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

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

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

TABLE OF CONTENTS ACKNOWLEDGEMENT... I TABLE OF CONTENTS...II LIST OF TABLES...III LIST OF ACRONYMS AND ABBREVIATIONS... IV ABSTRACT...V 1. INTRODUCTION...1 2. LITERATURE REVIEW...4 3. OBJECTIVES...9 4. METHOD... 10 4.1 Study design and period... 10 4.2 Study area... 10 4.3 Study population... 10 4.4 Sample size determination... 11 4.5 Sampling method... 11 4.6 Data collection and instrument... 12 4.7 Study Variables... 13 4.7.1 Independent Variables:... 13 4.7.2 Dependent Variables:... 13 4.8 Data processing and analysis:... 14 4.9 Ethical consideration... 14 4.9 Dissemination of the result... 14 4.10 Operational Definitions... 15 5. RESULT... 17 5.1 Quantitative survey... 17 5.2 Qualitative... 32 6. DISCUSSION... 37 7. LIMITATION OF THE STUDY... 40 8. CONCLUSION... 41 9. RECOMMENDATION... 42 5. REFERENCES... 43 ANNEXES... 45 Annex 1: Questionnaire... 45 Annex 2: Question guides for FGD and Key Informant Interviewing... 52 Annex 3: Consent form... 53 II

LIST OF TABLES Table 1: Socio-demographic profile of the households, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 18 Table 2: Family planning, ANC follow up and place and attendant of delivery, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 19 Table 3: Breastfeeding practice of respondents, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 20 Table 4: Child feeding practices, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 21 Table 5: Immunization history of the children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 22 Table 6: Childhood illness, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 23 Table 7: Water and sanitation indicators, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 24 Table 8: Housing condition, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 25 Table 9: Food Security indicators, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 26 Table 10: Nutritional status of children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 27 Table 11: Determinants of nutritional status as measured by weight for age, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 29 Table 12: Determinants of nutritional status as measured by weight for height/length, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 30 Table 13: Determinants of nutritional status as measured by height for age, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009... 31 III

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

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

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

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

is the highest among the 12-23 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

(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

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

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

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

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 1991 92 and 2001 02 (as well as a more localized drought in 1994 95).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 1991 92 than in 2001 02, 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

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

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

4. METHOD 4.1 Study design and period Quantitative and qualitative cross sectional study was conducted from Jan. to Feb. 2009 4.2 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 800-1465mm 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

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 = 1.96 2 0.516 (1 0.516 ) 2 0.05 = 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

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

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 10-12 each. 4.7 Study Variables 4.7.1 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 4.7.2 Dependent Variables: WHZ, WAZ, HAZ, MUAC and Food security 13

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

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

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

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 25-34 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

Table 1: Socio-demographic profile of the households, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Education: Mother Illiterate 664 77.8 (n=854) Literate 190 22.2 Education: Husband Illiterate 493 57.9 (n=852) Literate 359 42.1 Family main occupation (n=852) Mother s occupation Farming 798 93.7 Petty trading 46 5.4 Other 8 0.9 Housewife 824 98.2 (n=839) Other 15 1.8 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 799 93.8 Married not in union 3 0.4 Divorce 1 0.1 Widowed 49 5.8 15-24 74 8.8 25-34 501 59.4 35-44 248 29.4 45 and above 21 2.5 Hadiya 758 90 Wolayta 65 7.7 Other 19 2.3 Christian 819 96 Muslim 29 3.4 Other 5 0.6 18

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 37 4.8 planning method (n=772) No 735 95.2 Pills 8 21.6 Family planning methods Injectable 27 73 used (n=37) Implant 2 5.4 <24 months 221 33.8 Interval between the last two 24-48 months 302 46.2 children (n=653) >48 months 130 19.9 ANC attendance during Yes 403 48 index pregnancy (n=839) No 436 52 Place of birth (n=842) Home 795 94.4 Health facility 47 5.6 TTBA 700 83.4 Delivery attendant (n=839) Health personnel 40 4.8 Other 99 11.8 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

Table 3: Breastfeeding practice of respondents, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Breastfeeding (n=853) Yes 816 95.7 No 37 4.3 With in the 1 st hour 624 76.5 Time of initiation of With in the 1 st 8 hours 188 23 breastfeeding (n=816) After 2-3 days 3 0.4 Not remembered 1 0.1 < 6 months 89 10.9 6-12 months 98 12 Duration of breastfeeding 1-2 years 231 28.3 (n=816) More than 2 years 301 36.9 Still feeding 94 11.5 Not remembered 3 0.4 Reason for not breastfeeding Due to illness 16 43.2 (n=37) Others 21 56.8 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

Table 4: Child feeding practices, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Immediately after birth 56 6.6 Time of complementary food Within 1-6 months 230 27.1 started (n=850) Within 6-12 months 553 65.1 12 months later 11 1.3 Butter 3 5.4 Water and sugar 1 1.8 Food item given immediately Milk 24 42.9 after birth (n=56) Water only 2 3.6 Other 26 46.4 Milk 429 53.1 First complementary food Adult food 18 2.2 (n=808) Porridge 221 27.4 Other 140 17.3 Bottle-feeding practice Yes 50 5.9 (n=847) No 797 94.1 Yes daily 35 4.3 Feeding animal source foods Yes less frequently 395 48.2 (n=820) No 390 47.6 Yes daily 5 0.6 Feeding fruits source foods Yes less frequently 567 67.2 (n=844) No 272 32.2 Yes daily 3 0.4 Feeding vegetables source Yes less frequently 641 75.9 food (n=845) No 201 23.8 21

Table 5: Immunization history of the children, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Ever vaccinated Yes 471 55.3 (n=851) No 380 44.7 Vaccination card Yes 389 80.7 available (n=482) No 93 19.3 Type of vaccine (n=389) Reason for not get vaccinated (n=357) Vitamin A supplementation in the last six month (n=830) BCG only 9 2.3 BCG, Penta 1, Polio 1 42 10.8 BCG, Penta 2, Polio 2 40 10.3 BCG, Penta 3, Polio 3 36 9.3 BCG, Penta 3, Polio 3 and measles 262 67.4 Time shortage 13 3.6 Lack of knowledge 309 86.6 Inaccessibility of the service 6 1.7 Unavailability of the service 3 0.8 Fear of side effects 18 5 Other 8 2.2 Yes 495 59.6 No 335 40.4 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

Table 6: Childhood illness, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Any sickness within the Yes 296 36.8 last two weeks (n=804) No 508 63.2 Fever 215 72.6 Ailments (n=296) Cough 28 9.5 Diarrhea 38 12.8 Other 15 5.1 Home treatment 174 58.8 Treatment given for the Visited health facility 91 30.7 ailments (n=296) Consulted traditional healer 16 5.4 Other 15 5.1 Night blindness (n=801) Yes 128 16 No 673 84 Foamy scar on the Yes 118 14.1 eye(bitot spot) (n=836) No 718 85.9 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

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 834 98 Others 17 2 Latrine availability (n=845) Yes 408 48.3 No 437 51.7 Type of latrine (n=408) Traditional pit latrine 366 89.7 VIP 30 7.4 Other 12 2.9 Place of disposal of child s Open field 731 87.2 excreta (n=838) Latrine 107 12.8 Domestic waste disposal Open field 758 89.7 (n=845) Dumping 26 3.1 Burning 1 0.1 Other 60 7.1 Hand washing practice before Yes 559 69 giving food for the children (n=810) No 251 31 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

Table 8: Housing condition, East Badawacho Woreda, Hadiya Zone, South Ethiopia, March 2009 Characteristics Number Percent Living with domestic animal Yes 710 93.7 (n=758) No 48 6.3 Good ventilation Yes 372 45.6 (n=816) No 444 54.4 Tached or Tukul 718 84.8 Housing type Corrugated iron sheet 127 15 (n=847) Other 2 0.2 one 657 77.6 Number of rooms in the house Two 90 10.6 (n=847) Three 72 8.5 Four and above 28 3.3 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

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 837 98.5 No 13 1.5 If worried, how often? Always 472 56.4 (n=837) Sometimes 365 43.6 Eating the same food daily Yes 790 94.4 (n=837) No 47 5.6 Adults cut the size of food in the Yes 808 94.9 family (n=851) No 43 5.1 Ever eat less than you felt(n=849) Yes 799 94.9 No 50 5.1 Were you ever hungry? (n=847) Yes 779 92 No 68 8 Did you lose weight? Yes 741 87.2 (n=850) No 109 12.8 You or another adult not eat for the whole day (n=847) Yes No 258 589 30.5 69.5 26

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: 3.5-19.8), 77.5 cm (SD: 11.9, Range: 50-115), and 13.1 (SD: 1.3, Range: 8-16.5), 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 56 6.9 Wasted* 84 10.4 Normal 727 89.6 Severely under weight 206 24.1 * Includes moderate and severe categories Under weight* 366 42.8 Normal 490 57.2 Severely stunted 516 60.3 Stunted* 647 75.6 Normal 209 24.4 <11cm 38 4.4 11cm-12.4cm 202 23.6 12.5cm-13.4cm 242 28.3 13.5cm and above 374 43.7 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

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 48-60 months, there was lesser risk of becoming underweight for the age group 12-23 and 24-35 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

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) 6-11 13 3.6 34 6.9 0.39 (0.18-0.83) 0.43 (0.17-1.08) 12-23 41 11.2 110 22.4 0.38 (0.24-0.62) 0.29 (0.15-0.54)* 24-35 71 19.4 117 23.9 0.63 (0.41-0.95) 0.41 (0.24-0.69)* 36-47 141 38.5 126 25.7 1.15 (0.79-1.69) 0.82 (0.51-1.32) 48-59 100 27.3 103 21.0 1 1 Fathers education Illiterate 236 65.0 257 52.6 1.68 (1.27-2.22) 1.02 (0.68-1.52) (n=852) Literate 127 35.0 232 47.4 1 1 Year difference <24 130 46.1 91 24.5 3.21 (2.03-5.08) 2.5 (1.43-4.35)* between the last 24-48 112 39.7 190 51.2 1.33 (0.85-2.06) 1.43 (0.87-2.32) two births in months (n=653) >48 40 14.2 90 24.3 1 1 ANC (n=839) Yes 132 36.9 271 56.3 0.45 (0.34-0.6) 0.68 (0.45-1.01) No 226 63.1 210 43.7 1 1 Latrine availability Yes 159 43.9 249 51.6 0.74 (0.56-0.97) 1.39 (0.83-2.34) (n=845) No 203 56.1 234 48.4 1 1 Hand washing Yes 207 60.2 352 75.5 0.49 (0.36-0.66) 0.59 (0.38-0.92)* (n=810 ) No 137 39.8 114 24.5 1 1 Child excreta Open field 247 68.6 290 60.7 1.42 (1.06-1.89) 1.36 (0.8-2.31) disposal (n=838) Latrine 113 31.4 188 39.3 1 1 House type Tached 320 87.9 398 82.4 1.55 (1.03-2.34) 1.31 (0.79-2.19) (n=847) Iron sheet 44 12.1 85 17.6 1 1 * 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

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 <24 36 52.9 162 29.7 2.62 (1.19-5.89) 1.62 (0.68-3.9) between the last 24-48 22 32.4 266 48.7 0.98 (0.42-2.29) 0.91 (0.4-2.09) two births in months (n=614) >48 10 14.7 118 21.6 1 1 ANC (n=794) Yes 27 32.5 363 51.1 0.46 (0.29-0.75) 0.51 (0.27-0.96)* No 56 67.5 348 48.9 1 1 Hand washing Yes 41 52.6 502 72.8 0.42 (0.26-0.67) 0.72 (0.37-1.37) (n=768 ) No 37 47.4 188 27.2 1 1 Child excreta Open field 68 82.9 442 62.2 2.96 (1.63-5.36) 2.89 (1.35-6.15)* disposal (n=793) Latrine 14 17.1 269 37.8 1 1 *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 48-60 months, there was lesser risk of becoming stunted for the age group 12-23 and 24-35 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

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) 6-11 33 5.1 14 6.7 0.61 (0.29-1.33) 0.62 (0.3-1.28) 12-23 99 15.3 52 24.9 0.5 (0.3-0.82) 0.49 (0.3-0.8)* 24-35 134 20.7 54 25.8 0.65 (0.40-1.06) 0.62 (0.38-0.99)* 36-47 220 34.0 47 22.5 1.22 (0.75-1.99) 1.17 (0.72-1.89) 48-60 161 24.9 42 20.1 1 1 Fathers education Illiterate 388 60.2 105 50.7 1.47 (1.07-2.01) 1.08 (0.76-1.54) (n=852) Literate 257 39.8 102 49.3 1 1 ANC (n=839) Yes 287 45.3 116 56.6 0.64 (0.46-0.87) 0.73 (0.51-1.03) No 347 54.7 89 43.4 1 1 House type Tached 557 87.0 161 84.8 1.95 (1.28-2.97) 1.84 (1.21-2.8)* (n=847) Iron sheet 83 13.0 46 15.2 1 1 *P<0.05 31

5.2 Qualitative 5.2.1 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

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. 5.2.2. Key Informant Interview 5.2.2.1. 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