"People will talk about her if she is not circumcised": Exploring the patterning, drivers and gender norms around female genital mutilation in Ethiopia's Somali region.

Over the past decade there has been a burgeoning literature on social norms and the need to understand their context-specific patterning and trends to promote change, including to address the harmful practice of female genital mutilation (FGM), which affects around 200 million girls and women globally. This article draws on mixed-methods data collected in 2022 and 2023 with 1,020 adolescents and their caregivers, as well as key informants, from Ethiopia's Somali region to explore the patterning, drivers, and decision-making around FGM. Findings indicate that almost all Somali girls can expect to undergo FGM before age 15, and that infibulation is near universal. Critically, however, we find that respondents' understanding of infibulation is rooted in traditional practice, and many girls are now "partially" infibulated-an invasive procedure that girls nonetheless see as an improvement over the past. These shifts reflect religious leaders' efforts to eliminate traditional infibulation--and the health risks it entails--by promoting "less invasive" types of FGM as a requirement of Islam. We also find evidence of emergent medicalization of the practice, as mothers-who are the primary decision-makers-seek to further reduce risks. Adult and adolescent respondents agree that FGM is a deeply embedded social norm, but distinguish between FGM as a perceived religious requirement, and infibulation as a cultural requirement. For girls and women, the importance of FGM is framed around social acceptance, whereas boys and men focus on FGM as a requirement for marriage as it allows families to control girls' sexuality. The article concludes by reflecting on the implications of our findings for programming in high-prevalence contexts. Key conclusions include that FGM interventions should not rely on empowering individuals as "champions of change" but rather prioritize engagement with whole communities, and should be open in the short term to incremental harm-reduction approaches.

Challenges for research uptake for health policymaking and practice in low- and middle-income countries: a scoping review.

BACKGROUND: An estimated 85% of research resources are wasted worldwide, while there is growing demand for context-based evidence-informed health policymaking. In low- and middle-income countries (LMICs), research uptake for health policymaking and practice is even lower, while little is known about the barriers to the translation of health evidence to policy and local implementation. We aimed to compile the current evidence on barriers to uptake of research in health policy and practice in LMICs using scoping review. METHODS: The scoping review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) and the Arksey and O'Malley framework. Both published evidence and grey literature on research uptake were systematically searched from major databases (PubMed, Cochrane Library, CINAHL (EBSCO), Global Health (Ovid)) and direct Google Scholar. Literature exploring barriers to uptake of research evidence in health policy and practice in LMICs were included and their key findings were synthesized using thematic areas to address the review question. RESULTS: A total of 4291 publications were retrieved in the initial search, of which 142 were included meeting the eligibility criteria. Overall, research uptake for policymaking and practice in LMICs was very low. The challenges to research uptake were related to lack of understanding of the local contexts, low political priority, poor stakeholder engagement and partnership, resource and capacity constraints, low system response for accountability and lack of communication and dissemination platforms. CONCLUSION: Important barriers to research uptake, mainly limited contextual understanding and low participation of key stakeholders and ownership, have been identified. Understanding the local research and policy context and participatory evidence production and dissemination may promote research uptake for policy and practice. Institutions that bridge the chasm between knowledge formation, evidence synthesis and translation may play critical role in the translation process.

Burden of neglected tropical diseases and access to medicine and diagnostics in Ethiopia: a scoping review.

BACKGROUND: More than 1.7 billion people are affected by neglected tropical diseases (NTDs) worldwide. Forty percent of the NTD-affected people live in Africa with the poorest, most vulnerable, and hard to reach geographical areas. The NTDs cause significant social and economic burden and deepen marginalization and stigmatization. The World Health Organization's current roadmap for NTD aims to prevent, control, eliminate, or eradicate 20 tropical diseases. Ethiopia experiences a high burden of these diseases, but current access to diagnostics, medicine, and/or care has been little explored to inform the country's NTD strategic plan. The overall purpose of the scoping review was to map and characterize the burden of NTDs and challenges in access to diagnostics, medicine, and/or care in Ethiopia. METHODS: A systematic search of evidence was conducted in PubMed, Cochrane Library, and Google Scholar from January 2000 until May 2022, without restrictions of language or study design. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review was followed for screening of studies. Key findings were extracted and narrated qualitatively. RESULTS: The search resulted in 4532 articles, of which 105 met the inclusion criteria and were included in the scoping review under three themes: burden of NTDs, access to diagnostics, medicine and/or care, and key barriers. Although gains have been made in the prevention and control of NTDs in Ethiopia, the burden remains high, and progress in access to diagnostics, medicine/drugs, and/or care is very slow. Poverty, poor quality of life, and underfunding of NTD programs decelerate the process of NTD elimination program in the country. CONCLUSIONS: The scoping review identified a considerable number of studies on the burden of NTDs in Ethiopia and strategies for diagnosis, treatment, and/or care; however, there is a paucity of evidence on the suitability and potential benefits of novel diagnostic technologies and medicines in the country. A regular review and analysis of such country-level evidence is important to inform the country NTDs roadmap and local implementation strategies.

Improving Menstrual Health Literacy Through Life-Skills Programming in Rural Ethiopia.

Despite its cultural and biological importance, limited knowledge about menstruation and cultural taboos in many contexts mean that menarche often brings fear and stigma. In Ethiopia, the context of this paper, lack of knowledge and the stigma around menstruation create challenges for adolescent girls related to menstrual hygiene management and their reproductive health more broadly. This paper uses a cluster-randomized controlled trial (cRCT), with 97 communities (kebeles) randomly assigned to treatment or control, to assess the impact of a gender-transformative life-skills intervention [Act With Her-Ethiopia (AWH-E)] on the menstrual health literacy of very young adolescent girls and boys (10-14) in two diverse regions of Ethiopia (South Gondar, Amhara and East Hararghe, Oromia). The evaluation employs a longitudinal mixed-methods design, with baseline data collected in late 2017/early 2018 and follow-up data collected in late 2019/early 2020. Quantitative surveys were undertaken with 2,492 very young adolescents and their primary caregivers, and complemented by qualitative interviews with 291 adolescents and their caregivers, as well as 96 key informants at community and district levels. Our quantitative findings highlight large and statistically significant improvements on norms around menstruation, knowledge about menstruation and biological function, and knowledge and behavior related to menstrual hygiene management, but with important differences by location and gender. Qualitative findings further unpack these gender and regional differences, highlighting the importance of adapting programming to the local context and, where possible, connecting to other health and gender initiatives. This analysis helps fill the evidence gap on "what works" to improve menstrual health literacy in rural low- and middle-income contexts.

Ruptured school trajectories: understanding the impact of COVID-19 on school dropout, socio-emotional and academic learning using a longitudinal design.

This paper presents the findings of longitudinal research conducted in Ethiopia exploring the effects of COVID-19 school closures on children's holistic learning, including their socio-emotional and academic learning. It draws on data from over 2,000 pupils captured in 2019 and 2021 to compare primary school children's dropout and learning before and after school closures. The study adapts self-reporting scales used in similar contexts to measure grade 4-6 pupils' social skills and numeracy. Findings highlight the risk of widening inequality regarding educational access and outcomes, related to pupils' gender, age, wealth and location. They also highlight a decline in social skills following school closures and identify a positive and significant relationship between pupils' social skills and numeracy over time. In conclusion, we recommend a need for education systems to promote children's holistic learning, which is even more vital in the aftermath of the pandemic.

The Implications of COVID-19 for Early Childhood Education in Ethiopia: Perspectives from Parents and Caregivers.

Recent research on the effects of COVID-19 on school closures has mainly focused on primary and secondary education, with extremely limited attention to early childhood education (ECE). To address this gap, we identify the extent to which parents and caregivers with pre-primary school-aged children were engaged in their children's learning during school closures in Ethiopia. Our focus on Ethiopia is of particular relevance given that ECE provision has expanded dramatically in recent years, aimed at ensuring children are prepared for primary school. Using data collected through a phone survey with 480 parents and caregivers, the results revealed that learning disruption due to COVID-19 school closures is likely to be substantial and will probably widen existing inequalities further. Many poorer households and those where parents or caregivers are not literate, are less likely to have child-oriented learning resources, and home learning activities between parents and children in these households are limited. The study highlights that greater attention needs to be paid to mitigate the threats of COVID-19 on Ethiopia's recent gains in ECE, to prevent the pandemic from further reinforcing inequalities between children from advantaged and disadvantaged households.

Impact of the COVID-19 pandemic on anxiety and depression symptoms of young people in the global south: evidence from a four-country cohort study.

OBJECTIVE: To provide evidence on the effect of the COVID-19 pandemic on the mental health of young people who grew up in poverty in low/middle-income countries (LMICs). DESIGN: A phone survey administered between August and October 2020 to participants of a population-based longitudinal cohort study established in 2002 comprising two cohorts born in 1994-1995 and 2001-2002 in Ethiopia, India (Andhra Pradesh and Telangana), Peru and Vietnam. We use logistic regressions to examine associations between mental health and pandemic-related stressors, structural factors (gender, age), and lifelong protective/risk factors (parent and peer relationship, wealth, long-term health problems, past emotional problems, subjective well-being) measured at younger ages. SETTING: A geographically diverse, poverty-focused sample, also reaching those without mobile phones or internet access. PARTICIPANTS: 10 496 individuals were approached; 9730 participated. Overall, 8988 individuals were included in this study; 4610 (51%) men and 4378 (49%) women. Non-inclusion was due to non-location or missing data. MAIN OUTCOME MEASURES: Symptoms consistent with at least mild anxiety or depression were measured by Generalized Anxiety Disorder-7 (≥5) or Patient Health Questionnaire-8 (≥5). RESULTS: Rates of symptoms of at least mild anxiety (depression) were highest in Peru at 41% (32%) (95% CI 38.63% to 43.12%; (29.49-33.74)), and lowest in Vietnam at 9% (9%) (95% CI 8.16% to 10.58%; (8.33-10.77)), mirroring COVID-19 mortality rates. Women were most affected in all countries except Ethiopia. Pandemic-related stressors such as health risks/expenses, economic adversity, food insecurity, and educational or employment disruption were risk factors for anxiety and depression, though showed varying levels of importance across countries. Prior parent/peer relationships were protective factors, while long-term health or emotional problems were risk factors. CONCLUSION: Pandemic-related health, economic and social stress present significant risks to the mental health of young people in LMICs where mental health support is limited, but urgently needed to prevent long-term consequences.

The effect of early childhood stunting on children's cognitive achievements: Evidence from young lives Ethiopia.

BACKGROUND: There is little empirical evidence on the effect of childhood malnutrition on children's cognitive achievements in low income countries like Ethiopia. A longitudinal data is thus vital to understand the factors that influence cognitive development of children over time, particularly how early childhood stunting affects cognitive achievement of children up to the age of 8 years. OBJECTIVE: To examine the effect of early childhood stunting on cognitive achievements of children using longitudinal data that incorporate anthropometric measurements and results of cognitive achievement tests such as Peabody Picture Vocabulary Test and Cognitive Development Assessment quantitative tests. METHOD: Defining stunted children as those having a standardized height for age z-score less than -2; we used a Propensity Score Matching (PSM) to examine the effect of early childhood stunting on measures of cognitive performance of children. The balance of the propensity score matching techniques was checked and found to be satisfied (P<0.01). RESULTS: Early childhood stunting is significantly negatively associated with cognitive performance of children. Controlled for confounding variables such as length of breastfeeding, relative size of the child at birth, health problems of early childhood such as acute respiratory illness and malaria, baseline household wealth, child gender, household size and parental education, estimates from PSM show that stunted children scored 16.1% less in the Peabody Picture Vocabulary Test and 48.8% less in the Quantitative Assessment test at the age of eight, both statistically significant at P<0.01. CONCLUSIONS: It is important to realize the importance of early investment in terms of child health and nutrition until five years for the cognitive performance of children. As household wealth and parental education are particularly found to play an important role in children's nutritional achievements, policy measures that are directed in improving household's livelihood may have a spill-over impact in improving child nutritional status, and consequently cognitive development and schooling.

Growth recovery and faltering through early adolescence in low- and middle-income countries: Determinants and implications for cognitive development.

Child chronic undernutrition, as measured by stunting, is prevalent in low- and middle-income countries and is among the major threats to child development. While stunting and its implications for cognitive development have been considered irreversible beyond early childhood there is a lack of consensus in the literature on this, as there is some evidence of recovery from stunting and that this recovery may be associated with improvements in cognition. Less is known however, about the drivers of growth recovery and the aspects of recovery linked to cognitive development. In this paper we investigate the factors associated with growth recovery and faltering through age 12 years and the implications of the incidence, timing, and persistence of post-infancy recovery from stunting for cognitive development using longitudinal data from Ethiopia, India, Peru, and Vietnam. We find that the factors most systematically associated with accelerated growth both before and after early childhood and across countries include mother's height, household living standards and shocks, community wages, food prices, and garbage collection. Our results suggest that post-infancy recovery from stunting is more likely to be systematically associated with higher achievement scores across countries when it is persistent and that associations between growth trajectories and cognitive achievement in middle childhood do not persist through early adolescence across countries. Overall, our findings indicate that growth after early childhood is responsive to changes in the household and community environments and that growth promotion after early childhood may yield improvements in child cognitive development.

Household food group expenditure patterns are associated with child anthropometry at ages 5, 8 and 12 years in Ethiopia, India, Peru and Vietnam.

Population-level analysis of dietary influences on nutritional status is challenging in part due to limitations in dietary intake data. Household expenditure surveys, covering recent household expenditures and including key food groups, are routinely conducted in low- and middle-income countries. These data may help identify patterns of food expenditure that relate to child growth. OBJECTIVES: We investigated the relationship between household food expenditures and child growth using factor analysis. METHODS: We used data on 6993 children from Ethiopia, India, Peru and Vietnam at ages 5, 8 and 12y from the Young Lives cohort. We compared associations between household food expenditures and child growth (height-for-age z scores, HAZ; body mass index-for-age z scores, BMI-Z) using total household food expenditures and the "household food group expenditure index" (HFGEI) extracted from household expenditures with factor analysis on the seven food groups in the child dietary diversity scale, controlling for total food expenditures, child dietary diversity, data collection round, rural/urban residence and child sex. We used the HFGEI to capture households' allocations of their finances across food groups in the context of local food pricing, availability and pReferences RESULTS: The HFGEI was associated with significant increases in child HAZ in Ethiopia (0.07), India (0.14), and Vietnam (0.07) after adjusting for all control variables. Total food expenditures remained significantly associated with increases in BMI-Z for India (0.15), Peru (0.11) and Vietnam (0.06) after adjusting for study round, HFGEI, dietary diversity, rural residence, and whether the child was female. Dietary diversity was inversely associated with BMI-Z in India and Peru. Mean dietary diversity increased from age 5y to 8y and decreased from age 8y to 12y in all countries. CONCLUSION: Household food expenditure data provide insights into household food purchasing patterns that significantly predict HAZ and BMI-Z. Including food expenditure patterns data in analyses may yield important information about child nutritional status and linear growth.

Growth trajectories from conception through middle childhood and cognitive achievement at age 8 years: Evidence from four low- and middle-income countries.

Child chronic malnutrition is endemic in low- and middle-income countries and deleterious for child development. Studies investigating the relationship between nutrition at different periods of childhood, as measured by growth in these periods (growth trajectories), and cognitive development have produced mixed evidence. Although an explanation of this has been that different studies use different approaches to model growth trajectories, the differences across approaches are not well understood. Furthermore, little is known about the pathways linking growth trajectories and cognitive achievement. In this paper, we develop and estimate a general path model of the relationship between growth trajectories and cognitive achievement using data on four cohorts from Ethiopia, India, Peru, and Vietnam. The model is used to: a) compare two of the most common approaches of modelling growth trajectories in the literature, namely the lifecourse plot and the conditional body size model, and b) investigate the potential channels via which the association between growth in each period and cognitive achievement manifests. We show that the two approaches are expected to produce systematically different results that have distinct interpretations. Results suggest that growth from conception through age 1 year, between age 1 and 5 years, and between 5 and 8 years are each positively and significantly associated with cognitive achievement at age 8 years and that this may be partly explained by the fact that faster-growing children start school earlier. We also find that a significant share of the association between early growth and later cognitive achievement is mediated through growth in interim periods.

Cross-Sectional and Longitudinal Associations between Household Food Security and Child Anthropometry at Ages 5 and 8 Years in Ethiopia, India, Peru, and Vietnam.

BACKGROUND: Poor childhood nutritional status has lifetime effects and food insecurity is associated with dietary practices that can impair nutritional status. OBJECTIVES: We assessed concurrent and subsequent associations between food insecurity and height-for-age z scores (HAZs) and body mass index-for-age z scores (BMI-Zs); evaluated associations with transitory and chronic food insecurity; and tested whether dietary diversity mediates associations between food insecurity and nutritional status. METHODS: We used data from the Young Lives younger cohort composed of children in Ethiopia (n = 1757), India (n = 1825), Peru (n = 1844), and Vietnam (n = 1828) recruited in 2002 (round 1) at ∼1 y old, with subsequent data collection at 5 y in 2006 (round 2) and 8 y in 2009 (round 3). RESULTS: Children from food-insecure households had significantly lower HAZs in all countries at 5 y (Ethiopia, -0.33; India, -0.53; Peru, -0.31; and Vietnam, -0.68 HAZ; all P < 0.001), although results were attenuated after controlling for potential confounders (Ethiopia, -0.21; India, -0.32; Peru, -0.14; and Vietnam, -0.27 HAZ; P < 0.01). Age 5 y food insecurity predicted the age 8 y HAZ, but did not add predictive power beyond HAZ at age 5 y in Ethiopia, India, or Peru. Age 5 y food insecurity predicted the age 8 y BMI-Z even after controlling for the 5 y BMI-Z, although associations were not significant after the inclusion of additional confounding variables (Ethiopia, P = 0.12; India, P = 0.29; Peru, P = 0.16; and Vietnam, P = 0.51). Chronically food-insecure households had significantly lower HAZs than households that were consistently food-secure, although BMI-Zs did not differ by chronic food-insecurity status. Dietary diversity mediated 18.8-30.5% of the association between food security and anthropometry in Vietnam, but mediated to a lesser degree (8.4-19.3%) in other countries. CONCLUSIONS: In 4 countries, food insecurity at 5 y of age was associated with both HAZ and BMI-Z at age 8 y, although the association was attenuated after adjusting for other household factors and anthropometry at age 5 y, and remained significant only for the HAZ in Vietnam.

Climate change, crop production and child under nutrition in Ethiopia; a longitudinal panel study.

BACKGROUND: The amount and distribution of rainfall and temperature influences household food availability, thus increasing the risk of child under nutrition. However, few studies examined the local spatial variability and the impact of temperature and rainfall on child under nutrition at a smaller scale (resolution). We conducted this study to evaluate the effect of weather variables on child under nutrition and the variations in effects across the three agro ecologies of Ethiopia. METHODS: A longitudinal panel study was conducted. We used crop productions (cereals and oilseeds), livestock, monthly rainfall and temperature, and child under nutrition data for the period of 1996, 1998, 2000 and 2004. We applied panel regression fixed effects model. RESULTS: The study included 43 clusters (administrative zones) and 145 observations. We observed a spatio temporal variability of rainfall, stunting and underweight. We estimated that for a given zone, one standard deviation increase in rainfall leads to 0.242 standard deviations increase in moderate stunting. Additionally, a one standard deviation increase temperature leads to 0.216 standard deviations decrease in moderate stunting. However, wasting was found to be poorly related with rainfall and temperature. But severe wasting showed a positive relationship with the quadratic term of rainfall. CONCLUSIONS: We conclude that rainfall and temperature are partly predicting the variation in child stunting and underweight. Models vary in predicting stunting and underweight across the three agro ecologic zones. This could indicate that a single model for the three agro ecologies may not be not applicable.

Cohort profile: the Young Lives study.

Young Lives is an international longitudinal study investigating the changing nature of childhood poverty in four low-income countries [Ethiopia, India (Andhra Pradesh), Peru and Vietnam] over a 15-year period. In each country, the cohort is comprised of ≈ 2000 children aged between 6 and 18 months and up to 1000 children aged between 7 and 8 years, recruited in 2002 and sampled from 20 sentinel sites. The first survey data collection from primary caregivers and older children took place in 2002, the second in 2006-07 and the third in 2009-10. Data on the community contexts were collected to complement the household surveys. To elaborate and extend the quantitative data, longitudinal qualitative research with a subgroup of the children was carried out in 2007, 2008 and 2010-11. Topic areas covered included nutrition, health and well-being, cognitive and physical development, health behaviours and education, as well as the social, demographic and economic status of the household. Survey data from the study are archived in the International Section of the UK Public Data Archive.