Alive &Thrive IYCF Outcome Evaluation in Ethiopia Yared Mekonnen, PhD Mela Research PLC www.melaresearch.info November 20, 2012 Addis Ababa

Presentation outline Evaluation objectives Study design Methodology Coverage and frequency of Timed & Targeted Counseling (TTC) Program impact on key outcome indicators Summary Conclusion Study teams Acknowledgments

Evaluation Objective The overall objective of this endline survey is to assess the impact of the A&T program intervention in the implementation Woredas in SNNPR primarily concerning on Infant and Young Child Feeding Practices (IYCF).

Focus Indicators Infant and young child feeding practices of children 0 to 5 and 6 to 23 months that include: Knowledge of IYCF Early initiation of BF, Colostrum feeding Exclusive breastfeeding, Timely introduction of complementary feeding, Minimum Meal Frequency Minimum Dietary Diversity Minimum Acceptable Diet Continuation of breastfeeding Nutritional status of children Other indicators of interest include utilization of ANC, immunization of children, among others

Study design (Non-equivalent control group design) HEP Intervention area 4 Woredas Intervention area 4 Woredas + A&T intervention [Peer Mothers /TTC] Control area 4 Woredas Control area 4 Woredas HEP No A&T intervention Aug.-Sept. 2010 (Baseline) Aug.-Sept. 2012 (Endline)

Methodology A two-stage cluster sampling method A cluster is a Kebele A 40 by 40 factorial design was implemented (40 respondents in 40 Kebeles). 20 in the intervention & 20 in the control Target respondents per Kebele: 20 women with children 0-5 months 20 women with children 6-23 months

Selection of Kebeles Two reporting domains (1) Intervention area & (2) Control area Kebeles were selected separately for the intervention and control area All Kebeles in the respective areas were used as sampling frame A total of 40 Kebeles (20 in the intervention and 20 in the control area) were selected using probability proportion to size (PPS) The same Kebeles were surveyed at baseline and endline

Household selection procedure The selection of households was based on systematic sampling with a random start. We anticipated to find children age 0-23 months in every tenth household (DHS). The number of households and women in the Kebele were obtained from the HEWs to serve as sampling frame. Households with children 0-23 months were eligible for the interview

Sampling procedure Intervention Control 4 Woredas 4 Woredas 20 Kebeles 20 children: 0-5 months (per Kebele) 20 children: 6-23 months (per Kebele) 20 children: 0-5 months (per Kebele) 20 children: 6-23 months (per Kebele) 800 children 800 children

Questionnaire It is a structured and pre-coded questionnaire containing 44 pages. It collected information on various issues: Background information Household food security and economic status Household water supply and sanitation IYCF knowledge and practice Childhood illness and treatment, antenatal care, vaccination status, types and frequency of foods consumed, iron and vitamin A supplementation status.

Anthropometric measurements for children and women Weight of the children were measured with minimum clothing and without any ornaments on a digital scale to the nearest 0.1 kg (WHO recommendation). Laying length of under two children measured on a wooden board to the nearest 0.1 cm. Standing height of children older than two years was measured without shoes or anything on the head on a wooden board to the nearest 0.1 cm, Women' nutritional status was assessed using Body mass index (BMI). Women's height was measured on a wooden board to the nearest 0.1 cm with a minimum clothing. Weight will be measured using digital scale. Data collection – 30 days (September)

Method of analysis Difference-in-difference (DID) Binary Logit Model with dummy-by-dummy interaction effect (Multivariate) DID estimate (%) Visualizing interaction effect (graphical presentation) Static Group Comparison Exposed vs. unexposed to TTC in the intervention area Data entry & analysis software EPI-INFO for data entry STATA 11 for data nalysis (developed Syntax and do files)

Difference-in-Difference (DID) Estimate Indicator X P3 (P3-P1) DID=(P3-P1) - (P4-2) P1 (P4-P2) P4 P2 DID= (C-A) - (D-B)

Difference-in-Difference (DID) Estimate Indicator X P3 (P3-P1) DID=(P3- P1)-(P4-P2) P1=P2 DID=P3 – P4 P4 P1 (P4-P2) P2

Difference-in-Difference (DID) Estimate Indicator X P3 P4 DID=(P3-P1) - (P4-P2) (P4-P2) (P3-P1) P2 P1

Coverage and frequency of Timed & Targeted Counseling (TTC)

% of women visited by peer mothers according to number of visits (In the intervention area) – n=800

% women visited by peer mothers (for their most recent child age 0-23 months) – in the intervention areas

Type of information received during the TTC visit (during 3rd trimester & at delivery) Intervention area At the Third Trimester: Putting baby on the breast immediately within 1st hr Giving colostrums to the baby Pre-lacteal feeding is not necessary The benefit of feeding only breast milk first 6 months At the day of birth : 86.7 87.3 78.4 74.2 79.7 86.1

Type of information received during the TTC visit (at the 4th and 6 months) Intervention area At the 4th month after birth: Feed only breast milk up to six months Consulting health professional if any problem Monitoring Infant weight gain Waiting up to six month to start supplementary feeding At the 6th month after birth: Introducing complementary feeding Continuing breastfeeding 88.4 75.8 60.0 83.7 96.9 82.2

Type of information received Type of information received during the TTC visit (at the 8th and 12 months) Type of information received Intervention area At the 8th month after birth: Introducing complementary feeding Continuing breastfeeding Monitoring Infant weight gain At the 12th month after birth: 87.2 92.8 73.4 98.6 79.2

Program impact on key outcome indicators

The intervention has a net positive effect on women’s knowledge of key breastfeeding practices……

Multivariate Logistic Regression coefficient (β) -Interaction term (DID) Knowledge of breastfeeding practices Breastfeeding should start within an hour β Colostrums should be fed Fluid should be started at age 6th month Food should be started at age 6th month Study time Baseline (2010)-ref Endline (2012) Study arm Control -ref Intervention Interaction/DID (time X arm) 0.00 1.64*** 0.23* 0.36 0.80*** -0.28* 0.61*** 0.42*** 0.13 0.59*** 0.05 0.21 0.49* *p<0.05, ***p<0.0001; MV adjusted for several factors

% who said BF should be started immediately after birth DID=1.8 % (Not significant) DID=1.8 % (Not significant)

% who said colostrum should be fed DID= 12.3% DID estimate= 12%

% who said fluid should be started at 6 months DID= 10%

% who said food should be started at 6 months DID=8 % DID=8 %

The intervention has a net positive effect on key breastfeeding practices ….. -Early initiation of BF -Colostrum feeding -Pre-lacteal Feeding -Exclusive BF

Multivariate Logistic Regression Coefficient (β) -Interaction term (DID) Breastfeeding practices Initiation of breastfeeding within an hour (0-23 months) β Colostrums feeding Pre-lacteal feeding Exclusive breastfeeding up to age 6 months (0-5 months) Study time Baseline (2010)-ref Endline (2012) Study arm Control -ref Intervention Interaction/DID (time X arm) 0.00 0.22 -0.03 0.38* 0.05 0.17 0.67*** -0.83*** -0..14 -0.75*** 0.81*** -0.28 0.47* *p<0.05, ***p<0.0001; MV adjusted for several factors

% who initiated BF within 1 hr DID=6% DID=6%

% who fed colostrum DID=11.3% DID=11.3%

% who gave pre-lacteal feeding DID=3.1% DID=(-)3.1%

% with exclusive BF (0-5 months) DID=9.8% DID=9.8%

No evidence of program impact on meal Frequency, food diversity and acceptable diet…..

% Minimum Meal Frequency (6-23 months)

% Minimum Dietary Diversity (6-23 months) DID=3.3% DID=3.3% Not significant

% Minimum Acceptable Diet (6-23 months)

No evidence of decline in the prevalence of stunting among children 6-23 months….. Significant declining trend in the prevalence of wasting and underweight in the intervention area…

Nutrition status (6-23 months) Multivariate Logistic Regression Coefficient (β) -Interaction term (DID) Nutrition status (6-23 months) Stunting (6-23 months) β Wasting Underweight Study time Baseline (2010)-ref Endline (2012) Study arm Control -ref Intervention Interaction/DID (time X arm) 0.00 0.41* -0.02 0.29 -0.25 -0.69* 0.30 0.10 -0.63* *p<0.05, MV adjusted for several factors

Prevalence of stunting (among children 6-23 months) did not change significantly in both the intervention and control area

Net significant decline in wasting in the intervention area DID= -3 % DID= (-)3 %

Net significant decline in underweight in the intervention area DID=(-)5.2 %

Net positive gain in child immunization and ANC coverage in the intervention area…..

Net positive increase in the proportion of children fully vaccinated in the intervention area DID=17.8% DID=16%

Net positive increase in ANC uptake in the intervention area DID=7.8% DID=6%

High exposure to TTC is associated with better outcome…..

Exposure to TTC by peer mothers & knowledge of BF practices

Visit at the 3rd trimester or at delivery (by peer mother) and initiation of BF within 1 hr, Colostrum feeding and pre-lacteal feeding

Visit before 6 months and exclusive BF

MMF, MDD and MAD by exposure to TTC

Summary The intervention has a net positive effect on the following … knowledge of IYCF breastfeeding practices early initiation of breastfeeding, colostrum feeding, pre-lacteal feeding exclusive breastfeeding use of maternal and child health services (e.g. ANC and child immunization) Wasting and underweight (among 6-23 months) declined in the intervention area ????

Summary No evidence of program impact on dietary diversity and meal frequency Exposure to the TTC positively and significantly associated with better outcome Women who received TTC visit have significantly better IYCF knowledge, IYCF practices and use of other maternal; and child health services.

Summary Coverage with at least one TTC visit is only 46% Missed opportunity for TTC visit is high (~54%) Only 32% of the mothers were visited by PMs when their children were 6 months old.

Conclusion The findings of this evaluation suggest that when rural mothers are exposed to a timed and targeted counselling on IYCF by volunteer peer mothers, it is likely that their knowledge and behaviour regarding IYCF will improve. To achieve the maximum possible impact of the intervention… peer mothers should be able to reach out to more women and maintain scheduled visits program should find ways to improve the staggeringly low dietary diversity for children in the study area. Counseling alone may not be adequate to improve dietary diversity.

Ethical Clearance SNNP regional Health bureau Participation was based on Informed Consent

Mela study team 1 Lead Researcher (PhD) 1 Senior Nutritionist (PhD) 2 Field coordinators (1 for 4 Woredas) 4 Field supervisors (1 per team) 16 Interviewers 8 Anthro. Measurers 5 Land cruisers 1 Data Manager 2 Data Coders 4 Data entry clerks Data collection – 30 days (September)

Acknowledgments World Vision Ethiopia The SNNP regional health bureaus and the Woredas World Vision A&T team in SNNPR The HEWs, peer mothers in the study Kebeles The Women and their children who participated in the study Data collection teams Data entry clerks and coders