Final report July 2017 – April 2018 Wag Himra Zone, Amhara Region Ethiopia ACKNOWLEDGEMENTS The nutrition causal analysis Link NCA in Sekota and Dehana woredas, Wag Himra zone, Amhara region, Ethiopia was funded by the European Union. The study was conducted by Link NCA Analysts, Joanne Chui and Lenka Blanárová, under the supervision of study’s focal points: Amelia Lyons and Vincent Veillaud, Deputy Country Directors for Programs, Action Against Hunger, Ethiopia, and Janis Differt, Technical Advisor Food Security and Livelihoods, Action Against Hunger, France, with valuable contributions from the pool of Technical Advisors at Action Against Hunger, France and Action Against Hunger, Ethiopia, namely Celine Soulier, Xuan Phan, Tom Heath and Jogie Abucejo Agbogan. The Link NCA team wishes to express their thanks to all those who have contributed to this study and/or facilitated its development, in particular: To local authorities for their tireless dedication in the fight against undernutrition and their unwavering support over the course of the study; to Mr. Gardie Nigatu Abuye and his team for their absolute availability and support as well as creative troubleshooting during all stages of the study. To all technical experts who attended the Link NCA technical workshops, including the entire team of technical advisors and project managers at Action Against Hunger, Ethiopia, representatives of partner organizations, such as Danish Church Aid, Organization for Rehabilitation & Development in Amhara, Plan International and Save the Children, as well as all dedicated staff representing woreda and zone offices in their respective domains, for sharing their expertise and hence contributing to the high quality of the study. Special thank you is dedicated to Dr. Gizachew Yismaw, Director of Amhara Regional Public Health Institute, for genuine interest and valuable inputs during the Link NCA final technical workshop. To all residents of sampled and/or randomly visited localities for their hospitality and genuine collaboration. Special thanks to the quantitative and qualitative teams for their efforts in exceptionally trying conditions, especially to Mr. Tamirat Abebe for his patience, trustworthiness and professionalism. We would also like to thank the Link NCA Link Technical Unit, Action Against Hunger, France, in particular to Miss Gwenaëlle Luc, for her constant availability and encouragement. This study would not have been possible without the exceptional work and commitment of all people involved. 2 ABBREVIATIONS AAH / ACF Action Against Hunger / Action Contre la Faim ACSI Amhara Credit and Savings Institution ANC Antenatal Care ARI Acute Respiratory Infections CI Confidence Interval CMAM Community Management of Acute Malnutrition CSB Corn-Soya Blend DCA Danish Church Aid DHS Demographic and Health Survey ECHO European Civil Protection and Humanitarian Aid Operations ENA Emergency Nutrition Assessment EU European Union FANTA Food and Nutrition Technical Assistance FAO Food and Agriculture Organization FGD Focus Group Discussion FSL Food Security and Livelihoods GAM Global Acute Malnutrition GCM Global Chronic Malnutrition HAZ Height for Age z-score HH Household HHS Household Hunger Scale HDDS Household Dietary Diversity Score HQ Headquarters IDDS Individual Dietary Diversity Score IPC Integrated Phase Classification IYCF Infant and Young Child Feeding LCD Litres per Capita per Day Link NCA Nutrition Causal Analysis MAHFP Months of Adequate Household Food Provisioning MAM Moderate Acute Malnutrition MUAC Mid-Upper Arm Circumference NGO Non-Governmental Organization ORDA Organization for Rehabilitation & Development in Amhara OTP Outpatient Therapeutic Programme PHCU Primary Health Care Unit PLW Pregnant and Lactating Woman PNC Postnatal Care PPS Probability Proportionate to Size PSNP Productive Safety-Net Program rCSI Reduced Coping Strategy Index RESET EU Resilience Building Programme in Ethiopia RFS Risk Factor Survey RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition SCI Save The Children SFP Supplementary Feeding Programme SSI Semi-Structured Interview SMART Standardized Monitoring for Assessment in Relief & Transitions UNICEF United Nations’ Children’s Fund WASH Water, Sanitation and Hygiene WFP World Food Programme WHO World Health Organization WHZ Weight for Height z-score 3 LIST OF FIGURES Figure 1 Map of Wag Himra Zone illustrating main livelihood zones Figure 2 Summary of key barriers to healthcare in Sekota and Dehana woredas Figure 3 Cycle of malnutrition Price fluctuations (in ETB) of cereals and beans in Sekota and Dehana woredas between Figure 4 Nov./Dec. (post-harvest period) and Feb./Mar. (planting period) Causal pathway illustrating interconnections between household food security risk factors and Figure 5 nutritional status of women and infants in Sekota and Dehana woredas, Wag Himra zone Evolution of prevalence of undernutrition in Sekota woreda from May 2013 till December Figure 6 2017, based on available nutrition surveillance surveys. Causal pathway illustrating interconnections between household food security risk factors and Figure 7 nutritional status of women and infants in Sekota and Dehana woredas, Wag Himra zone Causal pathway illustrating interconnections between water, hygiene and sanitation risk Figure 8 factors and nutritional status of infants and young children in Sekota and Dehana woredas, Wag Himra zone Simplified causal pathway likely to explain most cases of wasting in Sekota and Dehana Figure 9 woredas, Wag Himra zone Simplified causal pathway likely to explain most cases of stunting in Sekota and Dehana Figure 10 woredas, Wag Himra zone LIST OF TABLES Calculation of a sample size for the Link NCA Anthropometric data collection with ENA for Table 1 SMART software, Wag Himra zone Table 2 Qualitative sampling framework for the Link NCA qualitative survey, Wag Himra zone Summary of community consultations during the Link NCA qualitative survey, Wag Himra Table 3 zone List of hypothesised risk factors validated for field-testing during Initial Technical Workshop, Table 4 including Technical Experts Rating Table 5 Therapeutic itineraries for current childhood diseases in Wag Himra zone Table 6 Seasonal calendar of main child illnesses in Wag Himra zone Table 7 Barrier analysis related to a use of birth-spacing/family planning Table 8 Perception of risk relating to certain birth-spacing behaviours Table 9 Results of a participatory exercise on meal composition Table 10 Seasonal calendar of main fasting seasons observed in Wag Himra zone Table 11 Barrier analysis related to exclusive breastfeeding Table 12 Perception of risk relating to breastfeeding practices Table 13 Barrier analysis related to complementary feeding of children 6-23 months Table 14 Perception of risk relating to certain child care practices Table 15 Seasonal calendar for economic activities and food security in Wag Himra zone Table 16 Results of a participatory exercise on household spending Table 17 Perception of risk relating to certain hygiene behaviours Table 18 Perception of difficulty relating to certain hygiene behaviours Table 19 Overview of decision-making powers within a household Summary of Anthropometric data collection findings for Sekota and Dehana woredas, Wag Table 20 Himra zone Prevalence of undernutrition by sex, Anthropometric data collection findings for Sekota and Table 21 Dehana woredas, Wag Himra zone List of expressions in a local language used to describe malnutrition and/or other childhood Table 22 diseases Table 23 Summary of results of a community rating exercise Table 24 Summary of categorisation of risk factors Table 25 Rating grid for the categorisation of risk factors 4 LIST OF PHOTOS Photo 1 Community restitution in Begugn, Silda Photo 2 Men ploughing fields in Guld, Tsata Photo 3 Community members reflecting upon their household expenditure in Begugn, Silda Photo 4 Example of a typical latrine in Debere Saine, Dabil Maryam Photo 5 Children during P.E. class at school in Dida Photo 6 Distribution of PlumpySup® in Debere Saine, Dabil Maryam 5 TABLE OF CONTENTS ACKNOWLEDGEMENTS....................................................................................................................................................................... 2 ABBREVIATIONS ..................................................................................................................................................................................... 3 LIST OF FIGURES .................................................................................................................................................................................... 4 LIST OF TABLES ...................................................................................................................................................................................... 4 LIST OF PHOTOS .................................................................................................................................................................................... 5 EXECUTIVE SUMMARY ......................................................................................................................................................................... 8 I. INTRODUCTION .................................................................................................................................................................... 11 II. STUDY OBJECTIVES .............................................................................................................................................................