History of nutritional status and Concern’s response in Dessie Zuria woreda, Ethiopia

By Sarah Style

Sarah graduated with a Masters in Public Health Nutrition from the London School of Hygiene and Tropical Medicine in 2009. She recently returned from Ethiopia having completed an internship with Concern Ethiopia.

The author acknowledges the technical and editorial support of Emily Mates in writing this article and the work and support of the Concern Ethiopia team.

Dessie Zuria is one of 21 woredas (districts) in South Wollo Zone of Amhara Region, Northern Ethiopia. The nutrition situation in Dessie Zuria has remained at 'serious' levels for the past 10 years, with the global acute malnutrition (GAM) rate only once dropping below 10% (cut off advised by Ethiopian guidelines to classify an emergency situation) in 2004 in the presence of an emergency feeding programme (Figure 1).

In 2008, Dessie Zuria was classified as a 'hot spot' area by the regional early warning department due to failure of the short belg rains on which the majority of the population depend. Following the results of a nutrition survey, Concern Ethiopia initiated a targeted supplementary feeding programme (TSFP) in July 2008, which has continuously operated since then. However, malnutrition rates in the woreda to date have remained relatively un-changed, despite two years of a TSFP intervention. The TSFP has been a well implemented programme, evidenced by high coverage rates (October 2008, TSFP period coverage 84.5%, TSFP point coverage 68.3%). However, recovery rates have been sub-optimal, particularly during 2009 (recovery rate 27%, non-recovery rate 59%, re-admission rate 57%) thus raising the question of what is going on in this area that may have contributed to the lower than hoped for recovery rates in the programme.

Focus group discussion in Guguftu kebele to investigate underlying causes of malnutrition

In order to further investigate this issue, three focus group discussions (FGDs) and four case studies were carried out in selected distribution areas in the woreda. In order to provide as representative a selection as possible within the time allowed, two areas, Guguftu and Gelsha, known for their chronic nutritional status were selected. Both are situated in the higher highlands. Serdem, a lowland kebele (village) situated near the town of Kombolcha was selected also. All children providing case studies were purposively selected based on having been readmitted (some on more than one occasion) to the SFP. Primary and secondary data was also reviewed including (but not limited to) Concern's 2006 Dessie Zuria Livelihoods Analysis (also building on suggestions from the Agricultural and Rural Development Agency), 2008-09 recovery information, 2008-09 early warning information (Concern and woreda) and 2008-10 Dessie Zuria Nutrition Surveys that included reports from the Woreda Agriculture and Rural Development Office (WARDO).

The relatively static nutrition situation in Dessie Zuria implies that this high level of acute malnutrition is becoming 'typical' for this population, who in the face of chronic food insecurity, are finding it increasingly difficult to recover from the repeated shocks. The chronic food insecurity in the woreda is also evident in the high prevalence of stunting. The July 2010 nutrition survey estimated global stunting at 47.5% (this is not significantly above the national average)¹. This figure is unlikely to be inclusive of older age stunted children as survey team leaders were trained to ascertain age using local seasonal calendars and had a good understanding of child developmental stages. The leaders were therefore able to validate the likelihood of the reported ages. Only when age was unclear, was the height cut off of betweeen 65-110cm (proxy 6 months to 5 years) used to consider children for the survey. Whilst harvests have been particularly poor in the last three years, indications are that an increasing number of households are unable to support themselves, even in a year of good harvest.

Concern has been present in Dessie Zuria for 10 years where it has supported the woreda through both development and emergency programmes. Based on the findings of the 2006 livelihoods analysis, Concern initiated a livelihoods programme in 2007, initially targeting 11 of the 31 kebeles in the woreda. Some of the key problems to be addressed were low rainfall, crop productivity and production (particularly in the higher-highland areas) and lack of agricultural diversification and non-agricultural sources of income. Although this programme has not been running for long and therefore cannot yet be expected to have solved all of these problems, we have not seen a reduction in chronic acute malnutrition, even with TSF interventions, the Governments general food distribution (GFD) and the Ethiopian social protection mechansism, the Productive Safety Net Programme (PSNP) (that provides food or cash for work for the poorest of the poor).

Hayat Seid, female, 29 months, has been in and out of OTP and SFP five times

It has been suggested that the "repeated 'emergency' operations are in fact serving the function of a welfare or safety net programme in the face of chronic poverty in the Wollo area of Ethiopia²".

Key challenges to improving Dessie Zuria's nutrition situation

The following key challenges were highlighted from analysis of the FGDs and case studies as well the aforementioned review of primary and secondary information provided by relevant Dessie Zuria woreda offices and Concern.

Climatic conditions and topography

Dessie Zuria rainfall is erratic and precarious. Although the rains this year have improved, woreda reports and surveys have indicated that the belg rains have been wholly inadequate for the last 3 years leading to insufficient or nonexistent crop production. This was further confirmed by the FGDs and case studies. The higher-highlands, being totally belg dependent, have been particularly affected. They are also more vulnerable to climatic variations due to being dominated by sloping land, with the soil erosion and colder weather making it difficult to grow crops. Additionally, small land holdings and population pressure, exacerbated by poor resource management and overuse, have also led to declining productivity.

In order to further investigate this link, the readmission rates from Concern's supplementary feeding programmes (SFPs) from July 2009 to June 2010 were analysed at kebele level and by agro-climatic zone. The results found that the five kebeles with the highest readmission rates were all from the higher highlands (as opposed to the highlands, midlands or lowlands). This gives testament to this area's increased vulnerability to factors leading to food insecurity, such as a colder environment resulting in higher metabolic rate, smaller land holding, erosion and the slow recovery of SFP beneficiaries, with high numbers requiring re-admission to the programme.

Food insecurity

The livelihoods and livelihood assets in Dessie Zuria are also frequently affected by shocks. Livelihoods analysis has indicated that crop production cannot be expected to offer much by way of outputs except in very limited areas such as in the lowlands, where crops depend on the more reliable meher rains and less undulating topography. Case studies conducted with parents of moderately acutely malnourished (MAM) children repeatedly readmitted to SFPs, found that due to crop failures and lack of other nutritional produce, households are often unable to use the SFP ration as intended i.e. as a supplement for the normal family diet. FGDs confirmed that the poorest of the poor are frequently unable to provide additional food from their own production to supplement SFP food. This means that even with supplementary food, beneficiaries' food intake is insufficient for recovery. This is further compounded by frequent sharing of the SFP food with other hungry siblings not in the feeding programme. Although parents knew that the SFP food was intended only for the malnourished child, they found it impossible to ignore the hungry cries of their other children who were not enrolled. Despite education on use of the supplementary food at every distribution site, one case study mother admitted to eating the SF food that was intended for her child, in order to improve the quality of her breastmilk. In children >6 months, supplementary food rations are intended for consumption by the child to complement breastfeeding.

The dependency on agriculture is also disproportionately large, given the precarious weather conditions. Although the woreda's climate and topography make it difficult to grow a diverse range of crops, there is a need for agricultural diversification to reduce reliance on single crops; a key objective of Concern's livelihood programme. More climatically tolerant seeds have been introduced in the last two years as a recovery mechanism and have proved a success. FGDs highlighted that potato seeds have provided a good opportunity for recovery as they can be eaten, used as a cash crop and are suited to the ecological zone. Expansion of such activities could aid in improving communities poor dietary diversity. Diets are dominated by carbohydrates with little fruit/vegetable consumption, exacerbated by limited knowledge of caregivers in the preparation of nutritious food. Consumption of meat and meat products is almost non-existent; farmers cannot afford to eat the products as they need to sell their livestock/ meat as a source of income. The population's resilience to agricultural shocks is further reduced by the lack of off-farm activities, as back up strategies in case of crop failure (again being addressed by the livelihoods programme). Although the woreda's current food security situation is showing improvement due to a productive belg performance in June/July, unless this trend continues over the longer-term, the nutrition situation will most likely remain bleak in the absence of further multi-sectoral action including expansion of the Concern livelihood programme.

Food Aid

Beyenech Hussen (female, 19 months) has been in and out of OTP and SFP on 4 occasions (Guguftu kebele)

In April 2010, nutrition survey results indicated that although the main source of income was household's own production, 82.4% of households had access to food aid. This is nearly double that of 2008, increasing pressure on resources. While GFD and PSNP have inevitably aided household food security to some extent, focus group discussions have indicated that distributions are often less than that forcasted by the woreda, in terms of quantity and frequency of provision (of cash/grain). Additionally, in Seredem, cash rations in March 2010 were found to be of little value due to price increases in the market. FGDs and case studies highlighted the influence of these factors on communities' inability to recover as well as the recovery being exacerbated by the limited linkage between GFD and SFP beneficiary lists. However, it was also pointed out that where provided in sufficient quantities, the GFD/PSNP did help to reduce sharing of SFP among households.

Poor infant feeding practices

In this district, inadequate infant feeding practices are suspected to have a considerable influence on children's ability to recover from malnutrition, and to maintain their recovery. FGDs have found that feeding infants a mixed diet of water and breastmilk is a common occurrence. This is worrying, given the poor water, sanitation and hygiene (WASH) conditions in the woreda (see below) and the likely exposure of infants to harmful pathogens. All caregivers reported to having received education on sanitation and hygiene provided during Concern's SFP distributions and by community outreach, and therefore had improved knowledge in this area. However, some added that although they had received this education, it was sometimes difficult to implement practically, due to heavy work loads and lack of family support.

Data from nutrition surveys has consistently indicated a low prevalence of exclusive breastfeeding in infants < 6 months. In the most recent nutrition survey (July 2010), introduction of complementary foods from 6 to 9 months was reported by only 66% of caregivers. This indicates that complementary foods are frequently introduced too late. Many infants are receiving only breastmilk/water for too long, therefore not obtaining sufficient energy or nutrients to meet their increased needs. This is further exacerbated by the inadequate quality and quantity of complementary foods. Higher rates of malnutrition are consistently found in children aged 6 to 29 months, compared to older age groups. FGDs also identified that many caregivers often prefer to take their sick child to traditional healers rather than modern health services. Some households still rely on traditional/spiritual healing to cure their children of malnutrition due to a belief in the 'evil eye', suggesting that they might not identify the cause of the sickness as being nutrition related. FGDs and case studies indicated that such beliefs tended to be more common of older carers such as grandparents, whereas most of the younger women demonstrated their understanding of the health and nutrition related education provided through Concern's community activities. The community mobilisation has led to greater awareness among the mothers and caregivers and increased their ability to detect early signs of malnutrition, as well as contributing to improvements in hygiene practices and utilisation of health services. Furthermore, local transporters are charging less for any transportation to health centres realising that this is for their children. Nevertheless, children's nutritional status could also benefit from an increased involvement of traditional healers in any future health-related interventions in order to improve health seeking behaviours.

Health environment

Nutrition survey results regularly reveal that less than half of all households (44%) have access to protected water supplies and just over half (53%) report to using a pit latrine. Observations from the field confirmed the poor sanitation and hygiene conditions in which some families are living. For example, many households in the highlands live with their animals and their excreta. Whilst this is reported to be a method of increasing warmth in the cold highland areas, it is also likely to be a source of increased infections and illness to younger children. As a result of the poor WASH conditions in households, nutrition surveys consistently find diarrhoea to be the most prevalent illness among children under 5 years and accounts for approximately 60% of illness. Concern has over the last few years significantly increased activities to provide clean water pumps to a greater number of kebeles. Nevertheless, it appears that further development in WASH infrastructure is required, to aid improvements in Dessie Zuria's nutrition situation.

Coping strategies

The seriousness of the Dessie Zuria situation is highlighted by the type of coping strategies that households have adopted, the most poignant of which is related to the dramatic decrease in under-5 population over recent years. The under-5 population has declined rapidly, reducing from 18.0% in 2005 to 10.8% in 2010 (Figure 2). This begs the question as to why people have stopped having babies - the steady decline indicates that this is not a mortality issue. The Government's efforts to scale up family planning services and uptake have increased over the last few years and are likely to have considerably influenced this decline. Furthermore, according to FGDs, households have been more willing to embrace these efforts over the last five years, due to the high levels of food insecurity. Participants indicated that people are choosing to have fewer children as they simply cannot afford to feed so many mouths. Many individuals stated that once the situation improves they wish to start having more children again, for security in their old age and to help them with farm activities.

Conclusions

Despite the current improvement in food security, the woreda's reliance on unreliable and erratic rainfall suggests that this improvement may be short lived; studies in the larger Wollo area have found that poverty appears to be worsening rather than improving³. Without Concern's presence in Dessie Zuria over the past 10 years, mortality rates are likely to have declined, along with progress in the area of livelihoods, health and nutrition which evidently has been made. However, the situation is complex. Improvement in agricultural production, for example, cannot be 'standalone' and requires "an integrated and holistic approach involving various sectors and sub-sectors"⁴. Additionally, it is important to consider the "physical and economic access that a child or his or her caregiver has to that food, the caregiver's knowledge of how to use available food and to properly care for the child, the caregiver's own health status, and the control the caregiver has over resources within the household that might be used to nourish the child"⁵. SFP alone cannot prevent occurrence of malnutrition and therefore is not a complete surprise that SFP inputs over the last two years has not translated into improvements in malnutrition rates. What is clear, however, is that SFP interventions cannot be successful without regular and sufficient general rations. Based on these research findings, a strategic multi-faceted, multisectoral response is required, that addresses both acute malnutrition and its root causes. This response should include, amongst others, infant and young child feeding interventions and enabling increased food access to families with young children through provision of small livestock and agriculture inputs. There are also plans for WASH interventions to work towards changing negative behavioural practices. Looking to the future, it will be useful to see how the malnutrition situation changes and why, so that the whole community learn how best to protect the nutritional status of its children.

For more information, contact: concern.ethiopia@concern.net

¹National average for stunting is 46.5% (Ethiopia DHS, 2005).

²Sharp and Devereux, 2004. 'Destitution in Wollo (Ethiopia): chronic poverty as a crisis of household and community livelihoods', Journal of Human Development and Capabilities, 5: 2, 227 - 247. http://dx.doi.org/10.1080/1464988042000225140

³See footnote 2.

⁴Chanyalew D. (2005). Food Security and Malnutrition in Ethiopia. Chapter 3. An Assessment of the causes of malnutrition in Ethiopia: A contribution to the formulation of a national nutrition strategy. International Food Policy Research Institute. Washington. USA.

⁵Benson T, Shekar M. (2006). Trends and Issues in Child Undernutrition. Disease and Mortality in Sub-Saharan Africa, 2nd Edition. 2006. Washington. World Bank.