Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial.

Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.

The Global Diet Quality Score predicts diet quality of women of reproductive age in Addis Ababa, Ethiopia.

Improving diet quality is recognised as a double-duty action that can simultaneously address multiple forms of malnutrition. This study aimed to assess diet quality among non-pregnant non-lactating women of reproductive age (WRA) in Addis Ababa, Ethiopia. A 1-d quantitative 24 h recall was conducted among 653 non-pregnant/non-lactating women. Diet quality, assessed using the women dietary diversity score (WDDS), the Global Diet Quality Score (GDQS) and the Nova 4 classification reflecting consumption of ultra-processed foods (UPF), was compared. The proportion that meets the minimum dietary diversity for women (MDD-W) was estimated. The average MDD-W score was 2·6 (sd 0·9), with only 3 % of women meeting the MDD-W (≥ 5 food groups). Consumption of wholegrain and legumes was high, but UPF were also consumed by 9 % of the women. GDQS was positively associated with WDDS, age and skipping breakfast and was negatively associated with eating out of home and UPF consumption (P < 0·05). The multivariate regression model showed that GDQS (total) was not associated with wealth but was significantly associated with both UPF and WDDS (P < 0·001). Unlike UPF and WDDS alone, GDQS was able to predict both nutrient adequacy and unhealthy dietary practices. The diet quality of WRA in Addis Ababa is low in diversity, possibly exposing them to higher risk of nutrient inadequacy and non-communicable diseases as reflected by the low GDQS. Understanding what drives food and dietary choices in urban settings is urgently needed.

Multiscalar Evaluation of the Water Distribution System and Diarrheal Disease Risk in Addis Ababa, Ethiopia.

Despite growing urbanization, our understanding of the impacts of water and sanitation on human health has largely come from studies in rural sectors. To this end, we collected data at both regional (water quality measures from water treatment systems) and community (cross-sectional surveys) scales to examine determinants of enteric pathogen infection and diarrheal disease among infants in Addis Ababa, Ethiopia. Regionally, the Legedadi water treatment plant had significantly lower heterotrophic plate counts, total coliform counts, and fecal coliform counts compared with the Gefersa water treatment plant. The number of pathogen types in infant stool also differed by plant. Decreases in chlorine levels and increases in the relative abundance of Gammaproteobacteria with distance from treatment plants suggest a compromised water distribution system. In communities, infants in households that obtained water from yard pipes or public taps had significantly lower odds of diarrhea compared to households that had water piped into their dwellings (OR = 0.35, 95% CI 0.16, 0.76, and OR = 0.39, 95% CI 0.15, 1.00, respectively). Similarly, infants in households that boiled or filtered water had significantly lower odds of diarrhea compared to households that did not treat water (OR = 0.40, 95% CI 0.19, 0.86 and OR = 0.23, 95% CI 0.06, 0.84, respectively). Integrating multiscalar data better informs the health impacts of water in urban settings.

The influence of adolescents' nutrition knowledge and school food environment on adolescents' dietary behaviors in urban Ethiopia: A qualitative study.

Adolescence is a critical period of physical, cognitive, and social development that needs to be supported with healthy diets. Dietary behaviours of adolescents can be shaped by their nutrition-literacy and their interaction with parents and peers as well as their school food environment. Therefore, the present study aimed to assess factors that influence dietary behaviours of adolescents in urban Ethiopia. Sex-disaggregated, focused group discussions (n = 70) were conducted in 36 private and government schools (n = 12/city) among adolescents (n = 432) 15-19 years of age in Addis Ababa, Bahir Dar, and Dire Dawa. Photovoice was applied in a subgroup of participants (n = 216) to gain further insights into adolescents' perception of their school food environment. Key informant interviews were conducted among school principals (n = 36). Adolescents had a relatively good nutrition knowledge and recognised the importance of diverse diets, but misperceptions also existed. They identified fruit and vegetables as healthy foods, but their consumption was deterred by food safety concerns. The adolescents identified foods high in salt, fat, and sugar, including processed/packaged foods as unhealthy, but still consumed them frequently due to their taste, affordability, availability and accessibility in and around schools. Both undernutrition and overweight/obesity were linked to social exclusion and bullying in school. Effective behavioural change communication is required to address common misperceptions. School nutrition programs should integrate water, sanitation and hygiene programs to ensure food safety. Regulations promoting healthy eating while discouraging unhealthy dietary behaviours are vital. Interventions to make nutrient-dense and healthy foods available, accessible, and affordable are urgently needed to improve the nutrition and health outcome of adolescents.

Magnitude of urban household food insecurity in East Africa: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this study was to determine the magnitude and determinants of urban household food insecurity in East Africa. DESIGN: Systematic review and meta-analysis. SETTING: Studies conducted in East Africa. PARTICIPANTS: Seventeen studies (fifteen cross-sectional and two cohort) that enrolled 156 996 households. We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search electronic databases (PubMed, Cochrane Library, EMBASE, CINAHL, African Journals OnLine, Web of Science, Scopus and Google Scholar; date of last search: 10 June 2020) for studies reporting the prevalence and associated factors of urban household food insecurity. RESULTS: A total of 17 studies with 156 996 households from 8 countries were used for the analysis. The pooled prevalence of urban household food insecurity in East Africa was 60·91 % (95 % CI 47·72, 74·11; I2 = 100 %; P < 0·001) where the highest (91 %) and lowest (36·5 %) was observed in Sudan and Burundi, respectively. Household head educational status (illiterate) (AOR = 2·53; 95 % CI 2·11, 2·95, I2 = 90 %; P < 0·01), female as household head (AOR = 1·45; 95 % CI 1·16, 1·75; I2 = 0·0 %; P = 0·993), large family size (AOR = 1·43; 95 % CI 1·09, 1·76, I2 = 0·0 %; P = 0·863) and poorest wealth quantile (AOR = 3·95; 95 % CI 1·93, 5·98; I2 = 57·2 %, P = 0·053) were factors which significantly increased odds of urban household food insecurity in East Africa. CONCLUSIONS: The prevalence of urban household food insecurity in East Africa remains high. Therefore, policies and intervention programmes should be designed to reduce the high burden of food insecurity among urban households considering the identified factors.

Co-coverage of reproductive, maternal, newborn and child health interventions shows wide inequalities and is associated with child nutritional outcomes in Ethiopia (2005-2019).

The health system is the primary vehicle for the delivery of nutrition-specific interventions that aim to reduce maternal and child malnutrition. The integration of nutrition interventions into existing health interventions is promising, but to ensure that no one is left behind requires that access to essential health services is equitably distributed. This study aims to assess trends and socioeconomic inequalities in coverage of reproductive, maternal, newborn and child health (RMNCH) and assess its association with child nutritional outcomes in Ethiopia. Using the Ethiopian Demographic and Health Survey (2005, 2011, 2016, and 2019), we estimated the coverage of RMNCH interventions in Ethiopia using the co-coverage index, which is a count of the number of interventions accessed. We assessed the trend and inequalities in co-coverage and evaluated its association with child nutritional outcomes like stunting, wasting, and minimum dietary diversity (MDD). The national co-coverage index has shown a significant increase over the 2005-2019 period. However, all of the RMNCH interventions constituting the co-coverage index showed a pro-rich and pro-urban distribution (p < 0.05). The highest inequality, based on the slope index of inequality (SII), was observed for skilled assistance during delivery (SII: 80.4%), followed by access to an improved source of drinking water (SII: 62.6%), and antenatal care visits (SII: 55.5%). The low coverage in RMNCH and the observed inequality were associated with stunting, wasting, and MDD. Reducing socioeconomic inequality in RMNCH is key to achieve the health, nutrition and equity-related goals of the Sustainable Development Goals.

Complementary feeding and food-group level inequality among Ethiopian children 6-23 months of age (2011-2019).

Ensuring diet quality in the first 2 years of life is critical to preventing malnutrition and instilling healthy food preferences. Children's diet quality has changed little over time and inequalities by socioeconomic status, rural-urban residence, but also by food group may exist. Using data from the 2011, 2016 and 2019 demographic and health surveys (DHS), we estimated the prevalence and inequalities in the minimum diet diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). We further assessed food group-level inequities. In 2019, only 13.5% of children 6-23 months of age met the MDD, 55% met the MMF and only 11% met the MAD indicator. Absolute and relative measures of inequality were calculated. Modest increases in MDD, MMF and MAD were observed over the past decade (2011-2019). These modest improvements were concentrated in limited geographical areas, among children in wealthier households, and urban residents. Unhealthy practices such as bottle-feeding and zero fruit and vegetables have been increasing; whereas, inequities in the consumption of nutrient-dense foods have widened. Nevertheless, children from the wealthiest quintile also failed to meet the MDD. Multisectoral efforts that span from diversifying the food supply, regulating the marketing of unhealthy foods, and promoting minimal processing of perishables (i.e., to extend shelf-life) are needed. Context-adapted behavioural change communication along with nutrition-sensitive social protection schemes are also needed to equitably improve the diet quality of children in Ethiopia.

Magnitude, trends and drivers of the coexistence of maternal overweight/obesity and childhood undernutrition in Ethiopia: Evidence from Demographic and Health Surveys (2005-2016).

Ethiopia faces a rising problem of overweight and obesity alongside a high prevalence of undernutrition; a double burden of malnutrition (DBM). This study aimed to quantify the magnitude and trends of household-level DBM-defined as the coexistence of maternal overweight/obesity and child undernutrition (i.e., stunting or anaemia)-in Ethiopia between 2005, 2011 and 2016 and understand the potential drivers influencing DBM and the change in DBM over time. Data come from the Ethiopian Demographic and Health Surveys. National and regional prevalence estimates of the DBM were calculated (n = 13,107). Equiplots were produced to display inequalities in the distribution of DBM. Factors associated with DBM were explored using pooled multivariable logistic regression analyses for 2005, 2011 and 2016 (n = 9358). These were also included in a logistic regression decomposition analysis to understand their contribution to the change in DBM between 2005 and 2016 (n = 5285). The prevalence of household-level DBM at the national level was low, with a modest increase from 2.4% in 2005% to 3.5% in 2016. This masks important within-country variability, with substantially higher prevalence in Addis Ababa (22.8%). Factors positively associated with DBM were maternal age (odds ratio [OR] = 1.04 [1.02, 1.06]), urban residence (OR = 3.12 [2.24, 4.36]), wealth (OR = 1.14 [1.06, 1.24]) and the number of children <5 in the household (OR = 1.30 [1.12, 1.49]). Overall, 70.5% of the increase in DBM between 2005 and 2016 was attributed to increased wealth, urban residence and region. Double-duty actions that address multiple forms of malnutrition are urgently needed in urban settings.

Evaluating the coverage and quality of nutrition programs via a bottom-up approach: A secondary analysis of real-time data from an end-user monitoring system in Ethiopia.

Over the last two decades, great efforts and investments have been made in Ethiopia to ensure that all children have equal access to nutrition services in health facilities. While quality health systems are a prerequisite for quality nutrition services, little attention has been given to the evaluation of the supply and delivery services. The purpose of the study was to evaluate the coverage and quality of the nutrition-specific interventions delivered through the health system. Using an end-user monitoring (EUM) system, we monitored the delivery of nutrition-specific interventions in 500 districts, having 2514 health facilities distributed throughout Ethiopia. Data were collected through third-party monitors between August 2020 and 2021. Roughly 90% of health facilities were performing severe acute malnutrition management in line with the national guideline/protocol, and 2/3 of the assessed facilities were delivering iron and folic acid, vitamin A supplementation and deworming. A third of the messages on AMIYCN were retained by beneficiaries. Warehouse conditions were good in 64.3% of the facilities, but only 22% had good recording practices and about half had problems related to the quality and availability of nutrition supplies. Most beneficiaries were satisfied with the nutrition supplies and service delivered at the health facility level. This study also suggests the relevance of an EUM system to assess the quality of nutrition service delivery and its related supply management, as well as to improve the implementation of nutrition interventions as a decision-making tool.

Child feeding practices in rural Ethiopia show increasing consumption of unhealthy foods.

The quality of complementary feeding can have both short- and long-term health impacts by delaying or promoting child growth and establishing taste preferences and feeding behaviours. We aimed to assess the healthy and unhealthy feeding practices of infants and young children in rural Ethiopia. We conducted two rounds of surveys in December 2017/18 in Habru district, North Wello, rural Ethiopia among caregivers of infants and young children (N = 574). We characterised the consumption of infants and young children using non-quantitative 24 h recall and the World Health Organization infant and young child feeding indicators. Sociodemographic characteristics, anthropometry and haemoglobin concentrations were assessed. Breastfeeding was a norm as 82% and 67% were breastfed in the first and second rounds. Between the two rounds, dietary diversity increased from 5% to 17% (p < 0.05), but more pronounced increases were observed in the consumption of ultra-processed food (UPFs). Up to one-in-five (22%) of the children consumed UFPs. With an average of only three food groups consumed, the consumption of nutrient-dense foods like animal source foods, fruits and vegetables was very low particularly among younger children. UPFs are an additional risk factor that contributes to poor quality diets. Behavioural Change Communication interventions, including those in rural areas, should explicitly discourage the consumption of UPFs. Future studies should aim to quantify the amount of UPFs consumed and evaluate how this is associated with diet adequacy and nutritional outcomes.

Drivers of change in weight-for-height among children under 5 years of age in Ethiopia: Risk factors and data gaps to identify risk factors.

The prevention of wasting should be a public health priority as the global burden of acute malnutrition is still high. Gaps still exist in our understanding of context-specific risk factors and interventions that can be implemented to prevent acute malnutrition. We used data from the four rounds of the Ethiopia Demographic and Health Survey (2000-2016) to identify risk factors that have contributed to the change in weight-for-height z-score (WHZ) among children under 5 years of age. We performed a pooled linear regression analysis followed by a decomposition analysis to identify relevant risk factors and their relative contribution to the change in WHZ. Modest improvements in WHZ were seen between 2000 and 2016. The sharpest decrease in mean WHZ occurred from birth to 6 months of age. Perceived low weight at birth and recent diarrhoea predicted a decline in WHZ among children aged 0-5, 6-23 and 23-59 months. Less than 50% of the change in WHZ was accounted for by the change in risk factors included in our regression decomposition analysis. This finding highlights data gaps to identify context-specific wasting risk factors. The decline in the prevalence of recent diarrhoea (15% of the improvement), decline in low birth size (7%-9%), and an increase in wealth (15%-30%) were the main risk factors that accounted for the explained change in WHZ. Our findings emphasize the importance of interventions to reduce low birthweight, diarrhoea and interventions that address income inequities to prevent acute malnutrition.

Estimating the number of deaths averted from 2008 to 2020 within the Ethiopian CMAM programme.

The management of wasting in Ethiopia is heavily reliant on the Community-based Management of Acute Malnutrition (CMAM) programme that has been implemented in more than 18,000 service delivery points scattered across the country. Despite the full-scale implementation of the CMAM, the number of child death averted, and the cost per child death averted remains unknown. This study aimed to estimate the cost and the number of child death averted by the CMAM programme between 2008 and 2020. Using data from routine monitoring of the CMAM programme, we estimated the excess mortality averted by the programme and estimated the cost per averted child death based on supply and labour. Over the past 13 years between 2008 and 2020, 3.6 million children under 5 years were admitted to the Ethiopian CMAM programme. The yearly average admission of 317,228 was achieved since 2011. On average, ~34,000 child deaths were averted yearly. The CMAM programme was estimated to have saved 437,654 (95% confidence interval [CI]: 320,161; 469,932) child deaths between 2008 and 2020, approximately 12% of the admitted cases. The average cost of the programme per adverted death was estimated at US$762/child death averted (95% CI = 639; 1001). The CMAM programme in Ethiopia is cost-effective and has continued to avert a significant number of child death. Given the high short- and long-term economic and health consequences of child wasting, concerted multi-sectoral efforts are needed to accelerate progress not only in its treatment but also in its prevention.

Seasonal variation in maternal dietary diversity is reduced by small-scale irrigation practices: A longitudinal study.

Some agricultural practices, such as irrigation, have the potential to buffer seasonal dietary gaps and through increased production and consumption improve diets, particularly of the rural poor relying on subsistence farming but also for rural and urban households purchasing irrigated produce on local markets. The study aimed to evaluate the effect of seasonality and irrigation on women's diet in rural Ethiopia. Using a longitudinal study design, three rounds of surveys were conducted among women of reproductive age (15-49 years). Data on socioeconomic status, food consumption and haemoglobin concentration was collected. Energy and nutrient intakes were estimated using an interviewer-administered multiple-pass 24-h recall. Women's dietary diversity score (WDDS), the proportion of women meeting the minimum dietary diversity for women (MDDW), haemoglobin concentration, the prevalence of anaemia and energy and nutrients intakes were compared between irrigators and nonirrigators and by season. Associations between MDDW/WDDS and irrigation status were assessed using fixed-effect models, after adjusting for covariates. WDDS was low (3-4 out of 10 food groups) and exhibited high seasonal variability (p < 0.05). Diets were predominantly cereal-based, with little consumption of nutrient-dense foods like fruits and animal source foods. High seasonal variability in energy, protein, vitamin C, calcium, iron and zinc intakes were observed (p < 0.01). Irrigators were more likely to meet the MDDW than women from non-irrigating households (p < 0.05). No cases of malaria were reported from the three rounds of screening. There is a high seasonal variation in women's diet, but this could be partly offset by irrigation practices.

Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography.

OBJECTIVE: To assess factors influencing dietary behaviours of adolescents in Addis Ababa, Ethiopia. DESIGN: Using the qualitative participatory method Photovoice, participants received training on the basics of Photovoice and took photographs related to (un)healthy eating in their environment. Transcripts of individual interviews, focus group discussions and photographs were coded for thematic analysis. SETTING: One private and one public school located in the same, central neighbourhood in Addis Ababa, Ethiopia to explore how school populations of different socio-economic status experience the same neighbourhood environment. PARTICIPANTS: Twenty-six adolescents aged 14-19 years old, of which there were seventeen girls and nine boys. RESULTS: Findings from the current study indicate that food safety concerns appear to be the major influencing factors for adolescents' dietary choices. Unhealthy and unsafe foods appear to be widely available and/or affordable in adolescents' neighbourhoods and almost half of the photographs taken by adolescents depicted poor hygiene conditions related to food vendors. Participants considered foods available in their environments as generally unsafe, calling for more packaged food. CONCLUSIONS: Concerns for food safety, hygiene and affordability are the dominating factors for adolescents' food choices. These concerns, together with limited nutrition knowledge and preference for packaged foods, could make cheap, ultra-processed packaged foods more desirable.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019).

Vitamin A supplementation (VAS), started as a short-term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all-cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural-urban residence. VAS has saved between 167,563 to 376,030 child lives (2005-2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale-up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set-up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.

Empowering women can improve child dietary diversity in Ethiopia.

Women empowerment is an underlying factor of child feeding and nutrition. However, the lack of standardized measurements has made it difficult to design interventions that embed women empowerment and measure their impacts. This study aimed to assess temporal trends in women empowerment in Ethiopia and evaluate their contribution towards improving dietary diversity in infants and young children. We used women and child data from the Ethiopian Demographic and Health Survey 2005, 2011, and 2016, yielding a total sample of 6113 mother-child pairs. The survey-based women's empowerment index (SWPER) developed and validated for use in Africa was used to assess three dimensions of women empowerment: (i) social autonomy, (ii) decision making; and (iii) attitude to violence. We used multiple-linear and multivariable logistic regression to assess the associations between SWPER and the number of food groups consumed/and the minimum dietary diversity (MDD). To determine drivers of changes over time, a regression decomposition analysis was run. Women empowerment indices have improved over the 2005-2016 period, but a significant proportion of women had low standardized SWPER scores for autonomy/social independence (47%) and attitude to violence (49%) domains in 2016. SWPER autonomy and SWPER decision-making scores were strongly associated with the odds of meeting MDD. Changes in women empowerment accounted for 17% of the improvements in MDD between 2005 and 2016. SWPER was a stronger predictor of the change in MDD, than known predictors like wealth, child age, and urban residence. As a critical underlying driver of child nutrition, women empowerment should be boldly addressed and integrated in nutrition interventions.

Subnational mapping for targeting anaemia prevention in women of reproductive age in Ethiopia: A coverage-equity paradox.

Anaemia in women of reproductive age (WRA) can be effectively addressed if supported by a better understanding of the spatial variations, magnitude, severity and distribution of anaemia. This study aimed to map the subnational spatial distribution of anaemia (any, moderate and severe forms) among WRA in Ethiopia. We identified and mapped (any, moderate and severe) anaemia hotspots in WRA (n = 14,923) at the subnational level and identified risk factors using multilevel logistic regression. Kulldorff scan statistics were used to identify hotspot regions. Ordinary kringing was used to predict the anaemia prevalence in unmeasured areas. The overall anaemia prevalence increased from 16.6% in 2011 to 23.6% in 2016, a rise that was mostly related to the widening of existing hotspot areas. The primary clusters of (any) anaemia were in Somali and Afar regions. The horn of the Somali region represented a cluster of 330 km where 10% of WRA were severely anaemic. The Oromia-Somali border represented a significant cluster covering 247 km, with 9% severe anaemia. Population-dense areas with low anaemia prevalence had high absolute number of cases. Women education, taking iron-folic-acid tablets during pregnancy and birth-delivery in health facilities reduced the risk of any anaemia (P < 0.05). The local-level mapping of anaemia helped identify clusters that require attention but also highlighted the urgent need to study the aetiology of anaemia to improve the effectiveness and safety of interventions. Both relative and absolute anaemia estimates are critical to determine where additional attention is needed.

Understanding delays in the introduction of complementary foods in rural Ethiopia.

Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding practices, ensure adequate energy and nutrient intake and prevent linear growth faltering. This study aimed to assess mothers' and health workers' knowledge of timely introduction to complementary foods and evaluate the relationship between delays in complementary feeding and subsequent linear growth. We conducted two rounds of surveys (March/August 2017) among 249 health workers (n = 249) and caregivers (n = 2635) of children 6-23 months of age. We collected information about socio-demographic characteristics, knowledge and practice related to timely introduction to complementary foods. The study was conducted in households from the Productive Safety Net Programme (PSNP) districts, in four highland regions of Ethiopia. Delays in the introduction to complementary feeding were widespread with 53% of children 6-8 months of age not consuming solid, semisolid or soft foods in the past 24 h. After controlling for child, caregiver and household characteristics, children not introduced to complementary foods by 6-8 months had a 0.48 SD lower length-for-age z-score at 12-15 months. Caregivers' knowledge was strongly and inversely correlated with untimely introduction of complementary foods in logistic regressions (OR = 0.55, p < 0.01). In turn, local health extension worker's knowledge was strongly correlated with caregiver's knowledge. Consequently, frequent and timely visits by health extension workers emphasising not only on what to feed but also when and how to feed a child are needed. Innovative ways of increasing reach, intensity and frequency of nutrition messaging by using the PSNP interactions as an additional point of contact would need to be explored further.

Child growth faltering dynamics in food insecure districts in rural Ethiopia.

Child undernutrition disproportionally affects children in low- and middle-income countries. In Ethiopia, both wasting and stunting are serious public health concerns, with high human and economic costs. Understanding the dynamics in ponderal and linear growth faltering is critical to inform the design of innovative interventions that can prevent both wasting and stunting in poor and complex settings. Using two longitudinal studies conducted in 2017 and 2019 in four highland regions of Ethiopia, we evaluated the dynamics and drivers of child growth faltering in children 6-23 months of age (N = 5003). Child wasting prevalence peaked during the first 6 months of life, whereas stunting increased significantly after 6 months of age. Male sex, child illnesses (i.e., diarrhoea or fever) and low consumption of fruits and vegetables were associated with higher odds of acute undernutrition (P < 0.05). The consumption of animal source foods (ASF) was associated with increases (ß: 95% CI) in weight-for-length Z-score (WLZ; 0.12: 0.0002; 0.242), whereas fruit or vegetables consumption was associated with increases in midupper arm circumference (MUAC; 0.11 cm: 0.003; 0.209). Only consumption of ASF was the statistically significant predictor of future linear growth (0.14: 0.029; 0.251). Distinct trends in WLZ and MUAC were observed by child sex and age. Improving diet quality through improved nutrition knowledge and increased access and affordability of ASFs, along with effective infection prevention/control measures could prevent both child wasting and stunting concurrently.

Whole egg powder makes nutritious diet more affordable for Ethiopia: A cost of the diet and affordability analysis.

Despite sustained nutrition education, consumption of animal source foods (ASFs) has been hindered by their low availability, accessibility and affordability. Drying eggs into powder can reduce transport/storage costs, increase shelf-life and allow easier dosage for use of smaller portions. This study aimed to evaluate the contribution of integrating egg powder to the nutrient adequacy and affordability of diets. Using the 'cost of the diet' analysis, we simulated the incorporation of egg powder into households' and children's diet and evaluated its contribution to the nutrient adequacy and affordability of diets. Analysis of the household consumption and expenditure survey (HCES 2016) revealed that only 0.2% of the total consumption expenditure was allocated for eggs, far below the 2.2% and 4.3% required to allow the consumption of one egg a day by the average and the poorest households, respectively. However, the minimum-cost nutritious diet required only 2.5 g of egg powder/person/day to reduce the cost of the optimized diet by 14% (0-24%), allowing an additional 1.2 million households (~4-6 million individuals) afford the optimized diet. The optimized diet for a child 6-23 months of age could be afforded by all households, except by those in the poorest wealth quintile. But, free distribution of egg powder to households in the poorest wealth quintile, if supplemented by effective nutrition education, can allow them to afford the minimum-cost nutritious diet for their 6- to 23-month child. The simple dehydration of egg into egg powder can have a substantial contribution towards increased egg consumption by increasing the affordability of the minimum-cost nutritious diet.