

Special thanks goes to the CARE Sidama in Hawassa, REST in Maichew, MCS in

Meki and ORDA Lay Gayint Project offices for their hospitality and supporting the

assessment. In particular, I would like to acknowledge Mr Demeke Eshete, Haftay Kahsay, Bedaso Endale and Girma Zewde who are project coordinators in

the study areas. I would also like thank Eden Getahun, Sisay Oljira, Tigist Abegaz, Senbeto Bonsa, Tesfu Kiros, Getnet Abie and Yezez Minuye for their field level and administrative supports.

I appreciate the contribution of CARE Debre Tabor Office, in particular Mr. Endalk

Molla for his transport services and administrative supports. Community

facilitators in the project areas as well as enumerators are highly acknowledged. Finally, I would like to thank the assessment participants for their hospitality,

time and valuable contributions.

Disclaimer This report was made possible through the generous support of the American

people through the United States Agency for International Development (USAID). The contents are the responsibility of CARE and its GRAD partners and

do not necessarily reflect the views of USAID or the United States Government.

The report was prepared by Solomon Bogale of the Feinstein International Center. The GRAD consortium partners have not endorsed the contents of this

report nor do they necessarily reflect the views of these organizations.

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Executive Summary

This report presents the findings of a nutrition baseline survey for GRAD project.

Launched in 2012, the GRAD Project “Graduation with Resilience to Achieve Sustainable Development” is being funded by the United States Agency for

International Development (USAID). The Program is led by CARE, and implemented by CARE, Catholic Relief Services (CRS) and partners Meki Catholic Secretariat (MCS), Agri-Service Ethiopia, the Organization for Rehabilitation and

Development in Amhara (ORDA) and the Relief Society of Tigray (REST). The consortium also includes technical partners, the Netherlands Development

Organization (SNV) and the Feinstein International Center, Tufts University. The

goal of GRAD is to sustainably graduate at least 50,000 households from the Productive Safety Net Program (PSNP).

This report presents the findings of a nutrition baseline survey that was carried

out by CARE from Mid October to November 2013. The assessments were carried out in Enda Mohoni woreda in Tigray, Zeway Dugda in Oromia, Lay

Gayint in Amhara and Hawasa Zuria in SNNPR. This report documents the

measurement of dietary diversity, meal frequency, minimum dietary diversity, maternal dietary diversity score and selected Infant and Young Child Feeding

(IYCF) practices and some project related indicators/key activities. Thus,

objectives of the study were:

• To assess breastfeeding practices among children aged 0-5 months

• To assess dietary diversity, meal frequency and minimum acceptable diet

among infant and young children aged between 6 and 23 months

• To assess dietary diversity of reproductive age women in the study area

• To assess the level of maternal knowledge, attitude and practices on selected

IYCF practices

Some specific outcomes of the nutrition baseline study were as follows:

The results show that about 99.1% of the children were ever breastfed. From

the total children less than 6 months of age, 98.6% of them were breastfed

during survey time. Initiation of breastfeeding within 1-hour of birth was reported by 80.6% of women while 16.6% of them started breastfeeding after

one hour after birth. Around 3% of the mothers initiated breastfeeding a day

after birth.

The findings confirmed that about 69.7% of the children were exclusively breastfeed, and ranged from 57.1% at Enda Mohoni to 82.4% at Lay Gayint in

the area. The EBF has reduced from 89.1% at one month of age to 39% at around 5 moths of child age. For this study, EBF was 89.9 for children 0-3 and

56.5% for 4-5 months of age respectively.

Mostly, EBF under 6 months was disrupted by early introduction of water to

infants. Unacceptably, a total of 30.3% of the mothers started complementary

feeding to their children at age of less than 6; with 10 and 43.5% of the mothers

initiated complementary feeding at 0-3 and 4-5 months of age respectively.

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According to mother with children less than 6 months, the mean age for

introduction of complementary foods was at infant stage, 4.5 months.

Majority of the mothers (74.4%) has started complementary feeding for their

children aged between 6 and 8 months, whereby more than half of them started complementary feeding exactly at 6-month of age. To the contrary, about 9.5% of the mothers with children 6-23 months begin complementary feeding at infant

stage. About 15.8% of them reported to commence feeding at around 9 month of age. In line with this, more than 90% of the children fed on foods made from

cereals, roots and tubers for both breastfed and non breastfed children. Animal

source foods mainly eggs and meat were consumed by less than 10% of them. About 84% of the breastfed children were able to consume Vitamin A rich foods

while only few (20.5%) of the non breastfed children consumed from the same

food source in the previous day and night of the survey time.

The current finding indicates that only about 6.6% of the children achieved

minimum acceptable diet (MAD) during the survey period. However, by 6-8

months of age, 59.5% of the breastfed children met MAD, while the non-breastfed children couldn’t at all. About 66% of the children have received

minimum meal frequency while about 17% of the children met the minimum

requirement of dietary diversity, i.e. feeding on four and more food groups.

Roughly, 58.6% of the children consumed less than two food groups while 24.2% of them feed on three food groups. The mean dietary diversity of child

was 2.4 while it was 2.8 for meal frequency.

The mean maternal dietary diversity score was 2.9, and the mean meal

frequency was 2.8 in this study. Out of the 9 food groups, about 28.3% of the females took the minimum dietary diversity. However, about 78.9% of the mothers had a meal frequency of 3 per day. Out of the nine food groups, nearly

40% of the mothers took less than 3 food groups per day. Almost all the respondent females (99.6%) consumed food made from cereas, followed by oils

and fats (65.9%), legumes (64.6%), and roots and tubers (64.3%). Only about

2.6 and 1.7% of the mothers fed on animal source foods- eggs and meat respectively.

The maternal knowledge, attitude and practice as well as their views on some of

the IYCF interventions are summarized below:

• Majority of the respondents participated in Village Economic and Saving Association (VESA). Roughly 90% of the mothers reported to receive

nutrition related education three times for the last year. The project has

been promoting recommended IYCF practices and Essential Nutrition

Action (ENA) through VESA.

• About 60.8% of the mothers had experienced change in their usual diet during pregnancy and lactation periods. However, only 28.5% of them

reported to consume diversified diet during these periods.

• Only 3% of the mothers increased frequency of breastfeeding when a

child is sick, indicating low level of maternal knowledge on increasing

frequency of breastfeeding during child’s sickness.

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• About 61.4% of women washed their hands with water alone while 29.5%

did with soap. Majority (about 83.3%) of them wash their hands when

going for food preparation. About 65% of the interviewers reported to wash their hands after toilet when only around water sources at home.

Lack of enough water in the vicinity and economic reasons to purchase soap frequently were some of the challenges that hinder them to practice sanitation and hygiene requirements.

• About 31.7% females had exposure to IYCF Behaviour Change

Communication (BCC); however less than 20% of women with child under

two years had IYCF tool B kit at home.

• About 65.2% of the mothers participate in cooking demonstration while

53.9% of them able to demonstrate the skills at home. Either lack of

diversified food sources at home from own produce (mainly animal products and key vegetables and fruits) or poor purchasing powers of the

respondents were among the influencing factors not to go beyond cooking

demonstration.

• 55.8% of the women trained on vegetable production. Out of those, only

38.6% of them did grow vegetables at garden. Moisture stress, lack of

irrigation scheme and shortage of seeds were the major influencing factors.

• Half of the sampled households (with child under 24-month) participated in GRAD’s value chain (VC) and income generating activities (IGAs).

Relatively larger respondents (42.5%) were participating in livestock production and the least (0.9%) in beekeeping. However, 23.1% of them were able to purchase food for their children with the income generated

from VCs and IGAs.

Lower MAD rate as low as 6.6% is due to the fact that some of the food groups

particularly animal source foods are far to be reached by farming communities

mainly due to lack of resources to produce or poor purchasing powers. This indicates that not only knowledge gaps but also food insecurity is determinant of

poor nutrition. Likewise, it could not be realistic to go for maternal dietary

improvement alone with giving less attention to food security at household level.

This is because the mothers usually share what they have with their family members during feeding. Maternal nutrition can be improved if and only if food security is achieved at household; this could be attained through minimizing the

root causes for malnutrition and food insecurity at grass root level.

In line with this, the GRAD project interventions designed to assist household

graduation from PSNP program such as value chain and income generating

activities are expected to have a multiplier impact of improving livelihoods and nutritional status at large. This could be an opportunity assisting the mothers to

implement the IYCF practices.

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1. Introduction

1.1 Background

Malnutrition is widespread in Ethiopia, particularly amongst children and women in rural areas, and the underlying cause of 57% of child deaths (SC-UK, 2009).

In early life, malnutrition is responsible for the deaths of millions of young children annually. Any damage caused by nutritional deficiencies during the first two years of life could lead to impaired cognitive development, compromised

educational achievement and low economic productivity (Victoria et al, 2008). Infant malnutrition results in growth retardation and smaller adult stature and

also is correlated with inadequate immune response and increased risk of

childhood mortality.

In Ethiopia, about 27% of women either thin or undernourished indicating that

the level of chronic malnutrition among women is relatively high (CSA and ICF,

2012). Undernourished mothers face greater risks during pregnancy and childbirth, and their children set off on a weaker developmental path, both

physically and mentally. For instance, low birth weight less than 2,500 grams at

birth are the reflection of maternal nutritional status. Likewise, undernourished children have lower resistance to infection and are more likely to die from

common childhood ailments as diarrhoeal diseases and respiratory infections

(IYCN, 2011). The same report pointed out that malnutrition prevents individuals

and even the whole country from achieving full potential, and is closely related

with survival, poverty and development. Similarly, Rao et al (2006) reported that the incidence of dietary inadequacies as a result of dietary habits and

patterns in pregnancy is higher during pregnancy than at any other stage of the

life cycle. And also, poor nutrition reduces the efficiency and amount of schooling

children attain and increases the likelihood of their being poor as adults, if they survive. The human and economic costs are enormous.

According to Black and Bryce (2003), an estimated 6% of under-five deaths can be prevented by ensuring optimal complementary feeding among which dietary

diversity and meal frequency are the most important ones, significantly contributing to the realization of Millennium Development Goal. In Ethiopia, 51%

of infants aged 6–9 months receive complementary food and continued

breastfeeding (CSA and ICF, 2012). However, meeting minimum standards of dietary quality is a challenge in Ethiopia, especially in food insecure areas. Roy

et al. (2007) and Dewey (2008) reported that children may not feed frequently

enough, or the quality of the food may be inadequate where food security is

poor (Roy et al., 2007; Dewey, 2008). Earlier studies revealed that the problem of early stunting in Ethiopia is mainly due to delayed introduction of complementary foods in the first year of life (Getahun et al., 2001). Based on

the Ethiopian Demographic and Health Survey 2011, the national prevalence of stunting among children estimated at 44.4%, the prevalence of underweight at

28.7% and wasting at 9.7%. Similarly, Tesema et al. (2013) found that the

prevalence of stunting was higher (43%) for children aged 6-8 months in Sidama zone.

Previous researches noted that intervention works to address under-nutrition

and scaling up is not happening quickly enough. Also, investment in other

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sectors such as agriculture, social protection, and health systems are not being

leveraged to improve nutrition to the extent that they could be. However, the

problem of malnutrition is correlated to low agricultural production, low and inadequate food consumption. In general, insufficient food availability,

inadequate provision of a healthy environment (e.g., poor water, sanitation and hygiene), maternal wellbeing and quality of caring practices, women’s decision making power and control of resources, and political economy factors are the

major underlying factors and are the key to understanding the causes of child malnutrition in Ethiopia.

Some literatures confirmed that through integrated approaches, known high impact nutrition interventions are expected to be scaled up and intensified. The

integration of nutrition programs with health, food security, education and

poverty reduction programs have been challenging where these entities are

highly interrelated. Good health on the other hand determines work performance of agricultural workers but at the same time is dependent on adequate intake of

nutrients derived from agricultural products. The educational level of

households, particularly of women, has been shown to be critical to ensuring adequate nutritional status of the family, particularly of children and pregnant

women.

1.2 National nutrition strategy: overview

In response to prevalent malnutrition in the country, the Government of Ethiopia launched its first National Nutrition Strategy (NNS) in 2008 thereby achieving a

major step forward in its efforts to tackle persistent malnutrition in the country

(MoH, 2008). Since then, Ethiopia has made remarkable progress in scaling up in child health and nutrition interventions, consequently reversing trends in

child mortality and malnutrition. According to UNIGME (2013) and APR (2013), child deaths were cut by 67% from 204 per 1000 live births in 1990 to 68 per 10004 live births in 2012 achieving millennium development goal (MDG) three

years ahead of time. CSA and ICF (2012) confirmed that between 2000 and 2011 the prevalence of both underweight and stunting of child declined 32 and

23% respectively. The number of children in school trebled from as low as 32%

in 1990s to 96.4% (MoE, 2011). Similarly, people with access to clean water more than doubled, with improved access to safe water for 54% of the

population (CSA and ICF, 2012). In addition, the country has seen the

proportion of people living below the poverty line decline from 44% in 1995 to

30% in 2011 (MoFED, 2012).

Even though the trend is clearly progressing in the right direction, recent reports indicated that under nutrition remains the underlying cause of around half of all child deaths particularly in food insecure areas (ECHO, 2013). As a consequence,

Ethiopian Government needed to accelerate efforts to reach the Health Sector Development Plan’s (HSDP IV) target of reducing the prevalence of stunting to

30% by 2015 (NNP, 2013). Thus, in June 2013, Ethiopia launched an ambitious

and revised National Nutrition Plan for Ethiopia, that seeks to transform the economic and development trajectory of millions of children and their mothers,

by addressing food and nutrition insecurity in the country. The revision process

of the NNP was based on a solid foundation of the current evidence base to

support large scale nutrition programming efforts. Indeed as part of the launch

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activities, the new Lancet child and maternal series for 2013 was also launched

in Ethiopia.

1.3 GRAD project overview

Launched in 2012, the GRAD Project “Graduation with Resilience to Achieve

Sustainable Development” is being funded by the United States Agency for International Development (USAID). The Program is led by CARE, and implemented by CARE, Catholic Relief Services (CRS) and partners Meki Catholic

Secretariat (MCS), Agri-Service Ethiopia, the Organization for Rehabilitation and Development in Amhara (ORDA) and the Relief Society of Tigray (REST). The

consortium also includes technical partners, the Netherlands Development

Organization (SNV) and the Feinstein International Center, Tufts University.

The goal of GRAD is to sustainably graduate at least 50,000 households from

the Productive Safety Net Program (PSNP). By definition, graduation from the

PSNP implies that a household can cope with modest income and food related shocks and still meets its food needs for twelve months of the year (MoARD,

2007). Consistent with this, the project aims to graduate the targeted

households from chronic food insecurity and strengthen their resiliency to cope with income and food related shocks. The project aims to improve people’s

overall productivity, increase on-and off-farm income and create new income

and livelihoods opportunities. In achieving these objectives, it is anticipated that

participating households will experience an increase in assets and improvements in their nutritional status.

1.4 GRAD nutrition component overview

In order to test the GRAD causal model an internal impact study was included as one component of the project’s Performance Monitoring Plan (PMP). Hence,

baseline study for GRAD project was conducted between September-December 2012 in Hawasa Zuria, Zeway Dugda, Lay Gayint and Enda Mohoni woredas. The study approach involves using a pre-post test design to collect panel data at

three points (baseline, midterm, and final) in four of the sixteen GRAD intervention woredas.

GRAD is also implementing nutritional interventions under Intermediate Result

2.2 stated “Nutritional status of infants, children and reproductive age women improved”. In line with this view, the implementing partners (REST, ASE, CARE,

CRS, and ORDA) provided various trainings, orientation and demonstration for

the targeted households and health care providers. A total of 1,292 females

participated on awareness raising sessions on essential nutrition actions (ENA) and hygiene practices. Besides, about 12 food demonstration sessions were conducted in the project areas (GRAD Annual Report, 2013). Based on the same

report, the major activities accomplished by the project are summarized:

• A total of 6,557 pregnant/lactating women were identified and linked to existing government mother support groups

• Support provided to GRAD beneficiaries particularly to women with less than five years children, pregnant and lactating mothers.

• Training was provided to 130 health care providers on Essential Nutrition

Action (ENA), Infant and Young Child Feeding (IYCF) practices and

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integration of Community Management of Acute Malnutrition (CMAM) with

hygiene

• About 24 women animator and 10 women role models were trained on

essential nutrition actions (ENA) messages, supplementary feed

preparation, vegetable production, post-harvesting and storage and adult facilitation skills.

• A total of 13,502 community members attended awareness-raising on

ENA and hygiene practices.

• About 41 demonstrations on nutritional food preparation were undertaken

• A total of 2,467 women from VESA groups participated in various income

generating activities (IGAs) where participation in IGAs is expected to

contribute to nutrition improvement at household level.

With this background, the nutrition baseline is demanded since only the household dietary diversity (HDD) component of the Nutrition was included in the GRAD baseline survey conducted from September to October 2012. Thus,

the GRAD nutrition baseline study was conducted to collect quantitative data on

exclusive breastfeeding (EBF), minimum dietary diversity (MAD) and women

dietary diversity score (WDDS) indicators as well as knowledge attitude and practices on selected IYCF and maternal nutrition practices on GRAD beneficiary

households.

Even though, WHO (2010) indicated several core indicators1 to assess IYCF

practices, only dietary diversity, meal frequency and minimum acceptable diet were taken into account for this baseline survey. Hence, nutritional baseline study was demanded to gather baseline data on three proposed key indicators:

excusive breastfeeding (EBF), minimum acceptable diet (MAD), and maternal dietary diversity score (WDDS) from GRAD households, to track changes over

the project period. Thus, the objectives of the study were:

• To assess breastfeeding practices among children aged 0-5 months

• To assess dietary diversity and meal frequency practices and minimum

acceptable diet among infant and young children aged between 6 and 23 months

• To assess maternal dietary diversity among reproductive age women in the study area

• To determine the level of nutrition knowledge, attitude and practices and nutritional status of reproductive age women in Enda Mohoni, Lay Gayint,

Hawasa Zuria and Zeway Dugda woredas

1Early initiation of breastfeeding, Exclusive breastfeeding under 6 months, Continued breastfeeding

at 1 year, Introduction of solid, semi-solid or soft foods, Minimum dietary diversity, Minimum meal

frequency, Minimum acceptable diet, and Consumption of iron-rich or iron-fortified food.

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2. Methodology

2.1 Research Question

The main research question was: “To what extent has GRAD contributed to improve nutritional status of infants and young children, and reproductive age

women?” More specific research questions2 include:

o What changes in infants and young children feeding have occurred since the nutritional component of the project initiated?

o To what extent has GRAD contributed to improve maternal dietary diversity in the study area?

o What changes in selected IYCF knowledge, attitude and practices have

occurred as a result of the GRAD project?

o What was the relative contribution of project factors to any assessed

nutritional change?

2.2 Study location

The geographical sampling for the survey was limited to the four GRAD baseline study locations; Hawasa Zuria, Zeway Dugda, Lay Gayint and Enda Mohoni

woredas located in the SNNPR, Oromia, Amhara and Tigray Regions,

respectively. Because of its scarce and erratic rainfall and poor soil fertility, the study areas are among the PSNP woredas in Ethiopia. The main rainy season

extends from June to September, usually followed by crop harvesting from late

October to November. Crop harvesting period is relatively late in Lay Gayint.

2.3 Indicators selection

The choice of indicators was based on the GRAD project’s Intermediate Results

framework: “Nutritional status of infants, children and reproductive age women’.

Therefore, the study took Exclusive Breast Feeding (EBF), Minimum Acceptable Diet (MAD) and Women Dietary Diversity Score (WDDS) indicators into

consideration. The indicators were refined during pre-testing.

2.4 Sampling method and size

A two stage stratified sampling technique was employed to identify the study

kebeles for each selected woreda. Participants were selected using simple random sampling. This was done using GRAD beneficiary lists, which identified

reproductive age mothers (15-49 years) as a sampling frame. In this case,

reproductive age mothers as well as mothers with infants and young children (0-23 months) were considered as the sampling frame for each of the indicators.

The sample size was purposively increased in order to achieve an adequate

sample size disaggregated by child’s age and breast-feeding status. The final sample included 1,232 mothers with 347, 425 and 460 respondents being

2The research questions were developed focusing on children less than 2 years and reproductive

age woman, especially on EBF, MAD and maternal dietary diversity

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interviewed for the EBF, MAD and WDDS questionnaires, respectively (see table

1).

Table 1: Summary of sample by indicator

Woreda

Exclusive Breast

Feeding (EBF)

Minimum Acceptable

Diet (MAD)

Women Dietary

Diversity Score (WDDS) Total

Respondents

# of Kebele Respondents

# of Kebele Respondents

# of Kebele Respondents

Hawasa Zuria 14 61 12 63 12 64 188

Zeway Dugda 15 68 16 58 17 65 191

Lay Gayint 15 141 15 193 15 211 545

Enda Mohoni 13 77 14 111 14 120 308

Total 57 347 57 425 58 460 1232

2.5 Data collection methods

Staffing and data gathering period: A team of eight to ten enumerators in each woreda carried out the interviews with support from three supervisors. The

data collection method was face-to-face interviewing on an individual basis using

a standardized questionnaire for each indicator. Each interview took between 15-

20 minutes to complete. Data collection was conducted from 18th of October to 7th of November 2013. Approximately 10 days was spent in each woreda, this

included training and questionnaire pre-test periods.

The Questionnaires: The study used WHO-recommended IYCF indicators and

FtF tools to gather baseline data for key practices such as exclusive breastfeeding (BF) for children aged 0-5 months and minimum acceptable diet among children aged 6–23.9 months (WHO, 2010). Other important information

such as nutrition related knowledge, attitudes and practices. Thus, three separate questionnaires were developed for EBF, MAD and WDDS indicators

(Annex I). The child’s mother, primary care giver, was considered eligible for

interview where each questionnaire is divided into two sections (see Annex I).

Key informant interview: Qualitative information was also collected through personal observations and key informant interviews at Lay Gayint and Enda Mohoni woredas. Hence, a total of 23 women were interviewed to gather key

information mainly on breast feeding and child feeding practices, feeding systems of household members targeting mothers, cultural aspects of feeding

household members, seasonality and so on. These interviews were also used to

collect information on the project and study areas.

Food consumption index: A qualitative recall of all foods consumed by

women and children (less than 23 months of age) was collected for the previous

24 hours. After listing types, frequency of consumption of each of the food group was also gathered for the previous 24 hours. Local feasts as well as

fasting days were systematically avoided. Using WHO IYCF operational

guidelines, seven food groups were taken into account for child between 6-23 months of age: cereals, roots and tubers; legumes and nuts; milk and dairy

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products; meat and fish; eggs; vitamin-A rich fruits and vegetables; and other

fruits and vegetables. Similarly, nine food groups were considered in case of

reproductive age women: cereals, roots and tubers; legumes and nuts; milk and dairy products; organ meat; eggs; flesh foods and fish; vitamin A dark

green leafy vegetables; other vitamin A rich vegetables and fruits; and other fruits and vegetables.

Other information: Demographic data such as age, sex and size of household

were gathered. Information on knowledge and use of Essential Nutrition Action (ENA), Behaviour Change Communication (BCC), supplementary feeding, and

economic activities were collected.

2.6 Training and pre-testing

Eight to ten enumerators were identified for the survey in each woreda based on

local language skills, previous nutrition survey experiences and academic

background. Enumerator training was provided at Hawasa, Meki, Nefas Mewcha

and Maichew for SNNP, Oromia, Amhara and Tigray Regions, respectively. The CARE CCU assigned supervisors were responsible to train the data collectors

prior to pre-testing the materials at household level. The training covered

presentation and participatory translation of the questionnaires into the local languages, good interview approach/practices followed by pre-testing at selected

villages in the study areas. The team then met again and thoroughly discussed

challenges encountered during pre-testing and refined all the three

questionnaires to accommodate these.

2.7 Data management and analysis

Data quality management was undertaken on a daily basis by the supervisors.

Data entry was performed with EpiData Software, version 3.1; and the quality was ensured by quality checks associated with the data entry process and by

further cleaning. Detailed food items were categorized into seven food groups to analyze child’s dietary diversity (WHO, 2010). Similarly, it was grouped to nine food groups for women dietary diversity scores (see Annex II).

The data was exported to Stata version 10.3, SPSS (PASW) version 18 and Excel for analysis. The mean value for knowledge, attitudes and practices related to

nutrition was also calculated at 95% confidence interval using the same function.

Background characteristics of the study samples and all the other results were summarized in excel using descriptive statistics. Data on breastfeeding status,

dietary diversity and meal frequency in the previous day and night of survey was

used to calculate EBF, MAD and WDDS.

3. RESULTS

3.1 Description of the study samples

The study samples from Hawasa Zuria, Zeway Dugda, Lay Gayint, and Enda

Mohoni shared similarities in maternal age, child age, proportion of male and female children. A total of 347, 425 and 460 mothers were interviewed for

exclusive breast feeding (EBF), minimum acceptable diet (MAD) and women

dietary diversity score (WDDS) indicators. All the participating mothers for EBF

8

and MAD indicators were with children under two years of age. Mothers in the

study were PSNP beneficiaries and between the age of 15-49 years. The mean

age of the mothers with children for study was 29 years. The mean age of the children was 3.6 and 15.8 months for EBF and MAD assessment respectively.

Table 2: Samples by sex and age

Woreda

0-5 months 6-23months

Sex Age

Total

Sex Age

Total Male Female

0-3 mo

4–5 mo

Male Female 6-8 mo

9-23 mo

Hawasa Zuria 31 30 20 41 61 34 29 6 57 63

Zeway Dugda 33 34 21 46 67 25 33 8 50 58

Lay Gayint 72 70 55 87 142 104 89 19 174 193 Enda Mohoni 44 33 42 35 77 53 58 10 101 111 Total 180 167 138 209 347 216 209 43 382 425

3.2 Breastfeeding of children less than 6 months

3.2.1 Initiation of breastfeeding

The percentage of children who are ever breastfed was 99.1% (see table 3).

About 98.6% of surveyed children less than 6 months of age were breastfed in the previous day and night of survey time. Initiation of breastfeeding within one

hour of birth was reported by 80.6% of women while 128 (16.6%) started

breastfeeding after one hour after birth. However, 3.2% of the mothers started breastfeeding only a day after birth (Figure 1). Large proportion of mothers

(92.8%) in Zeway Dugda initiated breastfeeding immediately after birth though 73.4% of them did in Lay Gayint (Table 3).

Table 3: Initiation of breastfeeding by location (%)

Woreda

n

Children ever

breastfed3

(%)

Percentage of mothers who started breastfeeding

Within 1 hour of

birth

Within 1 day of

birth

After a day of

birth

Hawasa Zuria 124 100 87.1 16.9 0.0 Zeway Dugda 125 100 92.8 6.4 1.6 Lay Gayin 335 100 73.4 21.8 5.4 Enda Mohoni 188 96.1 83.5 13.8 2.7 Total 772 99.1 80.6 16.6 3.2

3 For ever breastfeeding, a total of 347 respondents from EBF indicator were considered

9

Figure 1: Duration for initiation of breastfeeding (%)

3.2.2 Exclusive Breastfeeding

A total of 242 (69.7%) mothers practiced exclusive breastfeeding for children

less than six months of age in the study area (see figure 2, table 4). About 59,

67.2%, 81.7 and 58.4% of the children were exclusively breastfed in Hawasa Zuria, Zeway Dugda, Lay Gayint and Enda Mohoni, respectively. The EBF has

reduced from 89.1% at one month of age to 39% at around 5 moths of age of

the child (figure 3).

Table 4: Exclusive breastfeeding by age group (%)

Woreda 0 - 3 months 4 - 5 months 0 - 5 months

Hawasa Zuria 90.0 43.9 59.0

Zeway Dugda 95.2 54.3 67.2

Lay Gayint 98.2 72.4 82.4

Enda Mohoni 76.2 34.3 57.1

Total 89.9 56.5 69.7

Figure 2: Exclusive breastfeeding by location (%)

10

Figure 3: Exclusive breastfeeding by age (%)

3.2.3 Initiation of feeding of solids semi solids and soft foods

A total of 30.3% of the mothers started complementary feeding to their children at age of less than 6 months (figure 4). About 29.1% of them started

introduction of only liquids to their children while 12% of them extended to

feeding solid semi-solid and soft foods to their children (see table 5).

Unacceptably, 10 and 43.5% of the mothers initiated complementary feeding at 0-3 and 4-5 months of age respectively (figure 4). About 3.7% and 25.4% of the

children started feeding on liquids at 0-3 and 4-5 months of age, respectively.

The mean age for introduction of complementary foods was an unacceptably low about 4.5 months.

Figure 4: Initiation of complementary feeding by age group (%)

11

Table 5: Percentage of children less than 6 months of age feeding on breast,

liquids, SSS4 foods in the previous day and night

Woreda Breastfeeding Liquid feeding

Feeding on

SSS foods Overall

respondents n % % %

Hawasa Zuria 61 100 37.7 26.2 61

Zeway Dugda 67 100 31.3 14.9 67

Lay Gayint 141 99.3 16.9 4.2 142

Enda Mohoni 73 94.8 42.9 10.4 77

Total 342 98.6 29.1 11.5 347

3.3 Feeding of children 6-23 months of age

3.3.1 Continued breastfeeding at 23 months of age

About 82.8 % of the children continued feeding on breast. Proportion of children

(12-15 months of age) continued breastfeeding at one year was 93.6% (table

6). Among breastfed children, 94% of them continued breastfeeding for more than a year. The finding confirmed that breastfeeding status has reduced from

97.7% at 6-8 months of age to 58.9% at 19-23 months (figure 5).

Figure 5: Continued breastfeeding by age category (%)

4 Solid semi-solid and soft foods

12

Table 6: Percentage of children 6-23 months of age who continued breastfeeding

Woreda 6-11 mo

(n=89)

12-17 mo

(n=153)

18-23 mo

(n=183)

12-15 mo

(n=109)

12-23 mo

(n=265)

Breastfeeding,

%

n=425

Hawasa Zuria 100 100 77.8 100 88.0 90.5

Zeway Dugda 90 78.9 44.8 63.6 58.3 63.8

Lay Gayint 97.9 97.2 70.3 98.2 83.6 87

Enda Mohoni 100 92.3 66.0 92.9 77.2 81.1

Total 97.8 94.1 66.1 93.6 78.9 82.8

mo=months

3.3.2 Complementary feeding practices

A total of 74.4% of mothers started complementary feeding for their children

between 6 and 8 months, where majority (54.8%) of them initiated

complementary feeding at 6 months of age. About 9.5% of the mothers started complementary feeding at infant stage while the child is less than 6 months of

age (table 7). About 15.8% of them reported to start at around 9 month of age

(figure 6).

Foods made from cereals, oils/fat, and roots and tubers were dominantly consumed by children in the study areas. About 90.6% of the mothers feed foods made from cereals to their children. Flesh foods are almost not given to

the children less than two years (figure 7). Out of the seven categorized food groups, 93.2% of the children (6-23 months of age) consumed grains roots and

tubers. Dairy products and legumes were consumed by 45.4 and 44.5% of the

children, respectively (table 8).

Table 7: Complementary feeding initiation by age category (%)

Age at complementary feeding

initiation5 Total samples Respondent Percent

1-5 month 423 40 9.5

6 month 423 232 54.8

6-8 month 423 316 74.7

7-8 month 423 84 19.9

9 month 423 67 15.8

The disaggregated results on breastfeeding status indicated that majority of the breastfed children (92%) fed on foods made from cereals, roots and tubers (figure 8). Similarly, more than 98% of the non-breastfed children dominantly

consumed the same food group (figure 9). However, Vitamin A fruits and vegetables use was high among breastfed children aged 6–23.9 months (84%).

In contrast, only about 20.5% of the non breastfed children consumed vitamin A

rich foods in the previous day and night of the survey time.

5 All of the respondents were mothers with children a6-23 months of age

13

Figure 6: Complementary feeding initiation by age (%)

Figure 7: Proportion of children who consumed various food groups (15) during

the preceding 24 hours of survey.

14

Table 8: Proportion of children who consumed various food groups in the

previous day and night of survey

Food types Hawasa Zuria

Zeway

Dugda Lay Gayint Enda Mohoni Total

Grains roots and tubers 95.2 96.6 92.2 91.9 93.2

Dairy products 69.8 53.4 40.9 35.1 45.4

Legumes and nuts 49.2 58.6 42.5 37.8 44.5

Vit A rich fruits/

vegetables 44.4 31.0 25.9 9.9 25.2

Other fruits and

vegetables 41.3 69.0 18.7 4.5 25.2

Eggs 7.9 15.5 4.7 18.9 10.4

Flesh foods 0.0 1.7 1.6 0.0 0.9

Figure 8: Percentage of breastfed children feed on various food groups in the

previous day and night of survey

15

Figure 9: Percentage of non-breastfed children feed on various food groups in

the previous day and night of survey

3.3.3 Minimum Acceptable Diet

About 66.1% of the mothers could have fed their children the minimum meal frequency. Regarding child dietary diversity, roughly 58.6% of the children

consumed less than two food groups while 24.2% of them feed on three food groups. Only 17.2% of the children met the minimum requirement of dietary

diversity, which is feeding on four and more food groups. The mean dietary

diversity and meal frequency for child was 2.4 and 2.8 respectively (table 9). Only about 6.6% of the children achieved minimum acceptable diet (MAD)

during the survey period. At the early stage, 59.5% of the breastfed children

aged 6-8 months could met MAD while none of the non breastfed children could

achieved MAD (see figure 10).

Figure 10: Mininimum acceptable diet (%) for children aged 6-23 months

16

Table 9: Infant and young child feeding practices (%)

BF, breastfed children; NBF, non breastfed

3.4 Women dietary diversity score (WDDS)

The mean meal frequency and dietary diversity was 2.8 and 2.9 respectively

(see table 10). Out of the 9 food groups, about 32.8% of the respondent females consumed 3 food groups while 28.3% of them eat 4 food groups and

above. The study indicated that nearly 40% of the mothers took less than 3 diets per day. However, about 78.9% of them had 3 meal frequency per day. Almost all the respondent females (99.6%) consumed food made from cereas.

Oils/fats (65.9%), legumes (64.6%), and roots and tubers (64.3%) were the other important food groups fed (figure 11). Only about 2.6 and 1.7% of the

mothers fed eggs and meat respectively.

Figure 11: Proportion of women consuming different food groups (14) during the

preceeding 24 h

6 Stands for the proportion of children who received a minimum acceptable diet (%)

Component 6-8 months,

BF

9-23 months,

BF

6-8 months,

NBF

9-23 months,

NBF

Total

Meal Frequency, % Low 0 meal: 11.9 0-1 meal: 5.8 0-2 meal: 0 0-2 meal: 18.1 8.5 Medium 1 meal: 14.3 2 meal: 16.1 3 meal: 100 3 meal: 70.8 25.4

High ≥ 2 meal: 73.8 ≥ 3 meal: 78.1 ≥ 4 meal: 0 ≥ 4 meal: 11.1 66.1

Meal Frequency, n 2.3 1.8 3 3 2.8

Dietary Diversity Score, %

Low 0-2 groups: 73.8 0-2 groups: 55.8 0-2 groups: 0 0-2 groups: 62.5 58.6

Medium 3 groups: 21.4 3 groups: 22.6 3 groups: 100 3 groups: 31.9 24.2

High ≥ 4 groups: 4.8 ≥ 4 groups: 21.6 ≥ 4 groups: 0 ≥ 4 groups: 5.6 17.2

Dietary Diversity, n 2.8 2.5 3.0 2.2 2.4

Achieved MAD (%)6 59.5 1.0 0.0 0.0 6.6

17

Table 10: Proportion of women in the studied areas consuming various food

groups

Component

Hawasa

Zuria

Zeway

Dugda

Lay

Gayint

Enda

Mohoni

Total

Respondents 64 65 211 120 460

Food Group

Cereals, roots and tubers 96.9 100.0 100.0 100.0 99.6

Legumes 60.9 64.6 61.1 72.5 64.6

Other fruits and vegetables 76.6 78.5 29.4 10.8 38.0

Vitamin A dark green leafy

vegetables 68.8 40.0 30.3 15.0 33.0

Vitamin A rich fruits and

vegetables 4.7 6.2 39.3 19.2 24.6

Dairy products 56.3 27.7 17.1 11.7 22.6

Eggs 0.0 1.5 2.8 4.2 2.6

Flesh foods-meat etc 1.6 0.0 1.9 2.5 1.7

Organ meat 1.6 0.0 0.5 0.0 0.4

Dietary Diversity Score, %

1-2 Food groups 9.4 20.0 39.8 63.3 38.9

3 Food groups 26.6 38.5 35.1 29.2 32.8

≥ 4 Food groups 64.1 41.5 25.1 7.5 28.3

Meal Frequency, %

1-2 Meal 35.9 7.7 13.7 24.2 18.7

3 Meal 57.8 83.1 86.3 75.0 78.9

≥ 4 Meal 6.3 9.2 0.0 0.8 2.4

Meal Frequency, n 2.7 ± 0.72 3.1 ± 0.76 2.9±0.35 2.7 ± 0.51 2.8±0.54

Dietary Diversity Score, n 3.7 ± 0.94 3.2 ± 0.93 2.8 ±1.1 2.4 ±0.85 2.9 ± 1.1

3.5 Nutritional knowledge attitude and practices

3.5.1 VESA and nutrition education

Majority of the respondents participate in Village Economic and Saving

Association (VESA). VESA serves as a vehicle to enhance nutritional focused knowledge attitude and practices. Roughly 90% of the mothers received

nutrition related education three times for the last year (table 11).

Table 11: Participation in VESA and nutrition education by location

Variable

Hawasa

Zuria

Zeway

Dugda

Lay

Gayint

Enda

Mohoni Total

Respondents 188 190 546 308 1232

Households participated in VESA (%) 95.2 97.4 98.9 95.1 97.2

Households who received nutrition

education (%) 94.1 91.1 88.1 89.9 89.9

Number of nutrition educations

received 3.3 2.7 3.5 2.8 3.2

18

3.5.2 Maternal conditional dietary change

About 469 (60.8 %) of the mothers had experienced change in their usual diet

during pregnancy and lactation periods. In line with this, 18.7% of them reported to consume more number of meals with the same content as previous

time while 28.5% of the mothers consumed more and diversified meals during pregnancy and lactation (table 12).

Table 12: Proportion of mothers with diet change and feeding practices during pregnancy/lactation (%)

Component

Hawasa

Zuria Zeway Dugda Lay Gayint

Enda

Mohoni Total

Respondents 124 125 335 188 772

Those who changed diet during

pregnancy or lactation 76.6 66.4 55.5 55.9 60.8

More number of meals with the

same content as previous time 30.6 17.6 15.8 16.5 18.7

More and diversified meals 46.8 25.6 19.4 34.6 28.5

Less number of meals than

normal time 0.8 24 22.1 4.3 14.6

Others 0.0 0 0.0 0.5 0.1

3.5.3 Breastfeeding intensity

Most mothers in Lay Gayint and Enda Mohoni reported that they had

experienced change in breastfeeding based on health status of the child while they make no changes at Hawasa Zuria and Zeway Dugda woredas. Higher

proportion of mothers (56.1%) reduced frequency of breastfeeding during

sickness of child while 33.7% of them did not make any change at all. Only

about 3% of the mothers increased breastfeeding frequency when a child is sick (see table 13, figure 12).

Table 13: Change in frequency of breastfeeding of children less than 23 months

of age

Woreda When a child is healthy When a child is sick Always the same Sometimes

Hawasa Zuria 12.9 3.2 83.1 4.0

Zeway Dugda 26.4 3.2 63.2 7.2

Lay Gayint 76.1 5.4 8.7 9.9

Enda Mohoni 68.6 2.7 26.1 2.7

19

Figure 12: Changes in breastfeeding intensity

3.5.4 Hand washing practices

The majority of women (61.4%) washed their hands with water alone, while

29.5% did with soap. Occasionally (less than 7%), they used to wash with ash, soil and plant leaves too (table 14). Majority (83.3%) of them wash their hands

when going for food preparation. About 65% of the respondents reported to

wash their hands after toilet when only around water sources.

Table 14: Proportion of households with hand washing practices (%)

Component Hawasa Zuria Zeway Dugda Lay Gayint Enda Mohoni Total

Time for hand washing

Respondents 124 125 335 188 772

When serving 41.1 64.8 48.7 29.8 45.5

Before preparing food 77.4 83.2 80.3 92.6 83.3

After toilet 33.9 59.2 80.3 61.7 64.9

When feeding child 54.8 55.2 58.5 31.4 50.8

Sometimes 0.8 0.0 3.3 0.5 1.7

Commonly practiced means of hand washing

Respondents 138 190 546 308 1232

Wash with water alone 73.4 56.3 56.8 65.3 61.4

Wash with ash 4.8 3.7 11.2 2.9 7.0

Hand wash with soil 2.7 1.6 0.7 0.3 1.1

Hand wash with plant leaf 0.5 0.0 0.7 2.3 1.0

Wash with soap 18.6 39.5 30.4 29.2 29.5

n, number of respondent mothers

20

3.5.5 BCC and cooking awareness

Only about 31.7% females had exposure to IYCF behaviour change

communication (BCC). Less than 20% of the households had IYCF tool B kit at home. Exposure to IYCF BCC materials was large in Zeway Dugda (mean score

of 77.6%) while the least in Hawasa Zuria (16.9%) and Lay Gayint (19.4%).

About 65.2% of the mothers participated in cooking demonstration while 53.9% of them able to demonstrate the received knowledge at home. The participation

was better in Zeway Dugda (72.2%) while the least (45.2%) in Hawasa Zuria (table 15). Similarly, about 55.8% of the females participate on training in

vegetable production while only 38.6% of them did grow vegetables at garden.

Table 15: Behaviour change communication, cooking demonstration and garden vegetable production practices (%)

Component

Hawasa

Zuria

Zeway

Dugda

Lay

Gayint

Enda

Mohoni Total

Respondents 124 125 335 188 772

Behaviour change communication

Exposure to IYCF BCC

materials 16.9 77.6 19.4 32.4 31.7

IYCF tool B kit at home 12.9 61.6 11.6 15.4 20.9

Cooking demonstration

Participation in cooking

demonstration 45.2 67.2 72.2 64.9 65.2

Practiced cooking

demonstration at home 37.1 56.8 60.0 52.7 53.9

Vegetable cultivation

Participation on

vegetable production 48.4 71.1 50.7 59.7 55.8

Grow vegetables at

home 25.0 45.3 38.6 42.9 38.6

3.5.6 GRAD Value Chain and Income Generating Activities

A total of 51.8% of the households participated in GRAD’s value chain (VC) and

income generating activities (IGAs). More number of respondents involved in

Enda Mohoni while less number participates in Lay Gayint. In all the studied areas, more respondents were participating in livestock production and the least

in beekeeping. However, 23.1% of the households were able to purchase child

food with the income generated from value chains and income generating activities (table 16). Large number of mothers (49%) could access food for child

in than those in Lay Gayint where roughly 8% of the respondents purchase food

for child with the same income.

21

Table 16: Participation in GRAD’s IGA or VC activities (%)

Type Hawasa Zuria Zeway

Dugda Lay Gayint

Enda

Mohoni Total

Respondents 124 125 335 188 772

IGA/VC Engagement 57.3 57.6 26.0 90.4 51.8

Livestock production 48.4 47.2 13.4 87.2 42.5

Vegetable production 18.5 22.4 14.6 9.6 15.3

Chicken rearing 16.1 7.2 0.9 8.5 6.2

Petty trade 35.5 7.2 0.0 10.1 9.3

Others 0.8 8.8 2.4 1.6 3.0

Honey production 0.8 2.4 0.3 1.1 0.9

Child food purchases

with income from

IGA/VC

49.2 35.2 7.8 25.0 23.1

4. Discussion

4.1 Methodological limitations

The GRAD Baseline survey was conducted from September to November in 2012 while that of nutrition baseline was undertaken a year later in October and

November in 2013. Thus, due to technical delays it was difficult to get uncontaminated samples for the current baseline survey. Various nutrition linked

interventions were employed in the study area through value chain approach

(selected crop farming and livestock fattening), livestock production, and income generating activities (garden vegetables, chicken rearing etc). Likewise, nutrition

focused educations mainly on IYCF practices were provided to GRAD

beneficiaries through village saving and economic association (VESA). For

instance, according to GRAD Project Annual Report (2013), a total of 13,502 community members attended awareness-raising on ENA and hygiene practices

as well as about 6,557 women (pregnant and lactating) were linked to existing

mother support groups.

Productive Safety Net Programme (PSNP)7 beneficiary households were the

targeted population in the districts (Hawasa Zuria, Zeway Dugda, Lay Gayint and Enda Mohoni). These are chronically food insecure and exposed to shocks:

drought, erratic rains, poor soil fertility and other. Thus, this result does not

necessarily represent non PSNP communities residing in the area as wealth is one of the influencing factors of nutritional status. For instance, Aemro et al.

(2013) reported that children born from the richest household had 74% less

chance to have inadequate dietary diversity compared with children from

poorest household. Naturally, however, it seems reasonable that people would tend to diversify their diet as their income increases, as greater variety makes

diets generally more palatable and more pleasant.

7 The poor groups of the community were targeted for PSNP program.

22

The other methodological limitation is related to seasonality. This survey is

conducted when food is relatively plenty at household level. Accordingly, the

current result may underestimate the extent of malnutrition or nutritional gaps in the areas. For instance, key informant households in Lay Gayint and Enda

Mohoni responded that reducing the variety and number of meals consumed per day is among the various copping strategies employed during food shortage. In line with this, several reports stated that food is abundant from November to

February while scarce from June to August in the PSNP woredas in Ethiopia (Burns and Bogale, 2011 and 2013). Study conducted somewhere else also

suggested that seasonality has direct impact on dietary patterns particularly on

energy and nutrient intake (Savy et al., 2006).

In the case of dietary diversity and meal frequency, the actual quality of the diet

cannot be correctly captured through the previous day and night recall due to

the variations from one to the other. For instance, the fasting and festivity periods could have a significant effect on both meal frequency and dietary

diversity particularly among the Christian communities in the northern part of

the country8.

Besides, this study lacks the qualitative research part so that local knowledge on

the recommended IYCF practices and analysis of constraints and opportunities of

IYCF practices as well as nutrition related interventions and assessment of communities’ needs are missed. The study also did not capture religious

practices and mothers view on exclusive breastfeeding. For instance, almost all

the Christian kids are allowed to take eucarsite as a communion in the church most commonly every Sunday and holidays. It is, therefore, difficult to note as

usual food; otherwise all the children could have been reported non breastfed. Again, such type of religious practices cannot be negotiable for interventions.

4.2 Breastfeed initiation and breastfeeding

Initiation of breastfeeding was fairly early in almost all regions where more than 80% of the mothers initiated within an hour (figure 1). It was relatively low in

Lay Gayint; initiation of breastfeeding within 1 hour of birth was reported by

73.4% of women (table 3). But, the figure obtained in this study is much higher than those reported in other studies. According to Ethiopian Demographic and

Health Survey 2011, 52% of infants started breastfeeding within one hour of

birth, 80% within the first day. The prevalence of timely initiation of

breastfeeding in some areas was documented as 63.6% in Harar and 52% in Oromia (Setegn el al., 2011; Abera 2012). Setegn el al. (2011) indicated that maternal attendances of formal education, being urban resident and postnatal

information/advice on breastfeeding were positively associated with timely initiation of breastfeeding in Ethiopia. Those mothers who give normal births at

health facilities were reported to initiate breastfeeding within an hour. Key

informants indicated that giving fresh butter immediately after birth has been reduced these days mainly due to recent interventions. Reports confirmed that

over 48% of children were given fresh butter immediately after birth. In this

survey, as high as about 99.1% of the children were ever breastfed, which is

8 Days in a week such as Wednesday and Friday will have different meal frequency and dietary

diversity among the Orthodox Christians.

23

close to 97.5 and 98.5% reported in Ethiopia (CSA and ICT, 2012; Tefera et al.,

2012).

4.3 Exclusive breastfeeding

It is universally accepted that all children should exclusively breastfeed for the

first 6 months and continue for as long as the mother and child wish, where milk alone is sufficient to fulfil the nutritional and thirsty need of the baby. While only after six months of life, both appropriate and sufficient complementary food

should be added to the breast milk (UNICEF, 2009).

The mean proportion of children exclusively breastfed was 69.7%; although the

variation among regions was staggering, as high as 82.4% exclusive breastfeeding by mothers was documented in Lay Gayint while the lowest rate of

57.1% in Enda Mohoni (figure 2). In line with this, earlier studies indicated that

EBF practice was 62, 64 and 81% in Oromia, SNNNR and Amhara regions,

respectively (MoH, 2006). Similarly, Tefera et al (2012) reported EBF of 65.7% which is loser to the current finding. In contrast, the lowest EBF value (52%)

was documented by Ethiopian Demographic and Health Survey in 2011 (CSA and

ICF, 2012).

This higher finding in this study may be due to various documented interventions

made by government and non governmental organisations. For instance, about

90% of the respondent mothers had received nutrition related education through VESA9 (see table 11) with close supervision of community facilitators in the

project areas. According to the key informants, it is realistic to demonstrate

exclusive breastfeeding which is relatively requires less resource to do so when compared with other resource demanding interventions. Likewise, expansion of

improved health delivery systems could also contribute to the increments of exclusive breastfeeding practices. For instance, Abera (2012) noted that mothers who delivered their babies in a health facility were four times more likely to EBF

than those who delivered at home. The same author reported that 79.6% of mothers who delivered at home stopped breastfeeding compared to those who

delivered in public or private health facilities.

Some of the key informants in Enda Mohoni and Lay Gayint confirmed that they

have received nutritional training and, hence with some knowledge on benefit of

breast milk. They responded that they used to provide water to children aged

less than 6 months in the past, believing that it was harmless in those days. Currently, only 29% of the mothers started giving water and solid semi solid and soft foods to their children. Regarding continued breastfeeding, the studies

stated that lack of enough milk by mothers, mother’s return to work and, pregnancy were some reasons for early cessation of breastfeeding before 24

months in the country (Abera, 2012).

9 Members in VESA usually meet once or twice in a months to make small amount of money

contribution. This gathering is used as opportunity to deliver important messages on various

subjects each time.

24

4.4 Continued breastfeeding

Out of the respondents with child 6-23 months of age, 82.8% of the mothers

were practicing breastfeeding during survey period. Proportion of children (12-15 months of age) continued breastfeeding at one year was 93.6% (table 6).

Out of all of the children aged >12 months, a total of 78.91% of the children had been breastfed for a year and above while the remaining 21.1% had been breastfed for less than a year. Abera (2012) also reported 73.9% of the children

continued breastfeeding for more than a year. In this study, breastfeeding was reduced by 38.8% from 6-8 months to 19-23 months of age. Problems with

breasts, difficulties related to infant latching and sucking, producing insufficient

breast milk, pregnancy and mother’s workload are the determinants of early cessation breastfeeding (Alive & Thrive, 2012).

4.5 Complementary feeding

Infants are particularly vulnerable to malnutrition and infection during the

transition period when complementary feeding begins. Optimal complementary feeding depends on accurate information and skilled support. Nutrient dense

semi-solid or soft foods need to be introduced at the age of 6 months through

frequent feedings while breastfeeding continues. It is recommended that an infant needs to be fed on at least four of the seven major food groups in order to

get the minimum diversity of diet (WHO, 2010).

Mostly, EBF under 6 months was disrupted by early introduction of water into infants’ diets. For this study, a total of 30.3% of the mothers with children aged

0-5 months started complementary feeding at the inappropriate time. The mean

age for introduction of complementary foods was an unacceptably low 4.5 months. The study conducted in Tigray revealed that the primary reason for

introducing food earlier than 6 months was the concern by mothers that breast milk is not enough for the child, and that additional foods are needed to avoid hunger and ensure good growth and strength (Alive & Thrive, 2010)

On the other hand, for children between 6 and 23 months, the proportion of

mothers who started complementary feeding exactly at 6 months was about

54.8% (see figure 6), while 74.7% of the mothers had practiced complementary feeding between 6 and 8 months. This is higher than the national figure in

Ethiopia whereby 51% of the children age 6-9 months reported to receive

complementary foods the day or night preceding the survey (CSA and ICF,

2012). Likewise, inappropriate infant feeding practices were documented in the country, with complementary feed initiation ranged from 3.7 months in SNNPR to a high of 10 to over 12 months in Northern part of the country. The study

conducted in Sidama zone revealed that mothers who reported no increased food consumption during lactation and pregnancy were positively associated with

late introduction of complementary food (Tesema et al., 2013).

Cereals are the dominant child food in the area, although the increasing

dependence on these crops has increased the challenge of meeting micronutrient

requirements. Only 10.8% of the mothers fed vitamin A rich foods to their

children. Similarly, animal source foods particularly eggs and meat are the least foods provided to children (see table 8). However, the literatures confirmed that

children who consumed animal source food are less likely to be stunting and

25

underweight. In line with this, the prevalence of vitamin A deficiency is noted in

Tigray where more than 60% children are vitamin A deficient. However, the

prevalence of Vitamin A deficiency (VAD) particularly during the critical period of growth (1-5 years) does have serious implications for the health and wellbeing

of children. Fawzi et al. (1993) reported that VAD limits growth, weakens immunity, causes blindness and impairs the normal development of healthy skin and tissues.

4.6 Dietary diversity and meal frequency

Several studies confirmed that appropriate complementary feeding practice is

essential in the first two years of life for satisfactory growth and development of children and for prevention of childhood illness. Insufficient quantities, frequency

and inadequate quality of complementary foods have a detrimental effect on

health and growth in these important years. Whereas consumption of animal source foods and dietary diversity are reported to reduce stunting in children.

Thus, improved dietary diversity is a key point for the improvement of child

feeding practices (Black et al., 2008). Dietary diversity focuses more on quality

of the diet than the consumption of a particular food group.

About 66.1% and 17.2% of the children received age appropriate meal

frequency and dietary diversity respectively (table 9). Large variations were observed among the previous study findings; the proportion of children achieved

acceptable meal frequency was 44.7% and 8.4% in Ethiopia (Tefera et al., 2012;

Aemro et al., 201310). Likewise, 9.1% and 10.8% of the children were reported to achieve minimum dietary diversity. Lower dietary diversity may be due to

several reasons. According to Aemro et al. (2013), maternal education is

associated with dietary diversity and meal frequency, indicating that parental

education plays a significant role in meeting the appropriate dietary diversity and meal frequency.

4.7 Minimum acceptable diet

As the minimum acceptable diet takes both minimum dietary diversity and minimum meal frequency in to account (WHO, 2012), the proportion of children

with minimum acceptable diet achieved for this study is low. Only 6.6% of the children achieved the minimum acceptable diet (MAD). By 6-8 months, 59.5% of

children achieved MAD, while only 1% of the breastfed children aged 9-23 had

received minimum acceptable diet. None of the non breastfed children could achieve minimum acceptable diet, respectively. The result confirmed that as the

children gets aged those who achieved MAD dropped by 58.5%. This suggests

the need of more attention during complementary feeding practices since

feeding practices are often complex and change with a child age. According to the key informants11, the reason for lower dietary diversity and meal frequency is related mainly to the household’s food insecurity situation in the area. The

previous studies also confirmed that only 1% of the children received minimum acceptable diet (Tefera et al., 2012). According to Berti et al (2012), the

percentage of children meeting the minimum acceptable diet (MAD) was less

than 15%. 10 The report is based on secondary analysis of Ethiopian Demographic and Health Survey 2011. 11 These women also noted that their main problem to demonstrate what they leant during IYCF practice session was lack of enough basket of foods.

26

Child malnutrition is not only due to lack of knowledge of IYCF practices but also

as a result of poor resources. Poor households are usually limited in their ability to provide their children with the diet of necessary nutritious composition. The

key informant mothers also confirmed that quality diets (animal products, key vegetables and fruits) are either not produced at home or unable to purchase due to economic reasons or both. Cereals are the dominantly grown and

consumed food group in all the four study districts. Studies conducted in Ethiopia suggests the importance of adapting livelihood-based approach toward

recommended IYCF practices and the need to continue working through the

existing health extension delivery systems (Bekele, 2013).

4.8 Maternal dietary diversity

Out of the nine food groups, the mean dietary diversity for reproductive age

women (15-49) in this study was 2.9 (table 10). It is, however, accepted that

women need to consume at least four of the nine food groups in order to meet the minimum dietary diversity. This finding is a little bit higher than the previous

reports; Tefera et al (2012) noted that the mean dietary diversity score of 2.1.

In this study 28.3% of the women meet the minimum dietary diversity. In contrast to this, Berti et al. (2012) reported that less than 5% of women

consumed the minimum diet diversity. More than two-third of the adult women

were consuming below the minimum diet diversity in this study, indicating the

higher level of malnutrition.

Almost all (99.6%) of the women consumed cereals, roots and tubers which is in

line with Tefera et al (2012) who reported 94% of women consuming similar food groups. Previous reports also indicated that cereals such as maize, wheat,

teff and barley are the dominantly grown crops in the study areas (Bogale, 2013). Enjera12, bread and porridge are the foods usually made from these grains. The study conducted in Sidama Zone confirmed that feeding practices of

most mothers did not meet WHO recommendations (Tesema et al., 2013). In this study, the consumption of quality of the diet is low, where less than 33% of

the women could include animal source and vitamin A rich foods in their dishes.

Likewise, low maternal dietary diversity score (less than three food groups out of

nine, see table 10) is not necessarily because of knowledge gap. Unavailability of

enough baskets of foods for PSNP households also contributed to the low WDDS

in the area. Usually all the household members consume from the same food source except for infant and young children where food is prepared separately. According to the key informants, women are not the first to consume food in the

households or to feed better than the rest of the household members due to cultural and socioeconomic reasons13. In contrast, woman consumes special diet

during the first 2-3 months of giving birth, and when the household member

gets sick provided with special foods. Otherwise, all the household members usually share from the common food sources. Similarly, Holmes and Jones

(2010) confirmed that malnutrition can be the result of inadequate availability of

12 Ethiopian fermented traditional food made from cereals mainly from teff, barley, wheat, maize,

sorghum and mix of this although varies between the farming systems. 13 Some of the contacted women said “how could I feed better than my kids and husband?” They

added: “women who consume beyond their household members (alone) are valueless in the

society”.

27

food, but often is the result of household access to food supplies and how the

utilization of those supplies is negotiated within the household.

4.9 Nutritional knowledge attitude and practices

The GRAD project has been promoting recommended IYCF practices and

Essential Nutrition Action (ENA) through VESA. Group discussions, messaging, cooking demonstration, mothers support group, participation in IGAs, vegetable and chicken production were some of the activities, facilitated by health

extension workers, women animator, women role models and community facilitators.

The level of knowledge and attitude were found to be low in relation to the need of dietary changes during pregnancy, complementary feeding practices, and

conditional change in breastfeeding when the child gets sick (see tables 11, 12

and 13). Inline with this, the GRAD Projects Annual Report for 2013 indicates

that a total of 1,292 females were participated on awareness raising sessions on essential nutrition actions (ENA) and hygiene practices. Likewise, a total of 12

food demonstration sessions were conducted in the project areas.

This research showed only 2.7% of women had the knowledge of increasing

breastfeeding frequency when the child is sick while 68.6% of them increased

breastfeeding only when the child healthy. Likewise, the study showed only

28.54% of women had received more and diversified meal during pregnancy and lactation. In contrast, the other research findings showed only 64.4% of women

had nutrition knowledge during pregnancy (Daba et al., 2013).

Proportion of respondents who practiced hand washing before preparing food,

after toilet, when serving and feeding the child is above 50%. However, only 61.6 % and 29.5% of the mothers washed their hands with water alone and

soap respectively. The key informants indicated that poor access to water

especially during dry season is the major challenge to practice hand washing as required. Soap is occasionally used mainly due to economic reasons to purchase

while it is commonly used during washing of clothes.

Conclusions and recommendations

The mothers in this study have good exclusive breastfeeding practices when compared with other studies in the country. Only 30.1% of them did not practice

EBF. Majority of the mothers also initiated breastfeeding within one hour of

birth.

However, early introduction of complementary feeding for less than 6 months of

child as well as late initiation of complementary feedings for children 6-23 months were some of the unacceptable practices found in the area. Thus, GRAD should continue to encourage women to attend Essential Nutrition Actions (ENA)

and Infant and Young Child Feeding (IYCF) practices.

Both dietary diversity and meal frequency were inadequate among children aged

6-23 months. Very little proportion of children could have achieved the minimum acceptable diet. By 6-8 months, only one percent of breastfed children achieved

MAD while none of them in case of non-breastfed children. Hence, these findings

confirmed that there is high level of poor feeding which increased with age in the

28

first 24 months of life. Similarly, majority of the women were under-nutrition

with low maternal dietary diversity. Regarding feeding practices, all the

household members consume from the same food sources, while infant and young children are usually treated separately. Traditionally, little opportunity is

available for mother to be fed very well in the absence of enough baskets of food in the household. Hence, this finding suggests a holistic approach of livelihood improvement at household level to achieve minimum maternal dietary diversity

in the areas.

The findings confirmed that very few of mothers and their children consumed

animal source and vitamin A rich foods mainly due to lack of resources, which

are critical determinant of success in programs promoting recommended IYCF practices. Households that produce more diverse crops (cereals, legumes,

vegetables and fruits) and livestock are more likely to provide their children and

reproductive age women with more diverse and quality diets.

Some of the interventions are focusing only on behavioural changes mainly on

nutritional knowledge improvement. However, linking the child nutrition

programs together with livelihood support interventions helps to improve the recommended IYCF practices in particular and nutrition status at large. Hence,

the findings suggest that GRAD should continue focusing on nutrition-based

household food security approach with its already designed interventions that

are expected to have a multiplier impact of improving livelihoods and nutritional status. This could be an opportunity to achieve minimum maternal dietary

requirements and assisting the mothers to implement the IYCF practices.

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32

Annex

Annex I: Initiation of breastfeeding responded by mothers with child less than 6

months of age

Woreda Percentage of mothers who started breastfeeding

Within 1 hour of

birth

Within 1 day of

birth

After a day of

birth

Hawasa Zuria 83.6 16.4 0.0

Zeway Dugda 92.5 6.0 3.0

Lay Gayint 78.9 16.9 4.9

Enda Mohoni 87.0 10.4 3.9

Total 84.1 13.3 3.5

Annex II: Percentage of continued breast feeding (comparison made for overall respondents)

Woreda

N BF

(%)

6-11 months of

age

12-17 months of

age

18—23 months of

age

n % n % n %

Hawasa Zuria 63 90.5 13 20.6 23 36.5 21 33.3

Zeway Dugda 58 63.8 9 15.5 15 25.9 13 22.4

Lay Gayint 193 87 46 23.8 70 36.3 52 26.9

Enda Mohoni 111 81.1 19 17.1 36 32.4 35 31.5

Total 425 82.8 87 20.5 144 33.9 121 28.5 n, number of respondents

Annex III: Percentage of non breastfeeding children 6-23 months of age

Age category Children

6-11 months of age 2.7%

12-17 months of age 12.3%

18-23 months of age 84.9%

Non breastfed children (n=73) 17.2%

Annex IV: Complementary feeding initiation for children less than 2 years by location (%)

Component

Hawasa

Zuria

Zeway

Dugda

Lay

Gayint

Enda

Mohoni Total

Respondents 124 125 335 188 772

Mean age of first feeding on SSS, month

4.5 3.7 4.3 4.6 4.3

Those who started complementary

feeding 80.6 64.8 51.9 62.8 61.3

Not yet started feeding on SSS 18.5 32.0 35.2 25.0 29.5

33

Annex V: Pregnancy or lactation before participation in GRAD

Duration Hawasa Zuria Zeway Dugda Lay Gayint Enda Mohoni Total

Before 6 months 59.7 61.6 48.4 51.6 53.1

Before a year 31.5 28.0 43.6 38.3 37.8

Before 2 years 1.6 3.2 4.5 5.3 4.0

Above 3 years 6.5 6.4 3.6 4.8 4.8

Annex VI: Questionnaire exclusive breast feeding (EBF) indicator

Graduation with Resilience to Achieve Sustainable Development (GRAD) Nutrition Survey

Kebele Form

HH ID: |__|__|__| Date of the survey: _____/______/____/ Region: __________ Woreda: _____________ Kebele: ________________ Village: _________________ Kebele population: ___________

Household Roster

1. Ask about the name and sex of each person who lives here, starting with the head of the household? List the head of the household (in line 1), all household members; including those who are not at home now, children in school or household members at work.

Line #

Name Sex Age14 15 -49 years15

0-5 months16

6-23 months17 M F

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

10 1 2 10 10 10 Total

I. Infant Feeding Background information Mother Name: _________________________ Child Name: ______________________ Birth date: _____/____/_____ Age: |__|__|months Sex of child: � Male � Female Exclusive Breast Feeding (EBF) Note: Consider Infants 0–5 months of age and inform the mother that you would like to ask about breastfeeding and others since this time yesterday

1. Has the child e ver been breastfed? � YES � NO →go to Q3

2. Was the child breastfed since this time yesterday? 2a. Did the child consume breast milk in any of the se ways

(breastfed by other woman or milk from other woman given by spoon or bottle) since this time yesterday?

� YES � NO

� YES � NO

3. Did the child consume any of the liquids (except ORS, drops, syrups-vitamins, minerals and medicines) since this time yesterday?

� YES � NO

14Age is in months except for those above 2 years 15Circle line number if HH member is a woman aged between 15 and 49 years 16Circle line number if HH member is between 0 and 5.9 months 17Circle line number if HH member is between 6 and 23.9 months

34

4. Did the child eat any solid, semi - solid or soft foods since this time yesterday? � YES � NO

II. Knowledge & practice questions for GRAD Pregnant and lactating women and HHs

with < 2 children

Essential Nutrition Action (ENA)/Infant and Young Child Feeding (IYCF) Messages

1. Have you participated in Village Economic and Savin g Associations (VESA) group

education session? � YES � NO

2. If YES, how many VESA group nutrition education ses sions did you attend?

________sessions 3. Did your diet (food intake) change at time of pregn ancy/lactating? � YES � NO

If yes,

1. More number of meals with the same content per d ay 2. More number of meals with different additional v egetables/other

food items. 3. Less number of meals than normal period 4 . Other

4. When was your last pregnancy/lactation before y ou become part of GRAD? 1. Before 6 months 2. Before a year 3. Befor e 2 years 4. Above 3 years

5. How long after birth did you first put your child t o the breast?

1.___ immediately (<1 hour) 2.____ hours (<2 4 hours) 3. ___days (24 hours +)

6. When do you increase frequency of breastfeeding to your child? 1. When my child is healthy 2. When my child is sick 3. Always the same 4. Sometimes

7. When do you normally wash your hands?...there can b e more than one choice.

1. When serving 2. Before preparing food 3 . After toilet 4. When feeding young children 5 . Some times

8. What do you wash your hands with?

1. None 2. Ash 3. Soil 4. Plant leaf 5. Soap

9. At what age (months) did you first give your child food or drink (even water) other than breast milk? ______ months

Behaviour Change Communication (BCC)

10. Have you ever received /exposed to one of IYCF BCC materials used by GRAD?

� YES � NO

11. Do you have IYCF tool B kit at home? � YES � NO

Cooking demonstration

12. Have you participated on children porridge food coo king demonstration and

learning session by GRAD project? � YES � NO

13. Do you carry out the above (Q12) practice and skill at your home?

� YES � NO

Involvement on micro garden

14. Have you participated on vegetables cultivation dem onstration event at FTC or

model HHs garden? � YES � NO

15. Do you grow vegetables and/or fruits in your garden ? � YES � NO

Involvement on Income generating Activities or Value Chains IGA/VC

16. Did you engage in GRAD ’s value chains (livestock, vegetable, honey,

poultry...etc) or income generating activities? � YES � NO, If yes:

Vegetable Prod.

Chicken Rearing

Honey Prod.

Live. Prod.

Petty trading

Others (specify)

35

1= Yes 0= No

1 0 1 0 1

0 1 0

1 0

17. If (Q16) yes, have you used some amount of income g ained from IGA/VC to purchase additional food items to be consumed by yo ur child? � YES � NO

Annex VII: Questionnaire Minimum Acceptable Diet (MAD) indicator

Graduation with Resilience to Achieve Sustainable Development (GRAD) Nutrition Survey

Kebele Form

HH ID: |__|__|__| Date of the survey: _____/______/____/ Region: _____________ Woreda: ____________ Kebele: ________________ Village: _______________ Kebele population: _______________

Household Roster

1. Ask about the name and sex of each person who lives here, starting with the head of the household? List the head of the household (in line 1), all household members; including those who are not at home now, children in school or household members at work.

Line #

Name Sex Age18 15 -49 years19

0-5 months20

6-23 months21 M F

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

10 1 2 10 10 10 Total

I. Infant and Young Child’s Feeding

Background information Mother Name: _________________________ Child Name: ______________________ Birth date: _____/____/_____ Age: |__|__|months S ex of child: � Male � Female Minimum Acceptable Diet (MAD) Note: Ask mother about her child 6-23.9 months of age.

1. Has your child fed breast milk since this time y esterday?

� Yes � No

2. Did the child consume any of the following food group since this time

yesterday? � Yes � No

If ‘Yes’ probe: Since this time yesterday how many times did the c hild consume any of the listed food groups?

Food group Frequency

A. Plain water? |__|__| times

18Age is in months except for those above 2 years

19Circle line number if HH member is a woman aged between 15 and 49 years 20Circle line number if HH member is between 0 and 5.9 months 21Circle line number if HH member is between 6 and 23.9 months

36

B. Tinned, powdered, infant formula such as [INSERT LO CAL EXAMPLES] or milk (excluding breast milk) |__|__| times

C. Sweetened or flavored water, 'soda' drink, tea or i nfusion, soup, coffee, broth or homemade beer |__|__| times

D. Any food porridge, bread, enjera etc made from grai n such as millet, wheat, barley, sorghum, rice, teff, maize |__|__| times

E. Any food made from roots or tubers such as white po tatoes, white yams, cassava, onions, beets, false banana, kocho |__|__| times

F. Any food made from lentils, beans, guaya, peas, nut s (lewz), or seeds (peas, sesame, selyit, chickpea) |__|__| times

G. Liver, kidney, heart, or other organ meats. |__|__| times

H. Cheese, yoghurt, or other milk products. |__|__| times

I. Any meat such as beef, sheep, goat, chicken, or duc k |__|__| times

J. Fresh or dried fish, shellfish, or seafood. |__|__| times

K. Any dark green leafy vegetables (gommen, spinach, l ettuce, merengue leaves/ shifra, sama, kale, aleko,) |__|__| times

L. Eggs. |__|__| times

M. Any food made from fruits or vegetables that have y ellow or orange flesh such as carrots, pumpkin, squash, red sweet potatoe s, ripe mangoes, and papaya

|__|__| times

N. Any other fruits or vegetables (eggplant, tomatoes, peppers, zucchini, fosoliya, avocado, lemon, green mango, banana) |__|__| times

O. Sugary foods such as sweets, candies, chocolate, ca kes, and biscuits. |__|__| times

P. Any food made with oil, fat, butter, or ghee. |__|__| times

II. Knowledge & practice questions for GRAD Pregnant and lactating women and HHs with < 2

children

Essential Nutrition Action (ENA)/Infant and Young Child Feeding (IYCF) Messages

1. Have you participated in Village Economic and Savin g Associations (VESA) group education session? � YES � NO

2. If YES, how many VESA group nutrition education ses sions did you attend? ______________sessions

3. Did your diet (food intake) change at time of pregn ancy/lactating?

� YES � NO If yes,

1. More number of meals with the same content per d ay 2. More number of meals with different additional v egetables/other

food items. 3. Less number of meals than normal period 4 . Other

4. When was your last pregnancy/lactation before you b ecome part of GRAD? 1. Before 6 months 2. Before a year 3. Befor e 2 y ears 4. Above 3 years

5. How long after birth did you first put your child t o the breast?

1.___ immediately (<1 hour) 2.____ hours (<24 hours) 3. ___days (24 hours +)

6. When do you increase frequency of breastfeeding to your child? 1. When my child is healthy 2. When my child is sick 3. Always the same 4. Sometimes

7. When do you normally wash your hands?...there can b e more than one choice.

1. When serving 2. Before preparing food 3 . After toilet 4. When feeding young children 5 . Some times

8. What do you wash your hands with?

1. None 2. Ash 3. Soil 4. Plant leaf 5. Soap

9. At what age (months) did you first give your child food or drink (even water) other than breast milk? ______ months

Behavior Change Communication (BCC)

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10. Have you ever received/exposed to one of IYCF BCC m aterials used by GRAD? � YES � NO

11. Do you have IYCF tool B kit at home? � YES � NO

Cooking demonstration

12. Have you participated on children porridge food coo king demonstration and

learning session by GRAD project? � YES � NO

13. Do you carry out the above (Q12) practice and skill at your home?

� YES � NO

Involvement on micro garden 14. Have you participated on vegetables cultivation dem onstration event at FTC or

model HHs garden? � YES � NO

15. Do you grow vegetables and/or fruits in your garden ? � YES � NO

Involvement on Income generating Activities or Value Chains IGA/VC

16. Did you engage in GRAD ’s value chains (livestock, vegetable, honey,

poultry...etc) or income generating activities? � YES � NO, If yes:

Vegetable Prod.

Chicken Rearing

Honey Prod.

Live. Prod.

Petty trading

Others (specify)

1= Yes 0= No

1 0

1 0

1 0

1 0

1 0

17. If (Q16) yes, have you used some amount of income g ained from IGA/VC to

purchase additional food items to be consumed by your child? � YES � NO

Annex VIII: Questionnaire Women Dietary Diversity Score (WDDS) indicator

Graduation with Resilience to Achieve Sustainable Development (GRAD) Nutrition Survey

Kebele Form

HH ID: |__|__|__| Date of the survey: _____/______/____/ Region: __________ Woreda: ______________ Kebele:________________ Village: _________________ Kebele population: _____________

Household Roster

1. Ask about the name and sex of each person who lives here, starting with the head of the household? List the head of the household (in line 1), all household members; including those who are not at home now, children in school or household members at work.

Line #

Name Sex Age22 15 -49 years23

0-5 months24

6-23 months25 M F

1 1 2 1 1 1 2 1 2 2 2 2 3 1 2 3 3 3 4 1 2 4 4 4 5 1 2 5 5 5 6 1 2 6 6 6 7 1 2 7 7 7 8 1 2 8 8 8

22Age is in months except for those above 2 years

23Circle line number if HH member is a woman aged between 15 and 49 years 24Circle line number if HH member is between 0 and 5.9 months 25Circle line number if HH member is between 6 and 23.9 months

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9 1 2 9 9 9 10 1 2 10 10 10

Total

I. Women Dietary Diversity Score(WDDS) Note: Women of reproductive age (15-49 years) are considered

Respondent’s name: ___________________ Birth date: _____/____/_____ Age: |__|__|years

Confirmed pregnancy: � YES � NO Lactating: � YES � NO

1. Since this time yesterday how many times have you e aten/taken any of the following things to eat?

( Start with the recent food taken in the day. However, if the previous day was a fasting day ask her about the day before (or last non-fasting day).

Food group Frequency

A. Any food enjera, porridge, bread etc made from grai n such as millet, wheat, barley, sorghum, rice, teff, maize |__|__| times

B. Any food made from fruits or vegetables that have y ellow or orange flesh such as carrots, pumpkin, squash, red sweet potatoes, ri pe mangoes, and papaya |__|__| times

C. Any dark green leafy vegetables (gommen, spinach, l ettuce, merengue leaves/ shifra, sama, kale, aleko) |__|__| times

D. Any food made from roots or tubers such as white po tatoes, white yams, cassava, onions, beets, false banana, kocho |__|__| times

E. Any food made from lentils, beans, guaya, peas, nut s (lewz), or seeds (peas, sesame, selyit, chickpea) |__|__| times

F. Any other fruits or vegetables (eggplant, tomatoes, peppers, zucchini, fosoliya, avocado, lemon, green mango, banana) |__|__| times

G. Liver, kidney, heart, or other organ meats. |__|__| times

H. Any meat such as beef, sheep, goat, chicken, or duc k. |__|__| times

I. Fresh or dried fish, shellfish, or seafood. |__|__| times

J. Cheese, yoghurt, or other milk products. |__|__| times

K. Eggs. |__|__| times

L. Sugary foods such as sweets, candies, chocolate, ca kes, and biscuits. |__|__| times

M. Sweetened or flavored water, 'soda' drink, tea or i nfusion, soup, coffee, broth or homemade beer |__|__| times

N. Any food made with oil, fat, butter, or ghee. |__|__| times

Annex IX: Indicators (EBF, MAD and WDDS) definitions for outcome

a. Exclusive Breast Feeding (EBF) Indicator

DEFINITION: This indicator measures the percent of children 0-5 months of age who were exclusively breastfed during the day preceding the survey. Breastfeeding means

that the infant received breast milk (including milk expressed or from a wet nurse) and

may have received ORS, vitamins, minerals and/or medicines, but did not receive any

other food or liquid. The numerator for this indicator is the total number of children 0-5

months in the sample exclusively breastfed on the day and night preceding the survey.

The denominator is the total number of children 0-5 months in the sample with exclusive

breastfeeding data.

RATIONALE: Exclusive breastfeeding for 6 months provides children with significant

health and nutrition benefits, including protection from gastrointestinal infections and

reduced risk of mortality, due to infectious disease.

UNIT: Please enter these two data points:

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14. Percent of children 0-5 months of age in sample who are exclusively breast

fed

15. Total population of children 0-5 months of age in the sample survey

b. Minimum Acceptable Diet (MAD)Indicator

DEFINITION: This indicator measures the proportion of children 6-23 months of age who

receive a minimum acceptable diet (MAD), apart from breast milk. The “minimum acceptable diet” indicator measures both the minimum feeding frequency and minimum

dietary diversity, as appropriate for various age groups. If a child meets the minimum

feeding frequency and minimum dietary diversity for their age group and breastfeeding

status, then they are considered to receive a minimum acceptable diet.

Tabulation of the indicator requires that data on breastfeeding, dietary diversity, number

of semi-solid/solid feeds and number of milk feeds be collected for children 6-23 months

the day preceding the survey. The indicator is calculated from the following two

fractions:

1. Breastfed children 6-23 months of age in the sample who had at least the

minimum dietary diversity and the minimum meal frequency during the previous

day Breastfed children 6-23 months of age in the sample with MAD component

data and

2. Non-breastfed children 6-23 months of age who received at least 2 milk feedings

and had at least the minimum dietary diversity not including milk feeds and the

minimum meal frequency during the previous day Non-breastfed children 6-23

months of age in the sample with MAD component data Minimum dietary diversity

for breastfed children 6-23 months is defined as four or more food groups out of

the following 7 food groups (refer to the WHO IYCF operational guidance

document cited below):

1. Grains, roots and tubers 2. Legumes and nuts

3. Dairy products (milk, yogurt, cheese) 4. Flesh foods (meat, fish, poultry and liver/organ meats)

5. Eggs 6. Vitamin-A rich fruits and vegetables

7. Other fruits and vegetables

Minimum meal frequency for breastfed children is defined as two or more feedings of

solid, semi-solid, or soft food for children 6-8 months and three or more feedings of

solid, semi-solid or soft food for children 9-23 months. For the MAD indicator, minimum

dietary diversity for non breastfed children is defined as four or more food groups out of

the following six food groups:

1. Grains, roots and tubers 2. Legumes and nuts

3. Flesh foods (meat, fish, poultry and liver/organ meats)

4. Eggs 5. Vitamin-A rich fruits and vegetables

6. Other fruits and vegetables

Minimum meal frequency for non breastfed children is defined as four or more feedings

of solid, semi-solid, soft food, or milk feeds for children 6-23 months. For non-breastfed

children to receive a minimum adequate diet, at least two of these feedings must be milk

feeds.

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RATIONALE: Appropriate feeding of children 6-23 months is multidimensional. The

minimum acceptable diet indicator combines standards of dietary diversity (a proxy for

nutrient density) and feeding frequency (a proxy for energy density) by breastfeeding

status; and thus provides a useful way to track progress at simultaneously improving the

key quality and quantity dimensions of children’s diets.

c. Women’s Dietary Diversity Score (WDDS)

DEFINITION: This validated indicator aims to measure the micronutrient adequacy of the diet and reports the mean number of food groups consumed in the previous day by

women of reproductive age (15-49 years). To calculate this indicator, nine food groups

are used:

1. Grains, roots and tubers; 2. Legumes and nuts;

3. Dairy products (milk, yogurt, cheese);

4. Organ meat;

5. Eggs; 6. Flesh foods and other misc. small animal protein;

7. Vitamin A dark green leafy vegetables;

8. Other Vitamin A rich vegetables and fruits;

9. Other fruits and vegetables

The Mean number of food groups consumed by women of reproductive age indicator is

tabulated by averaging the number of food groups consumed (out of the nine food

groups above) across all women of reproductive age in the sample with data on dietary

diversity.

RATIONALE: Women of reproductive age are at risk for multiple micronutrient

deficiencies, which can jeopardize their health and ability to care for their children and

participate in income generating activities. Maternal micronutrient deficiencies during

lactation can directly impact child growth and development but the potential

consequences of maternal micronutrient deficiencies are especially severe during

pregnancy, when there is the greatest opportunity for nutrient deficiencies to cause long

term, irreversible development consequences for the child in uterus. Dietary diversity (assessed here as the number of food groups consumed) is a key dimension of a high

quality diet with adequate micronutrient content; and thus, important to ensuring the

health and nutrition of both women and their children.

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Annex X: Visited kebeles by woreda for exclusive breastfeeding (EBF) indicator

S/No. Zeway Dugda Lay Gayint Enda Mohoni Hawasa Zuria

1 Arba chefa 1 Dum Doya chale

2 Dimtu rareti 2 Emba Hasti Doyo otolcho

3 Chefe burkitu 3 Hadnet Galo argisa

4 Chefe jila 4 Hizba Emoshe humo

5 Hallo 8 Gelewsa Jara dado

6 Genale 9 Jema Jara damuwa

7 Golbe 11 Mekan Jara Hinesa

8 Kiyansho 14 Mesewaeti Jara Galalcha

9 Kobo Borara 15 Nikah Jara Karara

10 Meja Shenen 16 Senay Labu Koromo

11 Senbero 17 Simret Udo Watate

12 Sengo 18 Tahtay Haya Umbulo Wacho

13 Sheled Gutu 19 Tsebet

14 Ubo Bericha 25

15 Unshiti

Annex XI: Visited kebeles by woreda for minimum acceptable diet (MAD)

indicator

S/No.

Woreda

Zeway Dugda Lay Gayint Enda Mohoni Hawasa Zuria

1 Arba Chefa 01 Dum Dore Bafano

2 Burka Lemefo 02 Emba Hasti Doya Chale

3 Chefa Jila 03 Hadnet Doyo Otolcho

4 Chefa Burkitu 04 Gelewesa Emoshe Humo

5 Dimtu Rareti 08 Hizba Galo Argisa

6 Genale 09 Jema Jarra Damuwa

7 Golbe 11 Mekan Jarra Gelelcha

8 Hallo 16 Mesewaeti Jarra Hinesa

9 Herara 15 Nikah Jarra Kerera

10 Kiyansho 16 Senay Labu Koromo

11 Kobo Borara 17 Shemta Tankaka

12 Meja Shenen 18 Simret Umbullo Wacho

13 Sengo 19 Tahtay Haya

14 Senbero 21

15 Sheled Gutu 25

16 Ubo Bericha

17 Unshiti

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Annex XII: Visited kebeles by woreda for women dietary diversity score (WDDS)

S/No. Woreda

Zeway Dugda Lay Gayint Enda Mohoni Hawasa Zuria

1 Arba Chefa 01 Dum Dore Bafano

2 Burka Lemefo 02 Emba Hasti Doya Chale

3 Chafa Burkitu 03 Hadnet Emoshe Humo

4 Chafa Jila 04 Hizba Galo Argisa

5 Dimtu Rareti 08 Gelewesa Jarra dado

6 Hallo 09 Jema Jarra damuwa

7 Herera 11 Mekan Jarra Hinesa

8 Genale 14 Mesewaeti Jara Gelelcha

9 Golbe 15 Nikah Jarra kerera

10 Kobo Borara 17 Senay Labu Koromo

11 Kiyansho 18 Shemta Tankaka

12 Maja Shenen 19 Simret Uddo Wotate

13 Senbero 21 Tahtay Haya Umbulo Wacho

14 Sengo 25 Tsibet

15 Sheled Gutu

16 Unshiti

17 Ubbo bericha