Factors associated with dietary diversity and length-for-age z-score in rural Ethiopian children aged 6-23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation.

Infants and young children need diets high in nutrient density and diversity to meet the requirements of rapid growth and development. Our aim was to evaluate sociodemographic, agricultural diversity, and women's empowerment factors associated with child dietary diversity and length-for-age z-score (LAZ) in children 6-23 months using data collected as part of the Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study baseline survey in May-June 2016. We here present a novel analysis using directed acyclic graphs (DAGs) to represent our assumptions about the causal influences between the factors of interest and the outcomes. The causal diagrams enabled the identification of variables to be included in multivariable analysis to estimate the total effects of factors of interest using ordinal logistic/linear regression models. We found that child dietary diversity was positively associated with LAZ with children consuming 4 or more food groups having on average an LAZ score 0.42 (95% CI [0.08, 0.77]) higher than those consuming no complementary foods. Household production of fruits and vegetables was associated with both increased child dietary diversity (adjusted OR 1.16; 95% CI [1.09, 1.24]) and LAZ (adjusted mean difference 0.05; 95% CI [0.005, 0.10]). Other factors positively associated with child dietary diversity included age in months, socio-economic status, maternal education, women's empowerment and dietary diversity, paternal childcare support, household food security, fruit and vegetable cultivation, and land ownership. LAZ was positively associated with age, socio-economic status, maternal education, fruit and vegetable production, and land ownership.

Household food insecurity and its association with school absenteeism among primary school adolescents in Jimma zone, Ethiopia.

BACKGROUND: Household food insecurity and lack of education are two of the most remarkable deprivations which developing countries are currently experiencing. Evidences from different studies showed that health and nutrition problems are major barriers to educational access and achievement in low-income countries which poses a serious challenge on effort towards the achieving Sustainable Development Goals. Evidence on the link between food security and school attendance is very important to address this challenge. This study aimed to assess to what extent food insecurity affects school absenteeism among primary school adolescents. METHODS: A school based cross-sectional study was conducted among primary school adolescents in Jimma zone from October-November, 2013. Structured questionnaire was used to collect data on the household food security and socio-demographic variables. Data were analyzed using SPSS for windows version 16.0 after checking for missing values and outliers. Multivariable logistic regression analyses were used to determine the association of school absenteeism and food insecurity with independent variables using odds ratio and 95 % of confidence intervals. Variables with p ≤ 0.25 in the bivariate analyses were entered into a multivariable regression analysis to control for associations among the independent variables. RESULTS: The frequency of adolescent school absenteeism was significantly high (50.20 %) among food insecure households (P < 0.001) compared to their peers whose households were food secure (37.89 %). Findings of multivariable logistic regression analysis also showed that household food insecurity [AOR = 2.81 (1.70, 4.76)] was positively associated with poor school attendance while female-headed household [AOR = 0.23 (0.07, 0.72)], urban residence [AOR = 0.52 (0.36, 0.81)] and male-gender [AOR = 0.64 (0.54, 0.74)] were inversely associated with school absenteeism. Household food insecurity was positively associated with lack of maternal education [AOR = 2.26 (0.57, 8.93)] and poor household economic status [AOR = 1.39 (1.18, 2.83)]. However, livestock ownership [AOR = 0.17 (0.06, 0.51)] was negatively associated with household food insecurity. CONCLUSIONS: Findings of this study showed that household food insecurity has strong linkage with adolescent school absenteeism. Maternal education and household economic status were significantly associated with household food security status. Therefore, national policies and programs need to stress on how to improve family income earning capacity and socioeconomic status to handle household food insecurity which is a key contributor of adolescent school absenteeism.

Multisector Nutrition Program Governance and Implementation in Ethiopia: Opportunities and Challenges.

Governments globally are stressing both direct nutrition interventions combined with nutrition sensitive policies and programs to combat malnutrition. Governance at all levels has been identified as a critical element in ensuring success of national nutrition plans. For example, the most recent National Nutrition Program (NNP) in Ethiopia discusses the essentiality of governance and coordination at all levels. The research uses a qualitative study based on semi-structured interviews with key informant. The research discussed in this article focuses on governance structures from national to regional to district level in Ethiopia with an emphasis on translation of a strategy and implementation of the NNP. This article concentrates primarily on results from the national and regional levels. Data at both the national and regional levels indicate that there is general agreement on the nature of the nutrition problems in Ethiopia. At all levels of government, under nutrition, food insecurity, and micronutrient deficiencies were listed as the main nutrition problems. The challenges in governance and implementation identified at both the national and regional levels, however, varied. The implementation of the 2013 NNP was in its early stages at the time of this research. While there was palpable energy around the launch of the NNP, respondents indicated issues related to leadership, coordination, collaboration, advocacy, and budget would be challenges in sustaining momentum.

Precision of Measurements Performed by a Cadre of Anthropometrists Trained for a Large Household Nutrition Survey in Ethiopia.

BACKGROUND: Well-trained anthropometrists are essential for the delivery of high-quality anthropometric data used to evaluate public health nutrition interventions. Scant data are currently available on the precision of data collected by large teams of anthropometrists employed for nutrition surveys in low-income country settings. OBJECTIVES: The purpose of this study was to assess the precision of child midupper arm circumference (MUAC) and length/height measurements taken by fieldworkers training for nutrition survey deployment. METHODS: Following 3 d of training, an anthropometry standardization exercise was conducted in small teams of trainees at 7 sites in the Amhara region of Ethiopia. In groups of 2-4, trainee anthropometrists (n = 79) each measured 16 children aged 6-47 mo (n = 336) twice for MUAC and length/height. Both intraobserver and interobserver precision were analyzed using technical error of measurement (TEM), relative TEM, coefficient of reliability (R), and repeatability metrics. Bland-Altman limits of agreement were calculated for intraobserver measurements. RESULTS: Intraobserver TEM was between 0.00 and 0.57 cm for MUAC (Bland-Altman 95% limits of agreement: -0.50 to 0.54 cm) and between 0.04 and 2.58 cm for length/height measurements (Bland-Altman 95% limits of agreement: -1.43 to 1.41 cm). Interobserver TEM was between 0.09 and 0.43 cm for MUAC and between 0.06 and 2.98 cm for length/height measurements. A high proportion of trainees achieved intraobserver R >0.95 (MUAC: 95%; length/height: 97%). Most teams also achieved interobserver R >0.95 (MUAC: 90%; length/height: 95%). CONCLUSIONS: Large numbers of anthropometrists (>75) in low-income settings can attain satisfactory precision in anthropometry following training and standardization. These protocols permit researchers to assess trainees, identify individuals who have not achieved the desired level of precision, and retrain or adjust roles prior to survey deployment.

The fidelity and dose of message delivery on infant and young child feeding practice and nutrition sensitive agriculture in Ethiopia: a qualitative study from the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme.

BACKGROUND: In Ethiopia, 38% of children under 5 years of age are stunted (low height for age). A novel government-led intervention called the Sustainable Undernutrition Reduction in Ethiopia (SURE) aims to tackle the burden of stunting by improving complementary feeding and dietary diversity among young children. The SURE programme design applies a transtheoretical model of behaviour change, whereby exposure to recommended infant and young child feeding (IYCF) and nutrition-sensitive agriculture messages is a first stage to adopting key behaviours. This qualitative study explored the fidelity and dose of the IYCF and nutrition-sensitive agriculture messages delivered by extension workers. METHODS: A qualitative study was conducted across four regions in Ethiopia (Oromiya, Amhara, SNNP and Tigray) between April and October 2017. Across the four regions, 81 key informant interviews, 90 FGDs and 81 observations were conducted with 180 extension workers, 18 development agents and 54 mother-father pairs. Digitally recorded audio files were transcribed verbatim, and the data were analysed based on a framework analysis approach using NVivo (version 12) by coding and categorising texts into major themes and sub-themes. RESULTS: SURE target households had the intended exposure to messages about exclusive breastfeeding, timing of initiation of complementary feeding, food groups, diversified food consumption, irrigation, rearing small animals and vegetables. Few households reported receiving messages on the content or frequency of complementary feeding of a child beyond 6 months of age. Frequency of household visits and hence exposure to SURE messages was also variable. Agricultural messages delivered during household visits focussed on improving standard agricultural practices and rarely covered the importance of nutrition-sensitive agriculture to improve household or child nutrition. CONCLUSION: Despite variability observed in the breadth and depth of messages delivered, large-scale behaviour change communication programmes can achieve moderate to good message exposure among target groups. Qualitative data provide an in-depth insight into fidelity and may supplement our understanding of programme roll-out and implementation. Further research is required to understand longer-term message saturation including frequency and reach.

Dietary zinc intake and its determinants among Ethiopian children 6-35 months of age.

BACKGROUND: Adequate zinc intake is essential for the growth and neurobehavioral development of young children. Zinc deficiency in children is recognized as risk factor for stunting. In Ethiopia, 38% of children under five years of age are stunted. This analysis was conducted to measure dietary zinc intake and to identify its determinants among children 6-35 months of age to design appropriate intervention. METHODS: Nationally and regionally representative data available from 6752 children 6-35 months of age from the Ethiopian national food consumption survey were analyzed. A multivariate model was used to identify determinants of dietary zinc intake. RESULTS: We found low dietary zinc intake among children 6-35 month age. National average dietary zinc intake was 1.74 mg/day. Socio-economic status, maternal education, and maternal age were positively associated with dietary zinc intake, while the number of children under 5 years-of-age in a household was negatively associated with dietary zinc intake (p < 0.0001). Children reportedly sick in the previous 2 weeks were most likely to have low dietary zinc intake (p < 0.0001). CONCLUSION: The observed low dietary zinc intake in Ethiopian children has a significant association with health status of children, providing evidence for nutrition and health planners to emphasize on promoting consumption of zinc rich foods and preventing morbidity from common infections.

Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study: a protocol to evaluate impact, process and context of a large-scale integrated health and agriculture programme to improve complementary feeding in Ethiopia.

INTRODUCTION: Improving complementary feeding in Ethiopia requires special focus on dietary diversity. The Sustainable Undernutrition Reduction in Ethiopia (SURE) programme is a government-led multisectoral intervention that aims to integrate the work of the health and agriculture sectors to deliver a complex multicomponent intervention to improve child feeding and reduce stunting. The Federal Ministries of Health and Agriculture and Natural Resources implement the intervention. The evaluation aims to assess a range of processes, outcomes and impacts. METHODS AND ANALYSIS: The SURE evaluation study is a theory-based, mixed methods study comprising impact and process evaluations. We hypothesise that the package of SURE interventions, including integrated health and agriculture behaviour change communication for nutrition, systems strengthening and multisectoral coordination, will result in detectable differences in minimum acceptable diet in children 6-23 months and stunting in children 24-47 months between intervention and comparison groups. Repeated cross-sectional household surveys will be conducted at baseline and endline to assess impact. The process will be assessed using observations, key informant interviews and focus group discussions to investigate the fidelity and dose of programme implementation, behavioural pathways of impact and contextual factors interacting with the intervention. Pathways of impact will also be explored through statistical analyses. ETHICS AND DISSEMINATION: The study has received ethics approval from the scientific and ethical review committees at the Ethiopian Public Health Institute and the London School of Hygiene and Tropical Medicine. The findings will be disseminated collaboratively with stakeholders at specified time points and through peer-reviewed publications and presentations.

Enhancing Personal Hygiene Behavior and Competency of Elementary School Adolescents through Peer-Led Approach and School-Friendly: A Quasi-Experimental Study.

BACKGROUND: Recent studies showed that poor personal hygiene practices play a major role in the increment of communicable disease burden in developing countries. In Ethiopia, 60% of the disease burden is related to poor sanitation practices. This school based study was aimed to assess the effectiveness of school-friendly and peer-led approach in improving personal hygiene practices of school adolescents in Jimma Zone, Southwest of Ethiopia. METHODS: A total of 1000 students from 10 to 19 years were included into the study. The intervention was done using peer-led approach, health clubs and linking the school events with parents. Data were collected at baseline, midline and end-line using structured questionnaires. Repeated measurement analysis was done and statistical significance was considered at alpha 0.05. RESULTS: The findings of this study indicated that there was a significant difference in personal hygiene practices and knowledge between the intervention and control groups (P<0.001). A significant difference was also observed with the duration of time in the intervention schools (P<0.05). The proportion of adolescents who reported illness before the baseline survey was significantly high among the intervention schools (P<0.01). However, at midline of the survey, the proportion of self-reported illness was significantly high among the control group(P<0.001). CONCLUSION: The findings of this study showed that there was a significant improvement in personal hygiene knowledge and practice of students in the intervention schools. Therefore, there is a need for proper health education intervention through the framework of schools for the students to improve their personal hygiene knowledge and practices.

Linkages between health and agriculture sectors in Ethiopia: a formative research study exploring barriers, facilitators and opportunities for local level coordination to deliver nutritional programmes and services.

BACKGROUND: In Ethiopia, poor infant and young child feeding practices and low household dietary diversity remain widespread. The Government has adopted the National Nutrition Programme that emphasizes the need for multi-sectoral collaboration to effectively deliver nutrition-sensitive and nutrition-specific interventions. The Sustainable Undernutrition Reduction in Ethiopia (SURE) programme is one such Government-led initiative that will be implemented jointly by the health and agriculture sectors across 150 districts in Ethiopia. Prior to the design of the SURE programme, this formative research study was conducted to understand how the governance structure and linkages between health and agriculture sectors at local levels can support implementation of programme activities. METHODS: Data were collected from eight districts in Ethiopia using 16 key informant interviews and eight focus group discussions conducted with district and community-level focal persons for nutrition including health and agriculture extension workers. A framework analysis approach was used to analyze data. RESULTS: Few respondents were aware of the National Nutrition Programme or of their own roles within the multi-sectoral coordination mechanism outlined by the government to deliver nutritional programmes and services. Lack of knowledge or commitment to nutrition, lack of resources and presence of competing priorities within individual sectors were identified as barriers to effective coordination between health and agriculture sectors. Strong central commitment to nutrition, increased involvement of other partners in nutrition and the presence of community development workers such as health and agriculture extension workers were identified as facilitators of effective coordination. CONCLUSIONS: Federal guidelines to implement the Ethiopian National Nutrition Programme have yet to be translated to district or community level administrative structures. Sustained political commitment and provision of resources will be necessary to achieve effective inter-sectoral collaboration to deliver nutritional services. The health and agriculture extension platforms may be used to link interventions for sustained nutrition impact.

Improving dietary diversity of school adolescents through school based nutrition education and home gardening in Jimma Zone: Quasi-experimental design.

PURPOSE: The purpose of this operational study was to assess the effectiveness school-based health and nutrition intervention supported with backyard gardening on the dietary diversity among school adolescents. METHODS: A total of 1000 school adolescents from 10 to 19years were selected randomly. The intervention involved peer-led behavior change communication and health promotion through school media and health clubs. Data were collected at baseline, midline and end-line using structured questionnaires. Multivariable logistic regression analyses were used to determine the independent effect of interventions. RESULTS: There was a significant increment of proportion of school children consuming diversified diet among the intervention group from 34.8% at baseline through 65.6% at midline to 74.7% at the end-line (p<0.001). Among control group, there was no change from midline (49.4%) to endline (48.8%), though there was a change from baseline (32.1%) to midline (49.4%). A significant difference of dietary diversity intake was observed between intervention and control groups at midline (F=5.64, p=0.042) and endline (F=5.85, p<0.001) survey. Being in the intervention school (OR=2.55 [1.55, 3.50]), being a boy (OR=1.75 [1.91, 2.56]) and having farmer mothers (OR=2.58 [1.01, 6.87]) were independent positive predictors of a diversified diet intake. However, having a mother who attended secondary schools were inversely associated (OR=0.25 [0.06, 0.97]) with consuming a diversified diet. CONCLUSION: Findings of this study demonstrated that there was a significant improvement in dietary diversity of adolescents in intervention schools. The results imply that school based nutrition education should be a part of comprehensive school health programs to reach students and potentially their families.

Effect of integrated school-based nutrition education on optimal dietary practices and nutritional status of school adolescents in Southwest of Ethiopia: a quasi-experimental study.

BACKGROUND: Malnutrition and infection are major barriers to educational access and achievement in low-income countries and also work in conjunction with each other in deteriorating wellness and productivity of school adolescents. METHODS: A quasi-experimental design was used to evaluate the effectiveness of school-based nutrition education using a peer-led approach, health promotion through school media and health clubs. Data were collected at baseline, midline and end line from sampled participants. To account for the effect of time trend, the difference was measured using a repeated measure analysis. Variables that have p≤0.25 in the bivariate analyses were entered into multivariables to determine the independent effect of interventions. RESULTS: There is a significant difference in food variety between food secure and insecure households (p<0.01). A significant improvement of animal source dietary intake was observed among intervention schools (p<0.001) that was significantly associated with an intervention [adjusted odds ratio (AOR)=0.26, confidence interval (CI): 0.16, 0.42], male gender (AOR=0.48, CI: 0.31, 0.73) and household economic status (AOR=1.69, CI: 1.01, 2.84). The control group had high body mass index (BMI) at baseline, but a significant improvement was observed among the intervention schools, which positively associated with male gender (AOR=4.13, CI: 2.38, 7.15) and having a middle-income family (AOR=2.93, CI: 1.92, 6.15). CONCLUSION: This study showed that by integrating a dietary intervention into school-based activities, there might be significant improvements in dietary intake of primary school adolescents. Therefore, school-based nutrition education programs should be a part of comprehensive school health programs to reach the students and potentially their families.

Determining Iodine Status and Knowledge of Dietary Salt Restricted Hypertension Patients in Addis Ababa Hospitals, Ethiopia.

Objectives: Hypertension is public health problem worldwide and the trends of prevalence have increased in economically developing countries. Reducing dietary sodium is one of the main recommendations to treatment hypertension. Restriction of salt consumption could cause a reduction of iodine intake from iodized salt. This study aims in determining iodine status and knowledge of dietary salt restricted hypertensive patients and compare with non hypertensive individuals. Methods: Institution based cross-sectional design was employed and 239 hypertensive and non hypertensive individuals were selected randomly. Urine samples were collected immediately after interviewing using iodine free cups. Results: T The MUIC were 41.56(SE9.41μg/L) and 46.14(SE7.86μg/L) in hypertensive and non hypertensive respectively. More than 76% were iodine deficient and greater than 30% were severely deficiency. The prevalence of iodine deficiency is higher in salt restricted hypertensive patients than non restricted patients but the difference was not statistically significant (P. value=0.12). Females had better knowledge about iodine than males. Hypertension patients on medication were 88% more likely to be iodine deficient than those do not receive medication. UIE of both groups are lower than the recommended intake and dietary salt restricted patients are more likely to be iodine than unrestricted. Conclusions: Iodine deficiency is a problem of dietary salt restricted hypertensive patients and to address this problem, an alternative iodine intervention mechanism should be in place. Besides, the contribution of salt for iodine status and degree of salt restriction needs to be studied.

Iodine Deficiency Disorders (IDD) in Burie and Womberma Districts, West Gojjam, Ethiopia.

Objectives: To assess the magnitude and causes of goiter in West Gojjam, Amhara National Regional state, Ethiopia. Methods: The study was conducted in July 2010. The sample size was determined by assuming 50% prevalence of total goiter rate, 5% error, 95% confidence interval, design effect of 1 (random) and 5% of non-response rate. Two stage random sampling; sub-district and village was used to select children aged 6-12 years and their biological mothers from 10 randomly selected villages in each of the districts. Overall, 403 households participated in the study. The assessment was conducted using palpation of thyroid size, urinary iodine level determination, household level interview and Focus Group Discussion (FGD). Results: The study revealed a total goiter prevalence rate of 54% and 30.1% in children and their biological mothers respectively. More than 64% of the children were severely iodine deficient. Younger age mother were more affected than older and female children are more afected than male ones. The major cause for goiter as revealed by urinary iodine level and concentration of iodized salt is dietary iodine deficiency. There are no goitrogenic foods such as cassava, however, goitrogenic chemicals such as Dichloro Diphenyl Trichloroethane (DDT) and 2,4-Dichlorophenoxyacetic acid (2,4-D) were widely used. The study areas are known for surplus produce of cereals, legumes and chilli. Conclusions: In order to reverse the problem, immediate and sustainable distribution of iodated salt/oil capsule, prohibition of direct application of pesticides on foods and awareness creation on adverse effects of IDD and benefits of iodine nutrition is highly recommended.

The Prevalence of Zinc Deficiency among Vulnerable Populations in Ethiopia.

Objectives: Widespread zinc deficiency is likely to exist in developing countries where staple diets are predominantly plant based and intakes of animal source foods are low. In Ethiopia, there are no data which reflect the current prevalence of zinc deficiency at the national and regional levels. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional prevalence of Zinc deficiency among children 6-59 months old and non-pregnant women 15-49 years of age. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates of zinc deficiency. The prevalence of zinc deficiency will be determined by measuring serum zinc in venous blood samples using Atomic Absorption Spectrophotometry (AAS). Time of day for blood sampling, time of last meal, time of centrifugation, and other appropriate variables will be collected to assist in interpretation of data. The zinc deficiency cut-off defined by WHO is <70 μg/dL for all target groups will be used to analyze the results. Acute phase proteins alpha-1-acid-glycoprotein (AGP) and C-reactive protein (CRP) will be measured by immunoassay technique to account for the effects of inflammation when interpreting zinc deficiency. Results: The national and regional prevalence of zinc deficiency will be presented among children 6-59 months and non-pregnant women 15-49 years of age with and without inflammation in Ethiopia. Conclusions: This survey will provide national and regional data for zinc supplementation and fortification programs in Ethiopia.

The Prevalence of Iron Deficiency Anemia (IDA) and Associated Factors among Vulnerable Populations in Ethiopia.

Objectives: In Ethiopia, there are no data which reflect the current prevalence of iron deficiency (ID) or iron deficiency anemia (IDA) at national or regional levels. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional prevalence of ID and IDA among children 6-59 months old and non-pregnant women 15-49 years of age in Ethiopia. Methods: The prevalence of ID will be determined by measuring serum ferritin (SF) and soluble transferrin receptor (sTfR) from venous blood samples using an automated electrochemiluminescence immunoassay (ELISA) and immuno-turbidimetry technique. Iron deficiency will be defined by SF<12.0 μg/L and sTfR>6.0 mg/L for children 6-59 months of age and SF<15.0 μg/L and sTfR>5.33 mg/L for non-pregnant women. Acute phase proteins alpha-1-acidglycoprotein (AGP) and C-reactive protein (CRP) will be measured to account for the effects of inflammation. The prevalence of anemia will be determined from hemoglobin levels in venous blood samples using a Hemocue® photometer. Anemia will be defined as hemoglobin <11.0 and <12.0 g/dL for children 6-59 months of age and non-pregnant women, respectively. IDA will be defined as either: 1) low serum ferritin levels and low hemoglobin (anemia) or 2) elevated sTfR (iron deficiency) and low hemoglobin (anemia). Results: The national and regional prevalence of iron deficiency and IDA will be presented with and without inflammation among children 6-59 months and non-pregnant women 15-49 years of age in Ethiopia. Conclusions: This survey will provide national and regional data for anemia control and fortification programs in Ethiopia.

The Proportion of Households with Adequately Iodized Salt in Ethiopia.

Objectives: According to the Ethiopia Demographic and Health Survey 2011, the proportion of households using iodized salt (>15 parts per million [PPM]) was 15.4%. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional proportions of households using adequately iodized (>15 ppm) salt in Ethiopia. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates. Samples of salt (20 gram) usually consumed will be collected from approximately 4,000households for qualitative testing using the rapid test kit. Salt samples will be sent to the Ethiopian Health and Nutrition Institute Laboratory where iodometric titration will be conducted. Results: The national and regional proportions of households with adequately iodized (>15 ppm) salt will be presented. Conclusions: This survey will provide national and regional data for monitoring and evaluating the progress of the Universal Salt Iodization (USI) program in Ethiopia.

Daily Dietary Intake of Zinc is positively Associated With Height-for-Age Z-score (Haz) among Ethiopian Children 6-35 Months of Age.

Objectives: In Ethiopia, 44% of children under five years-of-age are stunted (i.e., height-for-age (HAZ) below -2SD). This is considered a major public health concern by the Ethiopian Ministry of Health’s National Nutrition Plan. Future efforts to reduce stunting depend largely on understanding the local determinants of stunting. Zinc deficiency is a recognized risk factor for stunting in this age group and we hypothesized this was also true in Ethiopia. Our objectives were to determine the association between daily dietary zinc intake (DDZI) and HAZ and to also identify determinants of DDZI among children 6-35 months of age. Methods: We used regionally representative data from the 2011 Ethiopian National Food Consumption Survey, weighted for relative population sizes (N=6752 children). Univariate general linear models served to assess the association between HAZ and DDZI and to identify determinants of DDZI. Models included potential socioeconomic, demographic and physiological confounders. Results: DDZI was positively associated with HAZ (p<0.0001). Socio-economic status, maternal education, and maternal age were positively associated with DDZI, while the number of children under 5 years-of-age in a household was negatively associated with DDZI (p<0.0001). Children from the Amhara and SNNPR regions, and those reportedly sick in the previous 2 weeks were most likely to report low DDZI (p<0.0001). Conclusions: Low height-for-age remains a major public health problem in Ethiopia. Our findings suggest that height-for-age is associated with low zinc intake in Ethiopia, providing evidence for Ethiopia’s National Nutrition Plan to emphasize increased consumption of zinc rich foods in young children.

Effects of Governance Structures in Ethiopia on Implementation of Nutrition Interventions.

Objectives: 1. Assess factors that enhance or constrain implementation of nutrition interventions at national and sub national levels. 2. Analyze how direct nutrition interventions and multi sector approaches are implemented at national, regional, zonal and woreda levels. 3. Identify models of effective governance for nutrition interventions. Methods: Key informants were interviewed using a structured questionnaire. National level interviews from the agricultural, health, education, finance, economic development, social protection sectors and UN agencies, civil society and donors were included. Parallel interviews were conducted in four regions - Amhara, Oromia, SNNPR and Tigray - and 16 woredas for a total of 312 interviews at the subnational level. Results: While there was general awareness of the Government's activities as part of the SUN movement, key individuals at the national level were, in general, not able to identify specific actions that had been launched as a result of the 2013 National Nutrition Programme. Linkages between policy and program initiatives between national and sub national levels varied. The vertical and horizontal collaborations were most active where a specific, coordinating body or mechanism had been established. Several models of effective implementation are identified and most often originate outside the health sector. Conclusions: Two dominant models of implementing a multi pronged strategy to alleviate malnutrition exist in Ethiopia. The appropriateness of these models and factors associated with each are discussed.