Study protocol to assess aflatoxin M1 health risks versus benefits of dairy consumption in Ethiopian children: an epidemiological trial and risk-benefit analysis.

INTRODUCTION: In Sidama, Ethiopia, animal-source foods can be difficult to access. Milk has important nutrients for child growth, but carries the risk of aflatoxin M1 (AFM1) contamination. AFM1 is a metabolite of the mycotoxin aflatoxin B1 (AFB1) in dairy feed; cows secrete AFM1 in milk when their feed contains AFB1 produced by Aspergillus fungi in maize, nuts and oilseeds. It is unknown whether AFM1 compromises child growth and health. METHODS AND ANALYSIS: This protocol paper describes our study in Sidama to determine the impact of milk consumption and AFM1 on child growth in the first 18 months of life. We will collect baseline and end-line data on dairy production, socioeconomic and nutritional factors of 1000 dairy-owning households with children ages 6-18 months at baseline; and gather samples of milk and dairy feed and child anthropometrics. We will conduct phone interviews every 6 months to ascertain changes in practices or child health. Dairy feed will be tested for AFB1; milk for AFM1, pathogens and nutrients. Controlling for herd size, socioeconomic, nutritional and behavioural factors, we will determine the association between child anthropometrics and milk consumption, as well as AFM1 exposure. We will examine whether AFM1 exposure affects child growth in the first 18 months of life, and weigh the benefits and risks of milk consumption. ETHICS AND DISSEMINATION: The protocol is approved by the Institutional Review Boards of the Ethiopian Public Health Institute (EPHI-IRB-481-2022), Michigan State University (STUDY00007996) and International Food Policy Research Institute (DSGD-23-0102). Written informed consent will be obtained from all participants, who may withdraw from the study at any time. Confidentiality of collected data will be given high priority during each stage of data handling. The study's findings will be disseminated through stakeholder workshops, local and international conferences, journal articles and technical reports.

Higher food prices can reduce poverty and stimulate growth in food production.

Food prices spiked sharply in 2007-2008, in 2010-2011 and again in 2021-2022. However, the impacts of these spikes on poverty remain controversial; while food is a large expense for the poor, many poor people also earn income from producing or marketing food, and higher prices should incentivize greater food production. Short-run simulation models assume away production and wage adjustments, and probably underestimate food production by the poor. Here we analyse annual data on poverty rates, real food price changes and food production growth for 33 middle-income countries from 2000 to 2019 based on World Bank poverty measures. Panel regressions show that year-on-year increases in the real price of food predict reductions in the US$3.20-per-day poverty headcount, except in more urban or non-agrarian countries. A plausible explanation is that rising food prices stimulate short-run agricultural supply responses that induce increased demand for unskilled labour and increases in wages.

Measuring consumption over the phone: Evidence from a survey experiment in urban Ethiopia.

The paucity of reliable, timely household consumption data in many low- and middle-income countries have made it difficult to assess how global poverty has evolved during the COVID-19 pandemic. Standard poverty measurement requires collecting household consumption data, which is rarely collected by phone. To test the feasibility of collecting consumption data over the phone, we conducted a survey experiment in urban Ethiopia, randomly assigning households to either phone or in-person interviews. In the phone survey, average per capita consumption is 23 percent lower and the estimated poverty headcount is twice as high than in the in-person survey. We observe evidence of survey fatigue occurring early in phone interviews but not in in-person interviews; the bias is correlated with household characteristics. While the phone survey mode provides comparable estimates when measuring diet-based food security, it is not amenable to measuring consumption using the 'best practice' approach originally devised for in-person surveys.

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.

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.

Food prices and marketing margins during the COVID-19 pandemic: Evidence from vegetable value chains in Ethiopia.

It is widely feared that the shock of the COVID-19 pandemic will lead to a significant worsening of the food security situation in low and middle-income countries. One reason for this is the disruption of food marketing systems and subsequent changes in farm and consumer prices. Based on primary data in Ethiopia collected just before the start and a few months into the pandemic, we assess changes in farm and consumer prices of four major vegetables and the contribution of different segments of the rural-urban value chain in urban retail price formation. We find large, but heterogeneous, price changes for different vegetables with relatively larger changes seen at the farm level, compared to the consumer level, leading to winners and losers among local vegetable farmers due to pandemic-related trade disruptions. We further note that despite substantial hurdles in domestic trade reported by most value chain agents, increases in marketing-and especially transportation-costs have not been the major contributor to overall changes in retail prices. Marketing margins even declined for half of the vegetables studied. The relatively small changes in marketing margins overall indicate the resilience of these domestic value chains during the pandemic in Ethiopia.

Institutional mistrust and child vaccination coverage in Africa.

INTRODUCTION: Despite considerable improvements in vaccination coverage over the last decade, half of the world's unvaccinated and undervaccinated children are located in Africa. The role of institutional trust in explaining vaccination gaps has been highlighted in several qualitative reports but so far has only been quantified in a small number of high-income countries. METHODS: We matched information on child vaccination status from the Demographic Health Surveys with information on institutional trust from the Afrobarometer surveys at the subnational level. A total of 166 953 children from 41 surveys administered in 22 African countries covering 216 subnational regions were used. Based on a principal component analysis, we constructed an institutional mistrust index that combined the level of mistrust in the head of state, parliament, electoral system, courts and local government. Associations between institutional mistrust and child vaccination uptake were assessed with multivariable fixed effects logistic regressions that controlled for time-invariant subnational region characteristics and various child, caregiver, household and community characteristics. RESULTS: A 1 SD increase in the institutional mistrust index was associated with a 10% (95% CI of ORs: 1.03 to 1.18) increase in the likelihood that a child had not received any of eight basic vaccines and with a 6% decrease in the likelihood a child had received all of the basic vaccines (95% CI: 0.92 to 0.97). Institutional mistrust was negatively associated with the likelihood that a child had received each of the eight basic vaccinations (p<0.05). CONCLUSIONS: Child vaccination rates in Africa are considerably lower in areas in which the local population displays high levels of mistrust towards local authorities. Institutional mistrust is an important dimension of vaccine hesitancy, considered as one of the most important threats to global health. Empowering local authorities with resources and communication strategies to address institutional mistrust may be needed to close the remaining vaccination gaps in Africa.

Food Consumption and Food Security during the COVID-19 Pandemic in Addis Ababa.

International humanitarian organizations have expressed substantial concern about the potential for increases in food insecurity resulting from the COVID-19 pandemic. We use a unique panel survey of a representative sample households in Addis Ababa to study both food security and food consumption during the pandemic. In contrast to some other countries in the region, Ethiopia never went into a full lockdown severely restricting movement. Despite subjective income measures suggesting a large proportion of households have been exposed to job loss or reduced incomes, we find that relative to a survey conducted in August and September of 2019, food consumption and household dietary diversity are largely unchanged or slightly increased by August 2020. We find some changes in the composition of food consumption, but they are not related to shocks found in previous phone surveys conducted with the same households. The results therefore suggest the types of subjective questions about income typically being asked in COVID-19 phone surveys may not appropriately reflect the magnitude of such shocks. They also imply, at least indirectly, that in the aggregate food value chains have been resilient to the shock associated with the pandemic.

Geography of public service delivery in rural Ethiopia.

Remote areas are often characterized by lower welfare outcomes due to economic disadvantages and higher transaction costs for trade. But their poorer situation may also be linked to worse public service delivery. Relying on large household surveys in rural Ethiopia, we explore this by assessing the association of two measures of remoteness - (1) the distance of service centers to district capitals and (2) the distance of households to service centers (the last mile) - with public service delivery in agriculture and health sectors. In the agriculture sector, we document statistically significant and economically meaningful associations between exposure to agriculture extension and the two measures of remoteness. For health extension, only the last mile matters. These differences between the two sectors could be due to the fact that more remote villages tend to have fewer agriculture extension workers who also put in fewer hours than their peers in more connected areas. This does not apply in the health sector. These findings provide valuable inputs for policymakers aiming to improve inclusiveness in poor rural areas.

Evaluation of Linear Growth at Higher Altitudes.

Importance: Irrespective of their genetic makeup, children living in an ideal home environment that supports healthy growth have similar growth potential. However, whether this potential is true for children residing at higher altitudes remains unknown. Objective: To investigate whether altitude is associated with increased risk of linear growth faltering and evaluate the implications associated with the use of the 2006 World Health Organization growth standards, which have not been validated for populations residing 1500 m above sea level. Design, Settings, and Participants: Analysis of 133 nationally representative demographic and health cross-sectional surveys administered in 59 low- and middle-income countries using local polynomial and multivariate regression was conducted. A total of 964 299 height records from 96 552 clusters at altitudes ranging from -372 to 5951 m above sea level were included. Demographic and Health Surveys were conducted between 1992 and 2018. Exposures: Residence at higher altitudes, above and below 1500 m above sea level, and in ideal home environments (eg, access to safe water, sanitation, and health care). Main Outcomes and Measures: The primary outcome was child linear growth deficits expressed in length-for-age/height-for-age z scores (HAZ). Associations between altitude and height among all children and those residing in ideal home environments were assessed. Child growth trajectories above and below 1500 m above sea level were compared and the altitude-mediated height deficits were estimated using multivariable linear regression. Results: In 2010, a total of 842 million people in the global population (approximately 12%) lived 1500 m above sea level or higher, with 67% in Asia and Africa. Eleven percent of the sample was children who resided 1500 m above sea level or higher. These children were born at shorter length and remained on a lower growth trajectory than children residing in areas less than 1500 m above sea level. The negative association between altitude and HAZ was approximately linear through most part of the altitude distribution, indicating no clear threshold for an abrupt decrease in HAZ. A 1000-m above sea level increase in altitude was associated with a 0.163-unit (95% CI, -0.205 to -0.120 units) decrease in HAZ after adjusting for common risk factors using multivariable linear regressions. The HAZ distribution of children residing in ideal home environments was similar to the 2006 World Health Organization HAZ distribution, but only up to 500 m above sea level. Conclusions and Relevance: The findings of this study suggest that residing at a higher altitude may be associated with child growth slowing even for children living in ideal home environments. Interventions addressing altitude-mediated growth restrictions during pregnancy and early childhood should be identified and implemented.

This is US: Geography of evidence in top health economics journals.

The Journal of Health Economics and Health Economics are arguably the top two journals in the field of health economics. Together, they published 1,679 empirical research articles in the past decade (2010-2019). In line with analyses based on earlier periods, the empirical evidence in top health economics journals continues to be dominated by the United States (37% of all empirical articles), whereas studies based on low-income countries remain rare (2%). Countries with higher disease burdens receive generally less attention from health economists publishing at the top of their field. Reflecting this, more research was published based on data from the Nordic countries (27 million people) than from sub-Saharan Africa and South Asia regions combined (2.9 billion people). Finally, one-third of the empirical articles did not indicate the country of evidence in the title or the abstract, possibly to signal external validity of the findings. This practice was particularly common for articles based on data from North America with more than half of the articles omitting the country of evidence from the title and the abstract. The study concludes by exploring some hypotheses that may explain these findings.

Assessing Community Health Information Systems: Evidence from Child Health Records in Food Insecure Areas of the Ethiopian Highlands.

OBJECTIVES: This study assessed the completeness of child health records maintained and collected within community health information system in Ethiopia. METHODS: A household listing was carried out in 221 enumeration areas in food insecure areas of Ethiopia to determine the presence of a child less than 24-months. This list of children was then compared against the information stored at the local health posts. A household survey was administered to a sample of 2155 households that had a child less than 24-months of age to assess determinants and consequences of exclusion from the health post registers. RESULTS: Out of the 10,318 children identified during the listing, 36% were found from the health post records. Further analysis based on the household survey data indicated that health posts that had adopted nationally recommended recordkeeping practices had more complete records (p < 0.01) and that children residing farther from health posts were less likely to be found from the registers (p < 0.05). Mothers whose child was found from the registers were more likely to know a health extension worker (p < 0.01), had a contact with one (p < 0.01), and their child was more likely to have received growth monitoring (p < 0.05). CONCLUSIONS FOR PRACTICE: The incompleteness of the data collected at the health posts poses a challenge for effective implementation of the national health extension program and various complementary programs in Ethiopia.

Affordability of the EAT-Lancet reference diet: a global analysis.

BACKGROUND: The EAT-Lancet Commission drew on all available nutritional and environmental evidence to construct the first global benchmark diet capable of sustaining health and protecting the planet, but it did not assess dietary affordability. We used food price and household income data to estimate affordability of EAT-Lancet benchmark diets, as a first step to guiding interventions to improve diets around the world. METHODS: We obtained retail prices from 2011 for 744 foods in 159 countries, collected under the International Comparison Program. We used these data to identify the most affordable foods to meet EAT-Lancet targets. We compared total diet cost per day to each country's mean per capita household income, calculated the proportion of people for whom the most affordable EAT-Lancet diet exceeds total income, and also measured affordability relative to a least-cost diet that meets essential nutrient requirements. FINDINGS: The most affordable EAT-Lancet diets cost a global median of US$2·84 per day (IQR 2·41-3·16) in 2011, of which the largest share was the cost of fruits and vegetables (31·2%), followed by legumes and nuts (18·7%), meat, eggs, and fish (15·2%), and dairy (13·2%). This diet costs a small fraction of average incomes in high-income countries but is not affordable for the world's poor. We estimated that the cost of an EAT-Lancet diet exceeded household per capita income for at least 1·58 billion people. The EAT-Lancet diet is also more expensive than the minimum cost of nutrient adequacy, on average, by a mean factor of 1·60 (IQR 1·41-1·78). INTERPRETATION: Current diets differ greatly from EAT-Lancet targets. Improving diets is affordable in many countries but for many people would require some combination of higher income, nutritional assistance, and lower prices. Data and analysis for the cost of healthier foods are needed to inform both local interventions and systemic changes. FUNDING: Bill & Melinda Gates Foundation.

Energy and nutrient production in Ethiopia, 2011-2015: Implications to supporting healthy diets and food systems.

Agricultural sector plays a key role towards achieving healthier diets that are deemed critical for improving health and nutritional outcomes. To what extent the current food supply systems support healthy diets remains unknown. Using annual and nationally representative data on crop and livestock production in Ethiopia, we assess the national agricultural sector from a nutrition lens and its role in supporting healthy diets in the country. We do so by converting the agricultural production into energy and nutrients for the period of 2011-2015. These data show that the national food production has increased dramatically over the 5-year period to supply more than 3,000 calories per capita in 2015. Moreover, nutrient production gaps have substantially decreased (2011-15), but deficits in energy (5%), vitamin C (16%), and calcium (9%) production remained in 2015. However, this production growth-coming primarily from the cereal sector and at the expense of other food groups-led to a decrease in production diversity as reflected by a drop in the Shannon index between 2011 and 2015. Together these findings imply that the production increases in Ethiopia would need to be sustained to feed the rapidly growing population but more emphasis should be given to diversification to support healthy and nutritionally diversified diets.

Rural Food Markets and Child Nutrition.

Child dietary diversity is poor in much of rural Africa and developing Asia, prompting significant efforts to leverage agriculture to improve diets. However, growing recognition that even very poor rural households rely on markets to satisfy their demand for nutrient-rich non-staple foods warrants a much better understanding of how rural markets vary in their diversity, competitiveness, frequency and food affordability, and how such characteristics are associated with diets. This article addresses these questions using data from rural Ethiopia. Deploying a novel market survey in conjunction with an information-rich household survey, we find that children in proximity to markets that sell more non-staple food groups have more diverse diets. However, the association is small in absolute terms; moving from three non-staple food groups in the market to six is associated with an increase in the number of non-staple food groups consumed by ˜0.27 and the likelihood of consumption of any non-staple food group by 10 percentage points. These associations are similar in magnitude to those de-scribing the relationship between dietary diversity and household production diversity; moreover, for some food groups, notably dairy, we find that household and community production of that food is especially important. These modest associations may reflect several specific features of our sample which is situated in very poor, food-insecure localities where even the relatively better off are poor in absolute terms and where, by international standards, relative prices for non-staple foods are very high.

Animal Sourced Foods and Child Stunting.

Stunting affects 160 million pre-school children globally with adverse life-long consequences. While work within nutritional science suggests that stunting in early childhood is associated with low intakes of animal-sourced foods (ASFs), this topic has received little attention from economists. We attempt to redress this omission through an analysis of 130,432 children aged 6-23 months from 49 countries. We document distinctive patterns of ASF consumption among children in different regions. We find evidence of strong associations between stunting and a generic ASF consumption indicator, as well as dairy, meat/fish, and egg consumption indicators, and evidence that consuming multiple ASFs is more advantageous than any single ASF. We explore why ASF consumption is low but also so variable across countries. Non-tradable ASFs (fresh milk, eggs) are a very expensive source of calories in low-income countries and caloric prices of these foods are strongly associated with children's consumption patterns. Other demand-side factors are also important, but the strong influence of prices implies an important role for agricultural policies-in production, marketing and trade-to improve the accessibility and affordability of ASFs in poorer countries.

Can governments promote homestead gardening at scale? Evidence from Ethiopia.

Low intake of fruits and vegetables is a major cause of micronutrient deficiencies in the developing world. Since the 1980s, various non-governmental organizations have promoted homestead gardening (HG) programs, first in Asia, but now increasingly in Africa. Longstanding concerns with HG programs are: (1) they lack scalability, particularly for governments; (2) they only work in areas with/without good access to markets; and (3) they are only suitable for more water-abundant ecologies. We assess these concerns by analyzing a large and novel survey on the adoption of a nationwide HG program implemented by the Ethiopian government. We find that better market access encourages HG adoption; so too does greater public promotion of HGs, but only in more water-abundant ecologies.

Is Exposure to Poultry Harmful to Child Nutrition? An Observational Analysis for Rural Ethiopia.

Although strategic thinking on water, sanitation and hygiene (WASH) has prioritized reducing exposure to human feces in order to limit diarrheal infections, recent research suggests that elevated exposure to livestock-particularly poultry and poultry feces-may be an important risk factor for diarrhea, environmental enteric disorder (EED) and respiratory infections, all of which may seriously retard linear growth in young children. Yet a very different literature on nutrition-sensitive agriculture suggests that livestock ownership is highly beneficial for child growth outcomes through its importance for increasing consumption of nutrient-rich animal sourced foods, such as eggs. Together, these two literatures suggest that the net nutritional benefit of poultry ownership is particularly ambiguous and potentially mediated by whether or not children are highly exposed to poultry. We test this novel hypothesis using a large agricultural survey of rural Ethiopian households that includes measures of child height-for-age Z-scores (HAZ), ownership of poultry and other types of livestock, and an indicator of whether livestock are kept within the main household dwelling overnight. We used least squares regression analysis to estimate unadjusted and adjusted models that control for a wide range of potentially confounding factors. We find that while poultry ownership is positively associated with child HAZ [ß = 0.291, s.e. = 0.094], the practice of corralling poultry in the household dwelling overnight is negatively associated with HAZ [ß = -0.250, s.e. = 0.118]. Moreover, we find no negative associations between HAZ and corralling other livestock species indoors. These results suggest that while poultry ownership can be beneficial to child growth, overly close exposure to poultry poses a concurrent risk factor for undernutrition, most likely because of increased risk of infection.