DETERMINANT OF NUTRITION SECURITY IN SHONE DISTRICT, HADIYA ZONE, SNNPR

Transcription

1 DETERMINANT OF NUTRITION SECURITY IN SHONE DISTRICT, HADIYA ZONE, SNNPR BY: ENDASHAW SHIBRU (BSc) ADVISOR: FIKRU TESFAYE (MD, MPH, PHD) A thesis submitted to the school of graduate studies of Addis Ababa University, Medical Faculty, School of Public Health in partial fulfillment of the requirement for the Degree of Masters of Public Health Jun 2009 ADDIS ABABA, ETHIOPIA

2 ACKNOWLEDGEMENT I would like to express my heartfelt gratitude for my advisor Dr Fikru Tesfaye for his continued support during proposal writing, data collection and finalizing this paper. I also thank government and non-government official of East Badawacho woreda for allowing and facilitating this study. I am grateful for Addis Ababa University, School of Public Health for financing this study. My thanks also go to Ato Eskindir Loha for support during statistical data analysis. I thank community members of East Badawacho for their willingness to participate in this study, and also Health Extension Workers and their supervisors for involvement in data collection. I

3 TABLE OF CONTENTS ACKNOWLEDGEMENT... I TABLE OF CONTENTS...II LIST OF TABLES...III LIST OF ACRONYMS AND ABBREVIATIONS... IV ABSTRACT...V 1. INTRODUCTION LITERATURE REVIEW OBJECTIVES METHOD Study design and period Study area Study population Sample size determination Sampling method Data collection and instrument Study Variables Independent Variables: Dependent Variables: Data processing and analysis: Ethical consideration Dissemination of the result Operational Definitions RESULT Quantitative survey Qualitative DISCUSSION LIMITATION OF THE STUDY CONCLUSION RECOMMENDATION REFERENCES ANNEXES Annex 1: Questionnaire Annex 2: Question guides for FGD and Key Informant Interviewing Annex 3: Consent form II

4 LIST OF TABLES Table 1: Socio-demographic profile of the households, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 2: Family planning, ANC follow up and place and attendant of delivery, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 3: Breastfeeding practice of respondents, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 4: Child feeding practices, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 5: Immunization history of the children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 6: Childhood illness, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 7: Water and sanitation indicators, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 8: Housing condition, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 9: Food Security indicators, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 10: Nutritional status of children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 11: Determinants of nutritional status as measured by weight for age, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 12: Determinants of nutritional status as measured by weight for height/length, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March Table 13: Determinants of nutritional status as measured by height for age, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March III

5 LIST OF ACRONYMS AND ABBREVIATIONS ANC BCG CI DPPC GAM HAZ HEW MUAC NCHS NGO FAO OR OTP RUTF SAM SC SD SNNPR SPH SPSS SSA WAZ WHO WHZ Antenatal care Bacili, Calamete Gurin Confidence interval Disaster Prevention and Preparedness Committee Global Acute Malnutrition Height for age Z-score Health Extension Workers Mid Upper Arm Circumference National center for Health Statistics Non-governmental organization Food and Agricultural Organization Odds Ratio Outpatient Therapeutic Program Ready to Use Therapeutic Food Severe Acute Malnutrition Stabilization Center Standard deviation Southern Nations and Nationalities Peoples Region School of public Health Statistical Package for Social Sciences Sub-Saharan Africa Weight for Age Z- score World Health Organization Weight for Height Z-score IV

6 ABSTRACT Background: Underlying malnutrition is responsible for half of the deaths occurring among children under five years of age. Studying causes of malnutrition and acting upon, therefore, would help in magnificent reduction in mortality in this age group. Despite the fact that nutrition security is essential for improvement of child and maternal health little is known about the problem in the rural Ethiopia. Objective: To assess nutritional security and determinants at household level of Shone district, Hadiya Zone, SNNPR Method: A cross-sectional community based survey was conducted. Structured questionnaire and anthropometry measuring equipments were used for the quantitative survey involving 856 households having at least one 6-59 months old child, and check list were used to make 2 FGD s and 3 key informant interviews. Systematic sampling method was employed for the quantitative survey. WHO Anthro and SPSS 11 were used for analysis. Result: The mean household size was 6.6 and the average number of children per household was 4.2. The majority, 664 (77.8%) mothers were illiterate. Very few mothers, 37 (4.8%) were current family planning method users. Nearly half, 403 (48%) mothers attended ANC. Night blindness were observed in 128(16%) children and 118(14.1%) had bito t spot. Eighty four (10.4%), 366 (42.8%) and 647 (75.6%) children were wasted, underweight and stunted, respectively. Meanwhile, 38 (4.4%) had MUAC <11cm. Child s age, year difference between the last two births, antenatal care during the index child, hand washing practice before handling food, child excreta disposal and house type were important predictors of child malnutrition. Nearly all (98.5%) respondents reported that the food runs out before they get money, and 92% experienced hunger. Majority of respondents said coping mechanism to food insecurity in the community includes reducing the amount of food and frequency of eating; putting children in well-to-do relatives selling labor cheaply, renting land, begging, borrowing money chewing khat V

7 drop out of school and engage in petty trade to support family member and going to towns in search of work. Dependency syndrome entrenched in the community. Conclusion: Prevalence of malnutrition, vitamin A deficiency and food insecurity in the study area was very high compared to regional and national. Revision of approaches of intervention programs and enhancing concerted efforts of relevant bodies should be emphasized. VI

8 1. INTRODUCTION The nutritional status of young children and women of reproductive age reflects household, community, and national development. Children and women are most vulnerable to malnutrition in developing countries because of low dietary intakes, infectious diseases, lack of appropriate care, and inequitable distribution of food within the household (1). In communities that have little access to, and contact with, health care, children are more vulnerable to malnutrition as a consequence of inadequate treatment of common illnesses, low immunization rates, and poor antenatal care. Poor environmental sanitation, including insufficient safe water supply, also puts children at risk of infection which increases susceptibility to malnutrition. Infant and child care, along with household food security, adequate health services and a healthy environment are a necessary precondition for adequate nutrition (2). It is also well recognized that poor nutritional status in developing countries is mainly caused by fetal growth retardation which often result from low maternal food intake, hard physical work, limited nutritional knowledge, and infection during pregnancy (3). High malnutrition rates in Ethiopia pose a significant obstacle to achieving better child health outcomes. Ethiopia has among the highest underweight and stunting rates among young children in SSA. Almost one out two children are moderately to severely underweight, and 16 percent are severely underweight. Chronic malnutrition in Ethiopia is worst than in other SSA countries: about one in two children were moderately to severely stunted, and slightly more than one in four children (26 percent) were severely stunted. On the other hand, severe to moderate wasting at 11 percent was relatively lower compared to other SSA. Regional and urban/rural differences in child malnutrition are prominent in Ethiopia. Prevalence of underweight is more than three times higher in Tigray, Afar, Amhara and SNNPR than in Addis Ababa. Stunting is almost twice as high in SNNPR and Amhara compared to Addis Ababa. Urban /rural differences exist, which are as marked as regional differences. Severe to moderate underweight is 15 percentage points higher in rural areas than in urban areas, and moderate to severe stunting is ten percentage points higher in rural areas compared to urban areas. The rate of malnutrition 1

9 is the highest among the month olds for all the three forms stunting is a far more wide spread nutritional problem than wasting in Ethiopia (3, 4, and 5). Malnutrition slows economic growth and perpetuates poverty through three routes direct losses in productivity from poor physical status; indirect losses from poor cognitive function and deficits in schooling; and losses owing to increased health care costs (6). The supply of food is not a major determinant of malnutrition in the developing world. Rather, it is a lack of purchasing power of some households that prevents them from securing adequate diets (7). It has been argued that throughout the developing world there is a preferential allocation of food to adult men at the expense of adult women and children. This has been observed in various countries in the developing world, but it is not a universal phenomenon. Many different food distribution patterns have been observed, including biases favoring all adults (8). Over 800 million people in developing countries do not have, at all times, Physical and economic access to sufficient, safe, and nutritious foods to meet their daily dietary needs and food preferences for an active and healthy life (9). Nearly one-third of children in the developing world remain underweight or stunted, the picture was now changed in Sub- Saharan Africa malnutrition is on the rise in Asia malnutrition is decreasing, but South Asia still has both the highest rates and the largest numbers of malnourished children (5). Ethiopia is one of the least developed countries in the world and is the second most severely affected by malnutrition worldwide. The prevalence of malnutrition in Ethiopia continues to increase, affecting primarily women & children. (5) Earlier studies have estimated Ethiopia s food insecure people to be around 40-50% of the total population. Although on-going humanitarian interventions and the good prospects for the meher or main season continue to have a positive impact on the food security of the population, 10.4 million people require humanitarian assistance through the Productive Safety Net Program (7.3 million people) and the emergency program 2

10 (3.1 million people). This level of food insecurity is expected to persist, especially in pastoral areas (10). The chronically food insecure areas of eastern Ethiopia and the southern pastoral zones of Oromiya and Somali Regions continue to be the most food insecure areas (11). To my search no study was conducted on assessment of house hold nutritional security in the SNNPR so that, the finding of this research will give recent valuable data for comparison with other studies in developing countries. More over this will helps program managers in program designing planning, targeting, implementation, monitoring, and evaluation. 3

11 2. LITERATURE REVIEW Malnutrition undermines economic growth and perpetuates poverty. Yet the international community and most governments in developing countries have failed to tackle malnutrition over the past decades. The consequences of this failure to act are now evident in the world s inadequate progress toward the Millennium Development Goals (MDGs) and toward poverty reduction more generally. Persistent malnutrition is contributing not only to widespread failure to meet the first MDG to halve poverty and hunger but to meet other goals in maternal and child health, HIV/AIDS, education, and gender equity (5). The nutritional status of young children and women of reproductive age reflects household, community, and national development. Children and women are most vulnerable to malnutrition in developing countries because of low dietary intakes, infectious diseases, lack of appropriate care, and inequitable distribution of food within the household (1). Over 800 million people in developing countries do not have, at all times, physical and economic access to sufficient, safe, and nutritious foods to meet their daily dietary needs and food preferences for an active and healthy life (9). Sub-Saharan Africa (SSA) has had an aggregate malnutrition rate of nearly 30 percent for the last decade. While malnutrition prevalence has decreased significantly in most other developing countries in the last decade, it has been nearly static for SSA. This static trend in the percentage of malnourished children, however, does not fully reflect the rapidly rising numbers of malnourished children given SSA s high population growth rate. (12) Ethiopia has among the highest underweight and stunting rates among young children in SSA. (15) Forty-seven percent of children under five are stunted and 24 percent are severely stunted. Eleven percent of children under five are wasted and 2 percent are severely wasted. The weight forage indicator shows that 38 percent of children under five are underweight and 11 percent are severely underweight (1). Regional and urban/rural differences in child malnutrition are prominent in Ethiopia. Prevalence of underweight is more than three times higher in Tigray, Afar, Amhara and SNNPR than in Addis Ababa. 4

12 Stunting is almost twice as high in SNNPR and Amhara compared to Addis Ababa. Urban /rural differences exist, which are as marked as regional differences (5). The prevalence of wasting is higher than the national average among children age 9-23 months. The percentage of children classified as wasted is highest among children of birth order 4 and 5 (13 percent). Previous studies indicated relationship between malnutrition and human behaviour, particularly to maternal education, is very important, in developing countries where malnutrition in preschool children is common. Various studies indicate that when malnutrition occurs during one of the critical phases of development, permanent damage occurs in the functioning of the central nervous system with impaired motor and mental development (3). Among the socio-economic variables, household income is one of the major factors to be considered very important in determining children s nutritional status; however, income does not always directly contribute to improving the nutritional well-being of children. Lack of knowledge regarding the nutritional needs of children may lead to the withholding of needed food, even when it is available (2). Food security is a concept that has evolved during the 1990s far beyond a traditional focus on the supply of food at the national level. The definition adopted by the countries attending the World Food Summit of 1996, and reconfirmed in 2002, accepts USAID s three key concepts: i) food availability, ii) food access, and iii) food utilization. However, a fourth concept is increasingly becoming accepted; namely, the risks that can disrupt any one of the first three factors. Availability, access and utilization are hierarchical in nature food availability is necessary but not sufficient for access, and access is necessary but not sufficient for utilization. There is a feedback loop in that adequate and appropriate utilization is an input to achieving adequate access for all (via health, sound nutrition and other human capital effects), while access is required for sustainable food availability (where chronic undernourishment impairs labor productivity and encourages resource depletion). Risk represents a cross-cutting issue that affects all components of the food security framework (13). 5

13 Household food security is an important measure of well-being. Food security encompasses three dimensions: availability (a measure of food that is, and will be, physically available in the relevant vicinity of a population during a given period); access (a measure of the population s ability to acquire available food during a given period); and utilization (a measure of whether a population will be able to derive sufficient nutrition during a given period). Although it may not encapsulate all dimensions of poverty, the inability of households to obtain access to enough food for a productive healthy life is an important component of their poverty (16). Poor households typically make economically rational decisions in the face of a wide variety of risks and opportunities. They adapt local knowledge to multiple scenarios and balance possible gains against required investments in the form of their own labor, capital and natural resources. But risks arise in many quarters. Food supply can be affected by climatic fluctuations, soil fertility depletion, or the loss of a household s productive assets. Market access can be affected by changing global terms of trade, market disruption during crises, or non-farm employment insecurity. Food utilization is often impaired by epidemic disease, lack of appropriate nutrition knowledge or culturally prescribed taboos that affect access to nutritious foods according to age or gender (13). The supply of food is not a major determinant of malnutrition in the developing world. Rather, it is a lack of purchasing power of some households (and nations) that prevents them from securing adequate diets (7). It has been argued that throughout the developing world there is a preferential allocation of food to adult men at the expense of adult women and children. This has been observed in various countries in the developing world, but it is not a universal phenomenon. Many different food distribution patterns have been observed, including biases favoring all adults (8). Food insecurity is a daily reality for hundreds of millions of people around the world. The most extreme forms are obvious in the widespread malnutrition and preventable mortality of children in Niger, the micronutrient deficiency disease outbreaks in 6

14 refugee camps in Nepal, the recourse among food-deprived households of North Korea to foraged wild foods such as tree bark, acorns, and rotting seaweed. In relation to measures of poverty, much about poverty is obvious. One does not need elaborate criteria, cunning measurement, or probing analysis, to recognize raw poverty and to understand its antecedents. But not everything about poverty is quite so simple. Even the identification of the poor and the diagnosis of poverty may be far from obvious when we move away from extreme and raw [conditions]. Different approaches can be used, and there are technical issues to be resolved within each approach (13). Ethiopia, Zambia suffered two major droughts in recent years: in and (as well as a more localized drought in ).21 In an effort to protect food security during these droughts, Zambian governments attempted to increase food supplies through a combination of government commercial imports, food aid and private sector imports (and bans on exports). Food and cash transfer programs were implemented as well, in an effort to increase access to food by food-insecure households. These policies appear to have been relatively more successful in maintaining availability of food in than in , in spite of improved early warning capacity (1). The absence of adequate analytical capacity has been suggested frequently as a major factor in determining the appropriateness of food and nutrition policy interventions. Considerable efforts have been made in developing and strengthening institutions and the necessary human capacity for designing and implementing food and nutrition programmes in developing countries. However, the impact of such efforts in creating a sustainable core of food and nutrition policy analysts and planners has been limited (14). Recently governments in developing countries have focused on policy reforms as a major tool of intervention in the process of economic development. Although the methods of capacity-strengthening have changed accordingly, the capacity generated by such efforts remains grossly inadequate to meet the policy analysis needs of the governments (14). 7

15 Study done in Ecuador recognized that stunting most often occurs in the first few years of life. Although non-nutritional factors surely are important in the stunting process malnourishment is often the limiting factor. Targeting nutrient-dense foods available in the community to the children may cause a decrease in stunting and its associated complications. (8) 8

16 3. OBJECTIVES 3.1. General Objective To assess nutritional security and determinants at house hold level of Shone district, Hadiya Zone, SNNPR 3.2 Specific Objectives 1. To assess nutritional status of the children 2. To determine factors affecting nutritional status 3. To asses food security status at household level 9

17 4. METHOD 4.1 Study design and period Quantitative and qualitative cross sectional study was conducted from Jan. to Feb Study area The study was conducted in East Badawacho Woreda, Hadiya Zone. The district has a total population of 165,632 out of which 16,616 are urban and 149,016 are rural inhabitants. Shone town, the district capital is found 345Km, South of Addis Ababa, on the main road to Walayta Sodo. It is situated in the rift valley. The climate of East Badawacho Woreda is dry mid high land and moist mid high land with mm rain fall in a year. Its altitude ranges 1,560 to 2200 meters above sea-level. The soil type is dominated by brown sandy silt and highly susceptible for erosion. 4.3 Study population The study populations were all house holds with at least one under five years old child in the two selected peasant associations. Inclusion criteria 1. House holds with at least a child of age 6 to 59 months. 2. House holds with a minimum of 6 months residence Exclusion criteria 1. Mothers/care takers with mental illnesses, communication problems or other severe conditions interfering the interview 2. House holds where there is/are no child of age 6 to 59 months of age or children with severe deformities 10

18 4.4 Sample size determination The sample size required for this study was determined using the formula for estimating single population proportion. The prevalence of malnutrition in preschool children in rural communities of SNNPR using height for age is 51.6%. Using 95% confidence interval and 5% absolute precision the sample size was: n = Z 2 d pq 2 Where, n= minimum sample size Z= 1.96 (95% Confidence level) p=prevalence of stunting in SNNPR (51.6%) q=1-p d= margin of error n = ( ) = 384 Using the design effect of 2 the total sample size became:- 384*2=768 with 10% non respondents rate, the total sample size would be 845; however, data were collected from 856 households with a surplus of 11 households. 4.5 Sampling method Lottery method was used to select 2 of the 34 peasant associations. The sample size was allocated to each kebele using Probability Proportional to Size method. Data collectors went to the centers of 20 sub-kebeles of the two kebeles and spin a pencil and followed the direction to collect data from every other household till the required sample size obtained. Where there was more than one child in a household, one child was selected by lottery method for the anthropometric measurements. 11

19 4.6 Data collection and instrument Data were collected from mothers/care takers in the selected households and one child aged 6-59 months from each household was considered for anthropometric measurement. Pre-tested and structured questionnaire was used. Ten health extension workers were recruited as research assistants. To minimize interobserver variation of data collectors and increase their performance in field activities, two days training was given on the aim of the research, content of the questionnaire, and how to conduct questionnaire interview. Collected data was checked every day by supervisors and principal investigator for its quality and coding. Data collection was completed in one month. Anthropometric measurements (weight, height, and mid upper arm circumference) was done for all children included into the study. Weight was measured in kilogram to the nearest 0.1 Kg. Salter hanging scale for Children 6 to 23 months and beam scale for children over 24 months of age was used for measuring weight. Instruments were checked against a standard weight for its accuracy daily. Calibration of the indicator against zero reading was checked following weighting every child. Length was taken with length board for those children less than two years of age, while height was taken for children two and above years in centimeter. Length and height was measured to the nearest 0.1 cm. Left mid-upper arm circumference was measured. The nutritional indicators, weight-for-height, weight-for-age, height-for-age and mid upper arm circumference-for-age was compared with reference data from the WHO. Children 12

20 below -2 Z score of the weight-for-age, height-for-age and weight-for-height was considered under-weight, stunted or wasted, respectively. Values of the indicators below -2 Z score were considered to represent moderate under nutrition, while values below > or equal to -3 Z score were taken to indicate severe malnutrition. Data were collected from key informants that involved woreda food security coordinator, World Vision International Shone ADP food security officer and Woreda Health Office Head. Two FGDs were conducted. It involved religious leaders, cultural leaders, HEW, agricultural development agents, teachers, women representative, traditional birth attendants, kebele leaders, political coordinator of kebele and women s affair. The group size was each. 4.7 Study Variables Independent Variables: Socio-demographic variables such as age, occupation, marital status, religion, ethnicity, educational level, income, household size, etc. Personal hygiene of the care taker, sanitary practices, housing conditions, etc Health services utilization as measured by ANC, family planning, etc. Child feeding practices Dependent Variables: WHZ, WAZ, HAZ, MUAC and Food security 13

21 4.8 Data processing and analysis: Data were entered, cleaned and analyzed using SPSS 11.0 for Windows. Data were exported to WHO Anthro to calculate WHZ, WAZ and HAZ according to anthropometric standards/references of WHO. Binary logistic regression was used for analysis. Bivariate analyses were done to explore potential predictors of under nutrition. And multivariate analyses were carried out to control for potential confounders. Only those variables showing statistical significance (P <0.05) during bivariate analyses were entered into the multivariate model. Odds Ratio with 95% CI was reported. 4.9 Ethical consideration Ethical clearance for the proposal was obtained from the Research and publication Committee, Faculty of Medicine, Addis Ababa University. Written letter of permission was obtained from Hadiya Zone Health department, East Badawacho Woreda Health office. The aim, purpose, benefits and method of the study was clearly explained to the participant. All of the study groups were informed that, their response was kept secret. Finally, they were interviewed after informed consent obtained. The interview was done in a way that it will not violate their privacy and confidentiality of information. Thus, name and address of the interviewees were not recorded in the questionnaire. The respondents were informed that they have the right to be involved or not to be involved in the study. Those children with health problems were referred to health center for further management. 4.9 Dissemination of the result The study result will be disseminated to SPH, Medical Faculty of Addis Ababa University, Hadiya Zone health department, and East Badawacho Woreda health office. Attempts will be made to publish the finding in peer-reviewed journal and present in scientific conference. 14

22 4.10 Operational Definitions Food security (HFS):- refers to the ability of a household to assure all its members sustained access to sufficient quantity and quality of food to live active health lives. Family size: - The total number of people livving in a house during the study period. Literacy: - Ability to read and write. Parent: - Biological father and mother. Diarrhea: - Three or more loose stools over a period of 24 hours. Supplemental Diet: - Any kind of food items (liquid or solid-form) other than breast milk. Acute malnutrition or wasting: - A nutritionally deficient state of recent onset related to sudden food deprivation or mal-absorption or poor utilization of nutrients which results in rapid weight loss. The highest prevalence occurs in times of famine, during seasonal food shortages or during severe illness. Weight-for-height reflects body weight relative to height. Wasting refers to low weight-for height <-2 Standard deviations (SD) of the median value of the National Centre for Health Statistics /World Health Organization (NCHS/WHO) international weight-for-height reference. Chronic malnutrition or Stunting: - reflects long term cumulative effects of inadequate nutrition and health. Shortness in height refers to low height-for-age that may reflect either normal variation in growth or a deficit in growth. Stunting refers to shortness that is a deficit or linear growth retardation. Stunting is defined as low height-for-age at <- 2SD of the NCHS/WHO international growth reference. Severe stunting is defined as <- 3SD. Underweight: - An anthropometric index of weight-for-age represents body mass relative to age. Weight for age is influenced by the height and weight of a child and is thus a composite of stunting and wasting, making interpretation of this indicator difficult. Underweight refers to a deficit and is defined as low weight for age at <-2SD of the NCHS/WHO international reference. GAM (Global Acute Malnutrition); WFH < -2.0 Z-score or < 80.0% Median all with edema included. 15

23 SAM (Severe Acute Malnutrition): WFH < -3.0 Z-score or < 70.0% Median all with edema included. Night blindness: is poor vision at night or in dim light. Bitot's spots: foamy gray, triangular spots of keratinized epithelium on the conjunctiva, associated with vitamin A deficiency. 16

24 5. RESULT 5.1 Quantitative survey A total of 856 households, having at least one child aged 6-59 months, were included in the survey from two kebeles (Woyra Gere: 465, and Mehal Korga: 391) of East Badawacho woreda, Hadiya zone, South Ethiopia. The mean household size was 6.6 (SD: 2.2, Range: 2-17), meanwhile, the average number of children per household was 4.2 (SD: 2.1, Range: 1-15) and this figure for under five years age group was 1.5 (SD: 0.6, Range: 1-4). The majority, 664 (77.8%) mothers were illiterate, meanwhile, this figure was lower for husbands, 493 (57.9%). For most of the households, the main occupation was farming (798 (93.7%)), and nearly all, 824 (98.2%) mothers were housewives. Among the respondents, 799 (93.8%), 501 (59.4%), 758 (90%) and 819 (96%) were married in union, in the age group years, from ethnic group Hadiya and Christians, respectively (Table 1). Very few mothers, 37 (4.8%) were current family planning method users. Injectable method (73%) was the most preferred one. One third, 221 (33.8%) respondents gave the last two successive births within 2 years duration. Nearly half, 403 (48%) mothers attended ANC. However, the majority, 795 (94.4%) gave birth at home (Table 2). 17

25 Table 1: Socio-demographic profile of the households, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Education: Mother Illiterate (n=854) Literate Education: Husband Illiterate (n=852) Literate Family main occupation (n=852) Mother s occupation Farming Petty trading Other Housewife (n=839) Other Marital status of the mother(n=852) Maternal age* (n=844) Ethnicity (n=842) Religion (n=853) *Mean (SD) = 31.2 (5.8) years Married in union Married not in union Divorce Widowed and above Hadiya Wolayta Other Christian Muslim Other

26 Table 2: Family planning, ANC follow up and place and attendant of delivery, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Current use of family Yes planning method (n=772) No Pills Family planning methods Injectable used (n=37) Implant <24 months Interval between the last two months children (n=653) >48 months ANC attendance during Yes index pregnancy (n=839) No Place of birth (n=842) Home Health facility TTBA Delivery attendant (n=839) Health personnel Other The majority of 816(95.7%) mothers breastfeed their child, 624(76.5%) initiating breastfeed with in an hour and only89 (10.9%) discontinuing breastfeeding before six month. Illness and not enough milk are the two reasons not breastfeed the child. (Table 3) Only 56(6.6%) mothers start complimentary feeding immediately after birth, 230(27.1%), 553(65.1%) with in one to six month and with in six to twelve month respectively. Milk was became food item commonly given24 (42.9%) respondent mothers followed by 3(5.4%) butter and 2(3.6%) water. (Table 4) 19

27 Table 3: Breastfeeding practice of respondents, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Breastfeeding (n=853) Yes No With in the 1 st hour Time of initiation of With in the 1 st 8 hours breastfeeding (n=816) After 2-3 days Not remembered < 6 months months Duration of breastfeeding 1-2 years (n=816) More than 2 years Still feeding Not remembered Reason for not breastfeeding Due to illness (n=37) Others Bottle feeding was practiced by only 50(5.9%) mothers. Half of respondents were not feeding animal source to the children. However, fruits and vegetables was given by 567(67.2%) and 641(75.9%) respectively (Table 4). In immunization status 471(55.3%) vaccinating their children at least once and 389(80.7%) mothers were confirmed with vaccination card. Two-third 262 (67.4%) respondents fully vaccinating and lack knowledge 309(86.6%) were the major reason for not vaccinating. Vitamin A supplementation was given for 495(59.6%) children with in the last six months (Table 5). 20

28 Table 4: Child feeding practices, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Immediately after birth Time of complementary food Within 1-6 months started (n=850) Within 6-12 months months later Butter Water and sugar Food item given immediately Milk after birth (n=56) Water only Other Milk First complementary food Adult food (n=808) Porridge Other Bottle-feeding practice Yes (n=847) No Yes daily Feeding animal source foods Yes less frequently (n=820) No Yes daily Feeding fruits source foods Yes less frequently (n=844) No Yes daily Feeding vegetables source Yes less frequently food (n=845) No

29 Table 5: Immunization history of the children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Ever vaccinated Yes (n=851) No Vaccination card Yes available (n=482) No Type of vaccine (n=389) Reason for not get vaccinated (n=357) Vitamin A supplementation in the last six month (n=830) BCG only BCG, Penta 1, Polio BCG, Penta 2, Polio BCG, Penta 3, Polio BCG, Penta 3, Polio 3 and measles Time shortage Lack of knowledge Inaccessibility of the service Unavailability of the service Fear of side effects 18 5 Other Yes No One third 296(36.8%) children were sick with in the last two weeks, the majority 215(72.6%) had fever, 174(58.8%) managed by home treatment. Vision problem were observed in 128(16%) children and 118(14.1%) had foamy scar in there eye (Table 6). 22

30 Table 6: Childhood illness, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Any sickness within the Yes last two weeks (n=804) No Fever Ailments (n=296) Cough Diarrhea Other Home treatment Treatment given for the Visited health facility ailments (n=296) Consulted traditional healer Other Night blindness (n=801) Yes No Foamy scar on the Yes eye(bitot spot) (n=836) No Almost all 834(98%) of respondents were using pipe water, 408(48.3%) had latrine and the majority 366(89.7%) were used traditional pit latrine. Open field child excreta disposal was practiced by 537(64.1%) mothers, almost all 758(89.7%) and 559(69%) dispose domestic waste in open field and practiced hand washing before handling food respectively(table7). 23

31 Table 7: Water and sanitation indicators, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Main source of water (n=851) Pipe/tap Others 17 2 Latrine availability (n=845) Yes No Type of latrine (n=408) Traditional pit latrine VIP Other Place of disposal of child s Open field excreta (n=838) Latrine Domestic waste disposal Open field (n=845) Dumping Burning Other Hand washing practice before Yes giving food for the children (n=810) No Majority of respondents were living with domestic animal 710(84.3%) and good ventilation had in 372(45.6%).Thatched/Tukul house type were 718(84.8) and 657(77.6%) had only single room (Table 8). 24

32 Table 8: Housing condition, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Living with domestic animal Yes (n=758) No Good ventilation Yes (n=816) No Tached or Tukul Housing type Corrugated iron sheet (n=847) Other one Number of rooms in the house Two (n=847) Three Four and above Almost all the respondents, 837 (98.5%) were worried that the food runs out before they get money and 472(56.4%) worried always. Eating the same food daily were practiced by 790(94.4%) respondents and the same number of respondents also cuts the size of food and eating less than they felt. Seven hundred seventy nine (92%) respondents were became ever hungry, and 741(87.2%) had had weight loss and 256(30.5%) adults were not eating the whole day (Table 9). 25

33 Table 9: Food Security indicators, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Worried that the food runs out getting money (n=850) Yes No If worried, how often? Always (n=837) Sometimes Eating the same food daily Yes (n=837) No Adults cut the size of food in the Yes family (n=851) No Ever eat less than you felt(n=849) Yes No Were you ever hungry? (n=847) Yes No 68 8 Did you lose weight? Yes (n=850) No You or another adult not eat for the whole day (n=847) Yes No

34 Among 856 children, 447 (52.2%) were females. The mean age, weight, height and MUAC were 31.2 months (SD: 13.3, Range: 6-59), 10.7 kg (SD: 2.5, Range: ), 77.5 cm (SD: 11.9, Range: ), and 13.1 (SD: 1.3, Range: ), respectively. Eighty four (10.4%), 366 (42.8%) and 647 (75.6%) children were wasted, underweight and stunted, respectively. Meanwhile, 38 (4.4%) had MUAC <11cm (Table 10). Table 10: Nutritional status of children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Measures Status Number Percent WHZ (n=811) WAZ (n=856) HAZ (n=856) MUAC (n=856) Severely wasted Wasted* Normal Severely under weight * Includes moderate and severe categories Under weight* Normal Severely stunted Stunted* Normal <11cm cm-12.4cm cm-13.4cm cm and above Mothers education, fathers education, child s age and sex, number of children in the household, number of children aged less than five years in the household, household size, maternal age, year difference between the last two births, current family planning use, breastfeeding practice and duration, ANC follow up during the index child, vaccination, latrine availability, improper disposal of child excreta, hand washing practice, good ventilation of the house, availability of radio, presence of farm land, producing cashcrops, and house type were considered as potential determinants of nutritional status (as 27

35 measured by WAZ, WHZ and HAZ) of the child. However, bivariate analysis showed eight factors determining underweight, and four factors determining wasting and stunting (Table 11-13). Out of the eight variables determining underweight (during bivariate analysis), multivariate analysis confirmed only child s age in months, year difference between the last two births and hand washing practice as potential predictors of underweight. As compared to child s age grouped months, there was lesser risk of becoming underweight for the age group and months. Those who gave birth before the older child celebrated 2 nd birth day had 2.5 times more risk of having underweight child as compared to those who experienced 4 and more years of spacing births. Meanwhile, those practicing hand washing before feeding their child had 41% lesser risk of having underweight child (Table 11). 28

36 Table 11: Determinants of nutritional status as measured by weight for age, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Status Adjusted OR (95% Determinants Categories Under weight Normal Crude OR (95% CI) CI) # % # % Child age in months (n=856) ( ) 0.43 ( ) ( ) 0.29 ( )* ( ) 0.41 ( )* ( ) 0.82 ( ) Fathers education Illiterate ( ) 1.02 ( ) (n=852) Literate Year difference < ( ) 2.5 ( )* between the last ( ) 1.43 ( ) two births in months (n=653) > ANC (n=839) Yes ( ) 0.68 ( ) No Latrine availability Yes ( ) 1.39 ( ) (n=845) No Hand washing Yes ( ) 0.59 ( )* (n=810 ) No Child excreta Open field ( ) 1.36 ( ) disposal (n=838) Latrine House type Tached ( ) 1.31 ( ) (n=847) Iron sheet * P <0.05 Out of the four variables determining wasting (during bivariate analysis), multivariate analysis confirmed only ANC follow up for the index child and improper disposal of child excreta as potential predictor of wasting. Those who had ANC follow up had 49% lesser risk of getting their child wasted, and on the other hand, mothers disposing child s excreta to open field had nearly 3 times more risk of getting their child wasted (Table 12). 29

37 Determinants Table 12: Determinants of nutritional status as measured by weight for height/length, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Categories Wasted Status Normal # % # % Crude OR (95% CI) Adjusted OR (95% Year difference < ( ) 1.62 ( ) between the last ( ) 0.91 ( ) two births in months (n=614) > ANC (n=794) Yes ( ) 0.51 ( )* No Hand washing Yes ( ) 0.72 ( ) (n=768 ) No Child excreta Open field ( ) 2.89 ( )* disposal (n=793) Latrine *P<0.05 Out of the four variables determining stunting (during bivariate analysis), multivariate analysis confirmed only child s age in months and type of house as potential predictors of stunting. As compared to child s age grouped months, there was lesser risk of becoming stunted for the age group and months, as it was the case for underweight. Meanwhile, those living in tached /tukul houses had 84 % more risk of having stunted child (Table 13). CI) 30

38 Table 13: Determinants of nutritional status as measured by height for age, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Status Adjusted OR (95% Determinants Categories Stunted Normal Crude OR (95% CI) CI) # % # % Child age in months (n=856) ( ) 0.62 ( ) ( ) 0.49 ( )* ( ) 0.62 ( )* ( ) 1.17 ( ) Fathers education Illiterate ( ) 1.08 ( ) (n=852) Literate ANC (n=839) Yes ( ) 0.73 ( ) No House type Tached ( ) 1.84 ( )* (n=847) Iron sheet *P<

39 5.2 Qualitative Summary results of focus group discussion with community members All FGD participants religious leaders, cultural leaders, HEW, agricultural development agents, teachers, female representative, traditional birth attendee s, kebele leaders, political coordinator of kebele and women s affair are convinced that food security was the primary problem of the kebele. Major causes of food security Decrease in per capita farmland due to increasing density of population and sever erosion usually affecting the place, unreliable rainfall, animal disease, degradation of natural recourses base, caused by: high population growth, demand for arable land, high level unemployment, brought about by the absence of sustainable local level employment opportunities outside the agriculture sector. Poorly developed money markets causing farmers to borrow from lenders to pay 100 % lending rate with in months. Because of high lending rate farmers usually in negative balance (lending three or four month before Safety Net given and the lender take the money in the place where Safety net was given). There was high fertility rate, which did not keep pace with the level of productivity. Polygamy also made problem by facilitating population pressure ( I am the third wife of my husband, He got 15 children from the first two, 8 from me and 6 from the last one but he was 44 years only female participant said). Religious leader in Woyira Gere said Bizu Tebazu Yibka Bemeten Nuru to indicate no more population pressure according to the holly bible. The negative impact of inappropriate use and untargeted free distribution of food aid, which favors active political members disappoint others who are in need of food and declining self esteem and increasing sense of dependence Majority of respondents said copying mechanism to food insecurity in the community includes reducing the amount of food and frequency of eating specially adults in the family are the most common response. Putting children in well-to-do relatives are unacceptable previously now it was routine cultural leader said. Selling labor cheaply, 32

40 renting land, begging, borrowing money to pay for fertilizer was also another way to cope with food shortage. A 27 years developmental agent said Currently chewing khat was used as a method of preventing sense of hunger even by elderly without any payment and easily available at backyard. Students particularly girls drop out of school and engage in petty trade to support family member and going to towns in search of work. The members finally recommend solutions to cope with food shortage. One participant emphasize by saying government must decreases the pries of fertilizer b/c our land were not productive without fertilizer but the pries of this fertilizers are very painful and intolerable. To decrease population pressure the government should start settlement program in less dense areas like the Derge regimen Sefera stressed by all members of respondents. Cultivating drought resistance plants like enset and sweet potato in order to decrease hunger. The members also emphasize water problem may be alleviated by drilling deep well b/c the pipe in the kebele produce only 40 pots of water in one day which most females wasting there time by weighting. NGOs in the woreda were targets only for those who are severely affected and the food aid was too small when compared with house hold members. Education on family planning must be improved to create awareness Key Informant Interview Government food security coordinator I am working for the last 15 years here in shone but the community never recovers from food security problems mainly in the last two years government food security coordinator opens discussion. The major cause as indicated by food security officials includes chronic food security problem which was aggravated by erratic rain fall, high population pressure, poor whether condition, losing asset, high fertilizer cost and poor saving habit by the community. According to the current study done by DPPC and FAO, 35 % households need urgent food aid. The most important source of main staple food currently in the woreda and cash income is relief food. Coping mechanism in our community includes becoming prostitutes and daily laborers, selling of relief food 33

41 ,decreasing number of meals, selling household assets, selling crops before the time of harvesting, borrowing and expecting the government and NGOs to do some thing. There are big gap in family planning previously supplied by Ethiopian kale hiwot church and USAIDs but currently government attempt was not enough together with poor attitude of the community specifically males. Though the Safety Net program is spending a great deal amount of money, in most instances, the household utilizes the money in an incorrect way. For instance, when the household gets birr so to purchase fixed assets, the husband tends to take another wife or else share it with the kebele chair person who votes him as a candidate to take from the program. The major aim of safety Net program is to decrease community asset by giving cash or food every six month and graduating them when they paid back the money and having at least 2900 birr. The big problem was the number of families graduating from the program was very few because of mismanaging the money instead of using wisely. As solution to address the problem, the interviewee suggested that improving social infrastructures like establishing microfinance schemes, involving the households in Safety Net program, preventing soil erosion, scaling up family planning services, tackling dependency syndrome, exhausting alternatives other than crop production like animal husbandry like fattening and honey production. Improving the working habit of the community and avoiding dependency syndrome should be encouraged and aware them to save money and food during harvest season NGO food security officer The officer indicated that the area is chronically food insecure. Conditions that worsen food insecurity in the area include high population pressure, polygamy, erratic rain fall, erosion and dependency syndrome. As per the report from government officials, the number of households requiring food aid is usually lesser than that could be observed at the ground. This could inhibit to address the problem in a large scale. There is sabotage in preparing a list of beneficiaries at kebele level to the extent of receiving bribes and selecting relatives. This leads to involve well-to-do families at the expense of those who 34

42 are really in need. In some cases, when the food aid is received by the husband, he sells it to enjoy local beverages. Surprisingly most husbands sell the food aid near to the NGO office which disappoints the workers and government officials. To alleviate some of the problems mentioned above, the officers suggested close work relations and thorough discussion with government bodies specially in preparing list of beneficiaries Woreda Health Office Head He said the problem of food insecurity in the woreda is deep and extensive. And it may also be perpetual. It is one of the hot spot areas in the country. It is usual to our community to enjoy life during harvesting and then beg afterwards. Last year, a total of under fives were reported as malnourished and out of these were having GAM and the rest 4000 with SAM. There were 10 OTP and 2 SC sites in the woreda. In the OTP, 4380 children were admitted and treated. From the total MUAC less than 11 were 3770(86%) and the rest 610 were admitted because of bilateral edema. There were 8 deaths out of 144 admitted cases in SC. Meanwhile, malaria and acute watery diarrhea epidemics occurred in the fiscal year and worsened the outcome of malnutrition. Selling the RUTF for the purpose of purchasing adult food items and also sharing it to other non-eligible child were some of the causes for the failure of malnutrition management are the community level. There was also high rate of relapse of malnutrition that indicated the presence of household food insecurity. In order to decrease selling and sharing collaborative action was done with other sectors like administrative council, police, agriculture office and community members was involved but very difficult to control the problem. Mothers taken RUTF weekly from OTP goes directly to shop to sell the plumpy nut and buying salt, cabbage and kocho for the house hold instead of feeding the child who fulfills the criteria of SAM. Surprisingly almost all mothers were sign of relive and satisfaction when their child admitted to OTP Children survival meeting was done every two week in the capital Hosanna including woreda health office representatives, NGOs, zonal DPPC and zonal health department. As the woreda health office says in this meeting all the issue discussed but sharing and selling of RUTF at 35

43 household level was big challenge to control and this problem decrease during small harvesting time indicating mothers selling the magic RUTF because of household food insecurity despite of knowing its importance. 36

44 6. DISCUSSION According to WHO, underlying malnutrition is responsible for half of the deaths occurring among children under five years of age. Studying causes of malnutrition and acting upon, therefore, would help in magnificent reduction in mortality in this age group. This study showed the area to be chronically affected by malnutrition and food insecurity and also tried to figure out potential contributors of the problem. The prevalence of wasting (10.4%) was almost similar with the national figure for rural areas, which was 10.9% (1). However, severe wasting was very high; 6.9% as compared to 2.2% of the national figure. Both figures were higher as compared to the SNNP regional figures of 6.6 % (wasted) and 0.9% (severely wasted). Meanwhile, the proportions of children underweight (42.8%) and severely underweight (24.1) were greater than 39.7% and 11.6% (national), and 34.7% and 11.9% (regional), respectively. Similarly, the prevalence of stunting (75.6%) and severe stunting (60.3%) were much higher than 47.9% and 25.3% (national), 51.6% and 29.1% (regional), respectively (1). Unlike DHS 2005 that indicated the prevalence of stunting and underweight decreases after the age of 23 months, our data showed as increment there after (1). This could be due the lack of adequate and appropriate feeding when breastfeeding alone could not suffice the nutritional requirement of the child as the age goes on. Rampant food insecurity in the area could explain these all. A less than 2 years difference between the last two births increased the risk of having underweight child by 2.5 more, which is consistent with DHS 2005 (1) and the study done by Gugsa (2). This shows that as the birth interval is narrower, competition of food and care increases that would predispose the vulnerable child to be neglected and get malnourished. 37

45 Practice of hand washing by the mother/care-taker before providing food to the child was significantly reduced (41% reduction) the likelihood of having underweight child. Meanwhile, disposing child s excreta to open field increased the risk of having wasted child by 2.89 times more. Those living in a touched house had 84% increased risk of getting stunted. These all could imply that personal hygiene, sanitation and living condition play an important role in the domain of malnutrition. These findings are consistent with Zewditu and colleagues (4), and Gugsa (2). Mother s education was reported as if it is as important determinant of child s malnutrition (2, 4). However, findings of this study did not support this notion as we did not see any association. In this study, father s educational status was significantly associated with underweight and stunting, but this association disappeared during multivariate analysis. Antenatal care during the index child reduced risk (by 41%) of getting wasted child. However, it was the number of antenatal care visits that was associated not with wasting but with chronic malnutrition (2). Our study also showed association between antenatal care and stunting during bivariate analysis though it disappeared while adjusting for confounding. In this study the current users of family planning are by far lower (4.8%) than 10.9 % of DHS This was also evidenced by the fact that one third of mothers gave the last two successive births with in two years of duration. Meanwhile, the average family size was 6.6, which was also higher that a figure for rural areas of Ethiopia (5.2) (1). These might indicate high population pressure as it was mentioned during qualitative study as an important cause for food insecurity in the area. Nearly all (98.5%) respondents reported that the food runs out before they get money, and 92% experienced hunger. These huge percentages reflect how the problem is serious. On the other hand there could be over reporting by expecting from government or NGO because of the dependency syndrome. 38

46 As indicated by the key informants, efforts to tackle food insecurity and malnutrition seemed to be complicated since programs tend to fail to achieve objectives and address the most needy target groups. The absence of concerted effort was also one of the reasons for failure. 39

47 7. LIMITATION OF THE STUDY As the design of the study is cross-sectional, establishing cause and effect is difficult so the finding of this study should be seen from this context. As there is dependency syndrome, over reporting of food insecurity may be inevitable. Despite proper training of data collectors, there may be still measurement error which could have affected the result of this study. 40

48 8. CONCLUSION Malnutrition as measure by under weight, wasting and stunting was very high in East Badawacho woreda as compared to the regional and national figures. Child s age, year difference between the last two births, antenatal care during the index child, hand washing practice, child excreta disposal and house type were important predictors of child malnutrition. Family planning coverage was very low despite high population pressure was mentioned as a reason for food insecurity. Almost all respondent felt that they are food insecure. Dependency syndrome entrenched in the community. Failures to meet objectives and address the neediest ones were among the problems of interventions programs. 41

49 9. RECOMMENDATION 1. Improving family planning and antenatal care services coverage in the woreda 2. Promotion of personal hygiene,environmental sanitation and water supply 3. Revision of approaches of intervention programs and enhancing concerted efforts of relevant bodies should be emphasized 4. Further research should be encouraged to assess the effectiveness and challenges of intervention programs 42

50 5. REFERENCES 1. Ethiopia Demographic and Health Survey 2005 Central Statistical Agency Addis Ababa, Ethiopia ORC Macro Calverton, Maryland, USA 2. Gugsa Yimer. Malnutrition among children in Southern Ethiopia: Levels and risk factors. Ethiop. J. Health Dev. 2000;14(3): Timotewos Genebo, Woldemariam Girma, Jemal Haider, Tsegaye Demisse. The association of children s nutritional status to maternal education in Zigbaboto, Guragie Zone, Ethiopia. Ethiop. J. Health Dev. 1999;13(1): Zewditu Getahun, Kelbessa Urga, Timotewos Ganebo, Ayele Nigatu. Review of the status of malnutrition and trends in Ethiopia. Ethiop. J. Health Dev. 2001;15(2): Repositioning Nutrition as Central to Development; A Strategy for Large-Scale Action. The world bank, Ethiopia a Country Status Report on Health and Poverty, Volume II: Main Report No ET 7. Optimal consumer subsidies and income transfers for minimum nutritional requirements: A basic model. 8. Malnutrition in rural highland Ecuador: The importance of intra household food distribution, diet composition, and nutrient requirements 9. A review of the title II Development Food Aid Program: Food and Nutrition Technical Assistance; Technical Note No. 6. February Page Ethiopia Food security update, FEWS NET Ethiopia, October Ramakrishna G., Demeke A.; An empirical analysis of food insecurity in Ethiopia: The case of North Wello. Africa Development, vol 27. Nos 1 & 2. PP Frehiwot Bekele. Malnutrition: the 'silent emergency'. UN, Africa Recovery, downloaded from on May 16, Patrick W. and Beatrice R.: Assessing the in in food insecurity. USAID office of food for peace. Occasional paper No. 1. PP

51 14. Multidisciplinary capacity-strengthening for food security and nutrition policy analysis: Lessons from Malawi 15. Dorit N., Einat O., Tilahum A.: Food insecurity and nutrition- The Ethiopian Case for action. Public Health nutrition. Volume 5, number 3, July Pages Patrick W., Jennifer C., Edward A., Beatrice L, Rogers A., Swindale Z., and Paula B.: Measuring Household Food Insecurity: Why It s So Important and Yet So Difficult to Do? Advances in Developing Country, Food Insecurity Measurement. The journal of nutrition. Vol. 15. October PP

52 ANNEXES Annex 1: Questionnaire QUESTIONNAIRE DEVELOPED ON ASSESSMENT OF NUTRITION INSECURITY IN EAST BADAWACHO WOREDA HADIYA ZONE SOUTHERN NATIONAL REGIONAL STATE. My name is. You are one of the individual chosen to participate in the study. For the purpose of the study I would like to ask you some questions [on demographic, socio economic factors, Lifestyle, sanitation, and water supply and on sickness history, immunization feeding Practice and food security about yourself &your child. We would also check/examine the child for some diseases. No harm is expected to come on you, your child or your family if you participates this study. Information obtained from you and your child will be kept strictly confidential, only the research team will access it for research purpose. Your participation in this study is very important and would be very much appreciated. Part 1: General information 101. Questionnaire identification number 102. Area / Peasant association 103. Respondent available on: First visit: Second visit: (please tick) 104. Results (circle) Filled out...1 Not available..2 Unwilling.3 Other.. 4 If other, specify the reason 105. Interviewer s name and signature 106. Supervisors name and signature Part 2: Anthropometric measures 201. Weigh of the child in kilogram Kg 202. Height / length of the child in centimeter Cm Part 3 3.1: Socio Demographic Factors No. Questions 301 How old are you (mother)? (Age in completed years) 302 How many children do you have? 303 How many of them are less than 5 years? 304 How old were you when you got married? (Age in completed years) 203. MUAC cm Answer (if there are options please circle) years In number In number years Skip 45

53 305 What is your religion? Christian..1 Muslim.2 Other 3 If other, specify 306 How many people currently live in the house? 307 What is your education level (mother)? 308 What is your husband education level? 309 What would your family main occupation? In number Illiterate.1 Able read and write.2 If grade, specify (highest grade completed) Illiterate.1 Able read and write.2 If grade, specify (highest grade completed) Farmer...1 Merchant..2 Other..3 If other specify 310 What is your ethnicity? Hadiya. 1 Wolayta..2 Other 3 If other specify 311 Who is the head of the family? Husband...1 Wife.2 Other.. 3 If other specify 312 Marital status of the mother? Married in union 1 Married not in union 2 Single 3 Divorced.3 Widowed What is your job? Housewife.1 Daily laborer 2 Farmer..3 Herding.4 Other. 5 If other specify 314 What is the age of the child? in months 315 What is the sex of the child? Male..1 Female How many year differences are there between the last two of your children? Less than 24 months 1 With in months 2 Greater than 48 months.3 46

54 3.2 Child Health Indicators 317 Have you ever use family planning? Yes.1 No Which method of family planning? Pills 1 Injectable...2 Implant 3 Tubal legation 4 Calendar method.5 Other.6 If other specify 319 Have you ever attended ANC during your pregnancy of the index child? 320 Where did you give birth to the child? Yes.1 No..2 Home...1 Health facility.2 Not remembered.3 Other.4 If other specify 321 Who attended your delivery? TBA 1 Health personnel..2 Other 3 If other specify 322 Have you breastfed the child? Yes.1 No When did you first put the child on breast-feeding? 324 For how many months did you breast feed? With in the first hour of delivery..1 With in the first 8 hour of delivery...2 After 2-3 days...3 Seven days later 4 Not remembered..5 Less than 6 months..1 Six to 12 months 2 One to two years.3 More than 2 year..4 Still feeding.5 Not remembered Why do not breast-feed the child? Due to illness.1 Child refuses to suck..2 Other..3 If other specify 326 At what age did you start to give food in addition to your breast milk? Immediately after birth..1 With in 1to 6 months 2 With in 6 to 12 months.3 Twelve month later..4 skip to question 319 skip to question

55 327 What is the first food you used to feed the child? 328 Have you given any thing to the child immediately after birth? 329 Which one of the following you have given? Milk..1 Adult food.2 Porridge.3 Other..4 If other specify Yes.1 No..2 Butter..1 Water and Sugar.2 Milk..3 Water only.4 Other..5 If other specify 330 Did the child ever receive vaccines? Yes.1 No Do you have vaccination card? Yes.1 No If the child has vaccination card, check the type of vaccine the child received. 333 Why did not the child receive the vaccine? 334 Did the child-received vitamin A capsule? (Show the capsule) 335 Does the child have problem of vision at nighttime or does the child repeatedly fall at dusk time? 336 Does the child have foamy type of scar at the lateral side of his/her eye? (Check by your self) BCG only...1 BCG, Pentavalent1 and Polio1..2 BCG, Pentavalent 2and polio 2.3 BCG, Pentavalent 3, Polio3.4 BCG, Pentavalent 3, polio 3, Measles..5 Time shortage to the mother..1 Lack of knowledge 2 Inaccessibility of service..3 Unavailable of service..4 Fear of side effect.5 Other..6 If other specify Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 skip to question 330 skip to question 333 skip to question

56 337 Was the child sick in the last two weeks? Yes.1 No What is his/her illness? Fever 1 Cough.2 Diarrhoea..3 Other..4 If other specify 339 What did you do for the illness? Home treatment..1 Visited health facility..2 Consulted traditional healers..3 Other..4 If other specify 340 Have you ever fed the child on Yes.1 bottle-feeding? 341 Are you feeding the child animal source food? (E.g. meat, milk ) 342 Are you feeding the child fruits? (E.g. Papaya, mango ) 343 Are you feeding the child vegetables? 3.3 Economic Indicators 344 What is the main source of water for the household? 345 Does the household have latrine? No..2 Yes, daily 1 Yes, less frequently..2 No...2 Yes, once a week..1 Yes, less Frequently 2 No..3 Yes, once a week..1 Yes, less Frequently 2 No..3 Protected well..1 Unprotected well.2 River water.3 Rain water (dam) 4 Pipe (Tap)..5 Other...6 If other specify Yes.1 No Type of latrine Traditional pit latrine.1 Ventilated improved pit latrine(vip) 2 Other....3 If other specify 347 Where do you dispose child s excreta? No facility/ open field 1 Other..2 If other specify skip to question 340 skip to question

57 348 Do you wash your hands whenever you feed your child 349 Where do you dispose house hold/domestic wastes (both solid and liquid wastes)? 350 Are you keeping domestic animals with you in the same house 351 Does the house have good ventilation? (consider window) 352 Which one of the following do you have? And how much? (please fill only for available animals) 353 Does the household have its own farmland? 354 Who earns the income of the household? Yes.1 No..2 Open field 1 Dumping..2 Burning..3 Other..4 If other specify Yes.1 No..2 No domestic animal.3 Yes.1 No..2 Cattle Goat Sheep Donkey Camel Other, specify type Yes.1 No..2 Husband.1 Wife..2 Other...3 If other specify 355 What is the staple food of the household? Specify 356 What is the house type? Tached / Tukul..1 Corrugated iron sheet 2 Mobile house 3 Other 4 If other specify 357 How many rooms does the house have? In number 358 Does the family have radio? Yes.1 No What is the source of income of the family? 360 Does the house hold produce cash crops? Specify Yes.1 No Type of cash crop Coffee..1 Fruit 2 Other 3 If other specify skip to question Have you moved from your usual residence in the last one-year? Yes.1 No..2 skip to question

58 363 What was the reason for moving from the usual residence? 364 Have you got (ever received) support from any organization during your displacement (if your displacement is only disaster? 3.4 Food security 365 Were you worried that your food would run out before you had money to buy more? If yes how often did this occur? 366 The food you had didn t last, and you did not have enough money to buy more? 367 Did you have to eat the same foods daily because you did not have money to buy other foods? 368 Have you or any other adult in your household cut the size of your meal because you did not have enough money to buy food? 369 Did you ever eat less than you felt you should because you did not have enough money to buy food? 370 Were you ever hungry and did not eat because you didn t have money to buy enough food? 371 Did you lose weight because you didn t have money to buy food? 372 Did you or another adult in you house hold ever not eat for a whole day because you didn t have money to buy food? Famine..1 Clashes between tribes...2 Other.3 If other specify Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 Yes.1 No..2 51

59 Annex 2: Question guides for FGD and Key Informant Interviewing 1. Is there problem with food security? What is the extent of the problem? 2. Why it is a problem? 3. How do people cope? 4. What are the contributing factors? 5. Now, let us talk about the community 6. Food accessibility, availability and affordability 7. Difference in the community 8. Biggest problem related to food security 9. Resources to avoid the problem 10. What could be done to improve? 11. Key players? 12. Accessibility of alternative food sources? 52

60 Annex 3: Consent form Information Sheet and Consent Form Title of Study: Determinants of Nutritional Security in Shone District, Hadiya zone Southern Ethiopia Name of Investigator: Endashaw Shibru Research Advisor: Dr Fekru Tesfaye My name is Endashaw Shibru and I am working with the School of Public Health of Addis Ababa University. You have been invited to take part in this study. Before you decide whether to take part, it is important for you to understand why the research is being done. Please take time to read the following information carefully and feel free to ask if there is anything that is not clear or if you would like more information. This study is conducted as a partial fulfillment of a Masters thesis in Addis Ababa University, School of Public Health. It has got ethical approval from the Ethical Review Committee of the Faculty of Medicine of Addis Ababa University. The study is being conducted in East Badawacho woreda, Hadiya zone in SNNPR. The aim of the study is to determine factors that affect the districts nutritional security. That is why we contacted you for taking part in the study. All information that is collected about you during the study will be kept confidential, and your names will never be mentioned in any analysis and dissemination of findings. Please be informed that participation in this study is purely voluntary. If you wish not to participate or to discontinue the questionnaire at any time, you may. However, the information you give us is highly valuable to the study. If you choose not to participate in the study, or if you choose to participate but later choose to withdraw, this will not in any way have negative consequences in your service utilization or that you get from the health center clinics, or any other governmental or nongovernmental organization. And this will take about 30 minutes. Thank you very much. I confirm that I have been given a full explanation of the study and that I have read and understood the information sheet. I voluntarily agree to take part in the study. Signature: Date: 53