A B C Findings Introduction Objective Setting Implications Methods Agriculture to Nutrition (ATONU): Women’s empowerment is associated with dietary diversity in Ethiopia Isabel Madzorera1, Nilupa Gunaratna1, Ramya Ambikapathi1, Simone Passarelli1, Ramadhani Noor1, Chelsey Canavan1, Simbarashe Sibanda2, Tshilidzi Madzivhandila2, Amare Worku3, Yemane Berhane3, Semira Abdelmenan3, Lindiwe Majele Sibanda2 and Wafaie Fawzi1 1) Harvard T. H. Chan School of Public Health, 2) Food, Agriculture and Natural Resources Policy Analysis Network (FANRPAN), 3) Addis Continental Institute of Public Health Questions/comments: contact Isabel Madzorera: ism313@mail.harvard.edu Abstract Introduction: In Ethiopia, women’s empowerment may affect nutrition status, and dietary practices may be a pathway through which this relationship is mediated. Objective: To examine the relationship of women’s empowerment with dietary diversity in 2,120 women aged 15-49 years from poultry-producing rural households in Ethiopia’s ATONU project. Methods: Linear regression with correction for clustering by kebele, was used in mixed models. We assessed association of women’s empowerment, measured as: women’s participation in agricultural activities; an empowerment score; and mean empowerment score and standard deviation, with diet diversity in baseline survey. Diet diversity was assessed using a 10 food group MDD-W index. Results: Mean maternal age was 33.8 (±7.8) years. Mean diet diversity in women was low, 2.7 (±1.1) food groups and 95% of women did not meet minimum dietary diversity (5+ food groups). Women participated most in poultry activities(>85%) and least in use of crop inputs (52%) and off-farm income (70%) activities. In multivariate models, women in second tertile of empowerment scores had 0.2 points higher dietary diversity compared to those in lowest tertile. Women with greater variation in empowerment scores showed a trend towards lower dietary diversity, with a near significant association. Conclusion: Women’s input in decisions on agriculture activities, extent to which women feel they can make input, and decision making in use of agricultural income may be important for maternal dietary diversity. Table1: Scoring used for overall empowerment score (sum of scores) Participation in non-farm income and cash crop marketing was low for poultry faming households and women Does number of activities, intensity (mean score) or variability in perceptions of empowerment affect maternal diet diversity?   How much input did you have in making decisions about [ACTIVITY]? 1.  No input (score=1) 2.      Input into very few decisions (score=2) 3.      Input into some decisions (score=3) 4.      Input into most decisions (score=4) 5.      Input into all decisions (score=5) 6.      No decision made (score=0) To what extent do you feel you can make your own personal decisions regarding [ACTIVITY] if you want(ed) to? 1.      Not at all (score=1) 2.      Small extent (score=2) 3.      Medium extent (score=3) 4.      High extent (score=4) How much input did you have in decisions on the use of income generated from [ACTIVITY]? 1.  No input (score=1) 3.      Input into some decisions (score=3) 4.      Input into most decisions (score=4) 5.      Input into all decisions (score=5) Activity Description Chicken production (daily tasks: feeding, watering, cleaning, etc.)  X Chicken input use (feed, medicine, etc.) Use of eggs for home consumption Marketing of eggs Slaughter of chickens for home consumption Marketing of chickens Land use (including choice of crops and varieties) Crop input use (seed, fertilizer, pesticide, etc.) Daily tasks for crops primarily for home consumption, e.g. weeding Daily tasks for crops that are grown primarily for sale Use of food crops for home consumption Marketing of food crops Marketing of cash crops (chat, coffee, etc. include fodder) Non-farm economic activities: Small business, self-employment, petty trade Food expenditures Fig 3: Household participation in activities Fig 4:In these households: Women’s participation Table 6: Linear regression (mixed model): Variation in women’s scores of empowerment, women’s participation and empowerment score (exposures in 1 model) and MDD-W (outcome) A B C   Univariate Adjusted Effect Estimate p value Variation in empowerment score -0.060 0.053 -0.066 0.061 Women's participation tertile 1 reference Women's participation tertile 2 0.115 0.042* 0.110 0.073 Women's participation tertile 3 -0.026 0.673 -0.008 0.909 Mean empowerment score 0.011 0.478 0.492 Amhara region 0.078 0.582 Oromia region 0.001** SNNPR region -0.287 0.043* Tigray region Asset ownership quintile 1 -0.390 <.0001*** Asset ownership quintile 2 -0.297 Asset ownership quintile 3 -0.270 Asset ownership quintile 4 -0.214 0.004** Asset ownership quintile 5 Introduction Gender power dynamics and constraints relating to women’s empowerment may affect women’s decision-making in intra-household resource allocation activities related to dietary intake. Efforts are underway to evaluate the role of gender empowerment in pathways from agriculture production to maternal and child nutrition. Women’s Empowerment in Agriculture Index (WEAI) has been associated with maternal, child and household diet diversity in studies, but is not extensively validated.   We evaluate the associations of women’s empowerment (with selected modules from WEAI) with dietary diversity in women aged 15-49 years in a baseline study of the Agriculture to Nutrition (ATONU) project in Ethiopia. This is a cluster randomized trial of interventions for small-scale chicken production, home gardening and behavior change communication. X indicates inclusion in computation of overall women’s empowerment score. Maximum score possible 151(A=70, B=56, C=25) Table 2: Demographic characteristics of the study population Characteristic N % Maternal age – <30 yrs 596 31% 30 -<40 yrs 942 49% >40 yrs 400 21% Married 1870 88% BMI - Underweight (BMI<18.5) 502 24% Normal weight (BMI 18.5 - 24.99) 1494 71% Overweight and obese ( BMI 25+) 122 6% Education achievement - None or Koranic school 1152 57% Primary school (grades 1-8) and adult literacy 695 34% Secondary(grade 9+) and tertiary education 191 9% Parity - First pregnancy 131 1-3 children 561 26% 4-7 children 1082 51% 8+ children 345 16% Household size - mean (sd) 6.2 ±2.1 Is women’s participation in agricultural activities important for dietary diversity for women poultry farmers ? * <0.05, ** <0.01, and ***< 0.001 Adjusted for maternal age, maternal education, marital status, women head of household, electricity use, household size, months of adequate food, parity, study intervention, region and age of household head Table 4: Linear regression (mixed model): Women’s participation in agriculture production (exposure) and MDD_W (outcome) Findings   Univariate Adjusted Effect Estimate p value Women’s participation tertile 1 reference Women’s participation tertile 2 0.116 0.035 0.110 0.067 Women’s participation tertile 3 -0.011 0.852 0.001 0.989 Asset ownership quintile 1 -0.389 <.0001*** Asset ownership quintile 2 -0.295 Asset ownership quintile 3 -0.267 Asset ownership quintile 4 -0.214 0.004** Asset ownership quintile 5 . Diet diversity (MDD-W) in women was low - mean 2.7 (SD 1.1) food groups in 24-hour recall 94.7% of women did not meet minimum diet diversity (5+ groups/10) Women’s participation limited for income generating activities - crop production input use, non-farm income activities, daily activities for crops for sale and cash crop marketing Chicken rearing a woman’s domain - Women participated most in chicken production, use of eggs for home consumption, egg marketing and use of inputs for chicken production Women in second tertile of empowerment had 0.2 points higher dietary diversity compared to women with the lowest empowerment Variation in empowerment scores - trend towards significant association with MDD-W, controlling for women’s participation and mean empowerment scores. Objective Describe women’s empowerment and maternal dietary diversity in the ATONU project in Ethiopia. Evaluate associations of (a) women’s participation, (b) overall empowerment scores, and (c) variation in women’s empowerment scores, women’s participation and mean scores with maternal diet diversity. Table 3: Diets for women poultry farmers in ATONU are plant based, with limited consumption of animal based foods (based on 24H recall) Food groups in MDD-W Amhara (N=528) Oromia (N=655) SNNPR (N=529) Tigray (N=408) N (%) Starchy staples 525 (99%) 654(100%) 520(98%) 407(100) Beans and peas 396(75%) 363 (55%) 134(25%) 200(49%) Other vegetables 390(74%) 486(74%) 348(66%) 311(76%) Dairy 36(7%) 268(41%) 132(25%) 37(9%) Vit A rich (orange & red) veg 26(5%) 51(8%) 20(4%) 10(2%) Meats 19(4%) 29(4%) 15(3%) 46(11%) Nuts and seeds 16(3%) 28(4%) 1(0%) Other fruit 12(2%) 15(2%) 8(2%) 3(1%) Eggs 26(4%) 31(6%) 30(7%) Vit A rich dark green veg 2(0%) 138(21%) 25(5%) * <0.05, ** <0.01, and ***< 0.001 Adjusted for maternal age, maternal education, marital status, women head of household, electricity use, household size, months of adequate food, parity, study intervention, region and age of household head Setting ACGG, ATONU and control sites, 4 rural regions of Ethiopia: Amhara, Oromia, Tigray, and Southern Nations, Nationalities, and Peoples Region (SNNPR) Does overall empowerment matter for dietary diversity of women poultry farmers in Ethiopia? Methods Implications Table 5: Linear regression (mixed model): Overall women’s empowerment score (exposure) and MDD-W(outcome) Exposures: Women’s participation in 14 agricultural activities (list table 1) Computed as sum of activities woman participates in, tertiles computed   2. Overall empowerment score Women scored across (A) women’s input in decisions, (B) extent to which women feel they can make input, and (C) decision making in use of agricultural income. (see table 1, “adopted” from WEAI) Overall scores: sum of scores (A+B+C) for 14 activities (maximum score=151), tertiles computed 3. Influence of variation in women’s empowerment scores Variation of a woman's scores across activities, evaluated along with woman’s participation in 14 activities and the mean score among activities (total empowerment score / # of activities participated in) Outcomes: FAO’s Minimum Dietary Diversity for Women (MDD-W) - Measured by 24 hour dietary recall (food list), 10 food groups Analysis: Linear regression methods with correction for clustering by kebele (mixed models) Women’s empowerment - a modifiable factor to influence maternal diets in chicken producing households. In addition to women’s participation - input in decisions on agriculture activities, extent to which women feel they can make input, and decision making on income - important for maternal diet diversity. Women with greater variation in empowerment scores across different agricultural activities may be at greater risk for poor dietary diversity. Fig 1: Women’s consumption of food groups by region Fig 2: MDD-W varies by region but is overall poor   Univariate Adjusted Effect Estimate p value Empowerment score tertile 1 reference Empowerment score tertile 2 0.172 0.001 0.168 0.006* Empowerment score tertile 3 0.023 0.672 0.022 0.716 Asset ownership quintile 1 -0.396 <.0001*** Asset ownership quintile 2 -0.306 Asset ownership quintile 3 -0.270 Asset ownership quintile 4 -0.212 0.004** Asset ownership quintile 5 Conclusions Programs should consider not only women’s participation in key agricultural activities but also the strength of their input, extent of input and decision making in income generating activities as a measure of empowerment. * <0.05, ** <0.01, and ***< 0.001 Adjusted for maternal age, maternal education, marital status, women head of household, electricity use, household size, months of adequate food, parity, study intervention, region and age of household head Acknowledgments: In partnership with Addis Continental Institute of Public Health and African Chicken Genetic Gains (ACGG) project. The study would not be possible without the Agriculture to Nutrition (ATONU) project in Ethiopia supported by the Bill & Melinda Gates Foundation.