Sustainable Undernutrition Reduction in Ethiopia
Condition: Stunting; Dietary Deficiency; Anemia
MeSH terms: Malnutrition; Growth Disorders
Study type: Interventional

Summary: 
      The causes of malnutrition are complex and addressing the problem requires integrated action
      among various sectors. Globally, much attention has been given to nutrition-specific
      interventions to address the immediate causes of undernutrition. But undernutrition
      prevalence is decreasing at a very slow rate. Nutrition-specific interventions address the
      immediate determinants of child undernutrition, such as inadequate food and nutrient intake,
      but do not consider the underlying causes such as food insecurity, poverty, and limited
      access to clean water, hygienic environments, and health services.

      Ethiopia still has a high prevalence of undernutrition. The current situation of food
      insecurity and malnutrition in Ethiopia has pressurized the government in pursuing a number
      of nutritional-sensitive interventions to increase diversified food production and
      consumption like the Sustainable Undernutrition Reduction Program (SURE).

      This study aims to investigate whether joint nutrition specific and sensitive interventions
      can lead to improved household food security, dietary diversification and improved
      nutritional status in Ethiopian mothers and their young children.

      The study will be a community based longitudinal design and will use multistage cluster
      sampling at the Kebele and household levels in Amhara, Oromia, and Southern Nations,
      Nationalities, and Peoples' Region (SNNPR) regions.

      Households will be randomly selected from the intervention and the non-intervention arms at
      Kebele level, with 15 households per Kebele. The same children whose baseline are available
      who were 0-23 months of age at the time of the baseline assessment in 2016 will be recruited
      as well as their mothers. This represents approximately third of the total sample size at
      baseline.
    

Detailed description: 
      Globally 25% of children under age 5 years of age are stunted, i.e. the child's height is
      more than 2 standard deviations (SD) below the median length/height-for-age as determined by
      the world health organization child growth standards. Sub-Saharan Africa remains the region
      with the highest prevalence of undernutrition. Stunting, a multifactorial condition, develops
      as a result of sustained inadequate nutrition and recurrent infections. Socioeconomic and
      environmental factors are considered to be important determinants of stunting. Stunting has
      long term detrimental effects on cognitive development, school achievement and income and
      hence potentially perpetuates the vicious circle of poverty and malnutrition. Interventions
      that target directly maternal and child health and nutrition such as maternal supplementation
      with iron and folic acid and promotion of exclusive and continued breastfeeding, have proven
      effective in enhancing child and maternal nutrition status and in reducing mortality in women
      and children. The evidence accumulated over the previous years has also shown that if
      nutrition-sensitive approaches (i.e. women's empowerment, agriculture, food systems and
      education) are integrated in nutritional-specific interventions, they can significantly
      accelerate progress in countries with the highest burden of maternal and child undernutrition
      and mortality.

      Diversified diet provides a balance of nutrients that promote healthy growth and development.
      Agricultural interventions to improve production of micronutrient-rich foods, through
      increased productivity, home gardening and diversification efforts have a significant
      potential to improve dietary diversity and micronutrient intake of children. However, in
      Ethiopia there is limited evidence on the contribution of nutrition-sensitive agricultural
      interventions on dietary diversity and nutritional status of children. Our study evaluates a
      larger governmental programme "sustainable undernutrition reduction in Ethiopia (SURE)", a
      multi-sector integrated health and agriculture programme that aims to strengthen the existing
      nutrition specific interventions by addressing two key determinants of undernutrition:
      inadequate complementary feeding and household dietary diversity.

      The SURE package includes: 1) promoting diversified agriculture; 2) promoting infant and
      young child feeding practices; 3) women empowerment in decision making related to
      agriculture, food and health; and 4) enhanced food security and Water, Sanitation and Hygiene
      (so-called "WASH") practices.

      The programme started in 2016 and is implemented by the Ministries of Health and Agriculture
      in Ethiopia through a funding by the Children's Investment Fund Foundation (CIFF). The
      Ethiopian Public Health Institute (EPHI) has been contracted by the Ethiopian Ministry of
      health to deliver the programme and to carry out its evaluation at the level of impact,
      process and cost-effectiveness.

      Aims of the Study The study aims to investigate whether access to diversified food through
      improved nutrition education and enhanced diversity in local and household food production
      leads to improved household food security, which in turn results in diversified dietary
      consumption and improved nutritional status of children 4 -6 years of age.

      In a control longitudinal study design, our primary objective is to assess the extent of
      diversified food production and consumption as a result of SURE intervention and to evaluate
      their effects on nutritional status of children in the target/intervention communities
      compared to the agricultural practices, food insecurity and nutritional status of children in
      comparable communities in the control group.

      Our second objective is to identify factors that mediate the association between diversified
      food production and diversified food consumption and design a model for a modified
      intervention to strengthen the association between diversified food production and
      consumption at a household level.

      Our third objective is to identify key barriers and opportunities of adopting infant and
      young child feeding practices (IYCF) and nutrition sensitive agriculture interventions.

      Methodology The study is part of the evaluation of the government project "SURE". The
      evaluation will have a mixed-method study design (quantitative and qualitative). A
      longitudinal survey will be carried out in a representative sample of households four years
      post-intervention, at the end 2020. The survey will use multistage cluster sampling at the
      Kebele and household levels.

      Quantitative data

      Baseline data collection: The survey at baseline collects data on: 1) child (6-23 months)
      nutritional status (height, weight, and hemoglobin concentration); 2) Infant and YCF
      practices including breastfeeding, minimum meal frequency, minimum dietary diversity and
      minimum acceptable diet; 3) maternal knowledge, attitude and practice regarding IYCF; 4)
      women empowerment; 5) household food insecurity and dietary diversity; 6) water, sanitation
      and hygiene (WASH); and 7) health services and morbidity symptoms of the child during the 15
      day-preceding the interview day (received vitamin A supplement in the previous 6 months;
      diarrhea; cough; fever and; attending the growth monitoring program).

      Key behaviors and agriculture outcomes at household level in the intervention and in the
      control groups will also be collected. These are: number of trainings organized in the
      community; crop production diversity; animal husbandry (eggs, chicken, milk, small and large
      livestock for meat).

      In addition to outcome indicators, socioeconomic indicators such as age, ethnic group and
      education level will also be collected.

      Follow-up data collection: follow-up surveys will be conducted after an exposure of four
      years in the intervention and the control groups. The same indicators collected at baseline
      will be collected during 2020 but in households with children who will now be 4-6 years of
      age (hypothetically these children would have been exposed to the intervention).

      Qualitative data Qualitative methods will be used to examine the quality of implementation
      mechanisms of change, and contextual data to help interpret findings of the impact
      evaluation. Additionally, household expenditure will be estimated to determine the average
      cost of the intervention per case of stunting averted
    

Intervention name(s): Standard programme; SURE intervention
Intervention type(s): Behavioral; Behavioral
Intervention description(s): The control arm will receive national standard programme for women and children under the age of 2 years. This includes 1) national nutrition and health care including iron & folic acid (IFA) supplementation in pregnancy; 2) early initiation and exclusive breastfeeding until 6 months of age; 3) timely introduction of liquid and semi-solid complementary foods; and 4) diversified complementary foods.; The SURE package includes: 1) promoting diversified agriculture; 2) promoting infant and young child feeding practices; 3) women empowerment in decision making related to agriculture, food and health; and 4) enhanced food security and Water, Sanitation and Hygiene ("WASH") practices.
Other intervention name(s): Control; Intervention
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: The study is part of the evaluation of the Government project "SURE". SURE intervention districts were pre-selected in four regions out of the nine regions in Ethiopia. The regions were selected because they are agrarian and have high food insecurity and stunting prevalence (Oromia, Amhara, SNNPR and Tigray). A total of 36 districts were selected and assigned to the SURE intervention.
Comparison control districts were selected in equal number in the same four agrarian regional strata. Districts were roughly matched based on stunting prevalence tertiles (low, medium or high) and food insecurity scores. Eligible households are households with at least one child under the age of 2 years. The intervention started in 2016 and included 4299 households, 2146 of which were included in the intervention group and 2153 in the control group. After baseline data collection, all households in the intervention group received counselling at household and community levels.
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Stunting; Diet diversity; Food production; Household food security; Women empowerment; Knowledge, Attitudes and Practices; Anemia; Malaria