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Impact of Malnutrition in the
First 1,000 Days on a Child’s
Health in Rural Ethiopia
Tiffany Colburn, Mugdha Mokashi, Samuel Moss,
Priyanka Parajuli, Aaron Stuber
Malnourishment Cycle
Malnourishment
• Insufficient caloric
and protein intake
• Inability to utilize
nourishment due
to illness
Stunting
• Growth &
Development
severely slowed
• First 1,000 days
critical for
prevention
Negative Effects
• Serious health
issues
• Severe effects on
country GDP
• Perpetuates vicious
cycle of stunting
Amhara Region of Ethiopia
• Particularly affected by
undernourishment (USAID, 2016)
• 52% children in region stunted
• Approximately 42.9% women receive
prenatal care (TheWorld Bank, 2016)
• Estimated population of 17.7 million
(CIA, 2015)
• 43.5% Ethiopian Orthodox
• Agriculture is economic powerhouse
• Has led to poverty decrease
Targeted Zones
• Targeted zones in Amhara
district
• Yilmana Densa
• Goncha Siso Enese
• Children experiencing the
highest deprivation as compared
to national average
• Both urban and rural
representation
Motbainor, A., Worku, A., & Kumie, A. (2015). Stunting Is Associated with Food Diversity while Wasting with Food Insecurity among Underfive Children in East and West Gojjam Zones of
Amhara Region, Ethiopia. PLoS ONE, 10(8), e0133542. http://doi.org/10.1371/journal.pone.0133542
Socioecological Model
Public policy
Community
Organizational
Interpersonal
Individual
Direct provision of vitamins and resources
Education
Curriculum delivery
Microenterprises funded by microloans
CommunityAdvisory Board
Encourage mandatory fortification of sold
foodstuffs
Strategy
CAB
Education
Educating mothers
on breastfeeding
Educating farmers
on agriculture
practices
Educating
children/young
adults on nutrition
Resources
Microloans for
vitamin powder
production (rural)
Vitamins/incentive
for bread
enrichment (urban)
Emergency relief
Providing
agricultural supplies
Phase 1: Community Engagement and Emergency Relief
• Assess
ment
and
Trainin
Phase 2: Pilot
• Education of pregnant women
• Education of farmers
• Rural implementation/ dissemination of leaf powder microenterprise
• Vitamin distribution to bakers in urban settings
• Nutrition Education
Phase 3: Assessment and Scaling Up
• Post-pilot assessment
• Scaling up
• Policy development with CAB support
Phase 1: CommunityEngagementand
EmergencyRelief
Community Advisory Board
NGOs
• EcoAgriculture
• Project Management
Specialist from Ethiopian
branch of U.S. Agency for
International
Development
• Amhara Development
Association
Healthcare
• Local healthcare
professionals (nurses and
doctors)
• Health empowerment
workers(HEWs)
Religious
Organizations
• Female Ethiopian
Tewahedo Church leaders
• Wives of church leaders
• Mosque Imams
Schools/Other
• Teachers
• Administration
• Local government officials
• Other key influential figures
in the community
Short Term Emergency Relief: Plumpy'Nut
 High-energy peanut-based paste with
skimmed milk powder, sugar, vegetable fat,
vitamins, and minerals
• Does not need clean water to swallow
• Does not need to be cooked or refrigerated,
and stays fresh after opening
• Ethiopia’s Plumpy’nut therapeutic food
factory is located in neighboring Addis Ababa
• Two-month regimen for a child costs $60
(USD)
Phase 2: Pilot
Phase 1: Community Engagement
and Emergency Relief
•Assessment and Training
•Partnership with
EcoAgriculture
•Distribution of Plumpy'Nut
Phase 2: Pilot
•Education of pregnant women
•Education of farmers
•Rural implementation/
dissemination of leaf powder
microenterprise
•Vitamin distribution to bakers
in urban settings
•Nutrition Education
Phase 3: Assessment and Scaling
Up
•Post-pilot assessment
•Scaling up
•Policy development with CAB
support
Pregnancy Education Model
Curriculum Concepts Relevant Health Belief Model
Constructs
Importance of providing colostrum to babies within first hour of birth
for immune system + nutrition benefits
Perceived benefits
Breastfeeding is free and can be done in the home Self-efficacy, reduced perceived
barriers
Breastfeeding promotes bonding between mother and child Perceived benefits
Breastfeeding should be done exclusively for 6 months, and paired
with food afterwards
Maternal malnutrition during pregnancy occurs in 25% of Ethiopian
women and leads to low birthweight, delayed development, stunting,
and increased child mortality
Perceived severity, susceptibility
Improved Farming Practices
• Develop drought-tolerant seeds
• Prioritize local-led breeding and knowledge of plants
• Good farm management
• Crop rotation
• Crop diversification
• Effective Irrigation systems
• Low water waste systems
• Below average rainfall risk management
• Possible public policy promotion
• Practices to reduce crop waste
Necessary Vitamins for Immunity and Neonatal
Development
• Zinc- supports number and function of immune cells, categorized byWHO as
essential for the immune system
• Vitamin E, C- Work on the cellular level to quench free radicals and support cellular
health Also supports the function of immune cells throughout your body
• Vitamin E- inactivate harmful free radicals
• Vitamin A- phytonutrients works on cellular level to promote immunity and
protect DNA
• Selenium, Manganese, Magnesium- all minerals support immunity
http://www.airbornehealth.com/how-it-works
Agricultural Byproducts for Better Health
http://www.cimmyt.org/wheat-crp/
Barley Leaf
• Zn++, Ca++, Folic Acid, K+,
Mg+, Fe++, Cu++, P, Mn++, ß-
Carotene, B1, B2, B6, Folic Acid,
Pantothenic Acid
Wheatgrass
• Mg++, Ca++, Vitamin A, C, E
• Chlorophyll, antioxidants,
amino acids
Sweet Potato Leaf
• Ca++, Fe, Vitamin A, E,C,
K, Carotene
• Comparable to spinach
Source
Recommended
Daily Intake
(Infants, Adults)
Nutritional
Value
Powder Required
(Infants, Adults)
Vitamin A Wheatgrass 1000 IU, 3000 IU 500 IU/g 2 g,6 g
Folic Acid Barley leaves 150 mcg, 600
mcg
1.06 mcg/g 159 g, 566 g
Calcium Barley leaves, wheatgrass,
Sweet potato leaves
700 mcg, 1000
mcg
5 mg/g 0.35 g, 0.5 g
Iron Barley leaves,
wheatgrass, sweet potato
leaves
7 mg, 27 mg 3 mg/g 2.3 g,9 g
Table 1. Nutrition supplements recommended to avoid malnutrition and adverse birth
outcomes with amount of powder needed to reach recommended Daily Intake (Core
Group, 2004).
http://nutritiondata.self.com/facts/custom/900675/2
Rural Intervention
1.Allocate microloans to community members
2.Training of recipients
3.Building leaf dryers and supplying leaf product
4.Production and sale of leaf powder
5.Uptake by community
6.Return on investment and recycling of loans
Microfinance
in Rural
Districts
200 loans at $500 each
Entrepreneur receives loan
and training (ex. solar leaf
dryers)
Business is established
Product distributed
Food fortified
Repayment of loans
Urban Intervention
1. Fortification of bread and other locally manufactured
foodstuffs using commercially supplied vitamins
2. Incentivizing company involvement through grants
3. Encourage responsible civic engagement by businesses
4. Promote future policy to regulate fortification
Nutrition Education Curriculum
• Distributed in religious organizations,
schools, and hospitals
• Includes Amharic literature paired with
detailed pictures
• Target focus is older children and young
adults
• Education on foods needed to eat to
avoid symptoms or maintain certain
physiological functions
• Incentivize use of powder by education
on BENEFITS
• Possible uses include: beverages,
sprinkled on foods, baked into good
Solar Leaf Dryer Construction
Phase 3: Assessment and Scaling Up
Phase 1: Community Engagement
and Emergency Relief
•Assessment and Training
•Partnership with
EcoAgriculture
•Distribution of Plumpy'Nut
Phase 2: Pilot
•Education of pregnant women
•Education of farmers
•Rural implementation/
dissemination of leaf powder
microenterprise
•Vitamin distribution to bakers
in urban settings
•Nutrition Education
Phase 3: Assessment and Scaling
Up
•Post-pilot assessment
•Scaling up
•Policy development with CAB
support
Target Population Evaluation
Pregnant/Postnatal
Women + Infants
 Infant mortality
 Infant birthweight
 Comparison to baseline growth
curve
 Fundal height measures and key
milestones
 Attitude, self-efficacy, perceived
behavioral control, and perceived
norm changes
Children + Young Adults
 Number of Plumpy’Nut regimens
administered
 Number of children with access to
nutrition materials
 Long term health bureau collected
development measures
 Reduced mortality
 Attitude, self-efficacy, perceived
behavioral control, and perceived
norm changes
Intervention Delivery Evaluation
• Number of microloans distributed
• ROI of microenterprise
• Number of cooperating foodstuff (bread) manufacturers
• Internal content validity of educational training
• Number of teachers/church leaders trained on nutritional education
• Number of church leaders trained on breastfeeding/nutrition in pregnancy
education
• Breakdown of total fund allocation to proposed allocation
Limitations and Possible Risks
• Long term sustainability and community adoption
• Region has serious political instability and community tensions
• Region is facing a drought which presents additional challenges to
farmers
• Cultural resistance to introducing powdered vitamins
• Long-term process with delayed visible results reduces community
buy-in
• Limited supply of materials
Sustainability
• Utilization of pre-existing NGO infrastructure
• Microloans repaid and recycled within the community
• Continued demand for product and need for renewal
• Strong community interest in issue
• Organizational body comprised of community members

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2017 Statewide Case Competition: Team 6 - First Place (UAB)

  • 1. Impact of Malnutrition in the First 1,000 Days on a Child’s Health in Rural Ethiopia Tiffany Colburn, Mugdha Mokashi, Samuel Moss, Priyanka Parajuli, Aaron Stuber
  • 2. Malnourishment Cycle Malnourishment • Insufficient caloric and protein intake • Inability to utilize nourishment due to illness Stunting • Growth & Development severely slowed • First 1,000 days critical for prevention Negative Effects • Serious health issues • Severe effects on country GDP • Perpetuates vicious cycle of stunting
  • 3. Amhara Region of Ethiopia • Particularly affected by undernourishment (USAID, 2016) • 52% children in region stunted • Approximately 42.9% women receive prenatal care (TheWorld Bank, 2016) • Estimated population of 17.7 million (CIA, 2015) • 43.5% Ethiopian Orthodox • Agriculture is economic powerhouse • Has led to poverty decrease
  • 4. Targeted Zones • Targeted zones in Amhara district • Yilmana Densa • Goncha Siso Enese • Children experiencing the highest deprivation as compared to national average • Both urban and rural representation Motbainor, A., Worku, A., & Kumie, A. (2015). Stunting Is Associated with Food Diversity while Wasting with Food Insecurity among Underfive Children in East and West Gojjam Zones of Amhara Region, Ethiopia. PLoS ONE, 10(8), e0133542. http://doi.org/10.1371/journal.pone.0133542
  • 5. Socioecological Model Public policy Community Organizational Interpersonal Individual Direct provision of vitamins and resources Education Curriculum delivery Microenterprises funded by microloans CommunityAdvisory Board Encourage mandatory fortification of sold foodstuffs
  • 6. Strategy CAB Education Educating mothers on breastfeeding Educating farmers on agriculture practices Educating children/young adults on nutrition Resources Microloans for vitamin powder production (rural) Vitamins/incentive for bread enrichment (urban) Emergency relief Providing agricultural supplies
  • 7. Phase 1: Community Engagement and Emergency Relief • Assess ment and Trainin Phase 2: Pilot • Education of pregnant women • Education of farmers • Rural implementation/ dissemination of leaf powder microenterprise • Vitamin distribution to bakers in urban settings • Nutrition Education Phase 3: Assessment and Scaling Up • Post-pilot assessment • Scaling up • Policy development with CAB support Phase 1: CommunityEngagementand EmergencyRelief
  • 8. Community Advisory Board NGOs • EcoAgriculture • Project Management Specialist from Ethiopian branch of U.S. Agency for International Development • Amhara Development Association Healthcare • Local healthcare professionals (nurses and doctors) • Health empowerment workers(HEWs) Religious Organizations • Female Ethiopian Tewahedo Church leaders • Wives of church leaders • Mosque Imams Schools/Other • Teachers • Administration • Local government officials • Other key influential figures in the community
  • 9. Short Term Emergency Relief: Plumpy'Nut  High-energy peanut-based paste with skimmed milk powder, sugar, vegetable fat, vitamins, and minerals • Does not need clean water to swallow • Does not need to be cooked or refrigerated, and stays fresh after opening • Ethiopia’s Plumpy’nut therapeutic food factory is located in neighboring Addis Ababa • Two-month regimen for a child costs $60 (USD)
  • 10. Phase 2: Pilot Phase 1: Community Engagement and Emergency Relief •Assessment and Training •Partnership with EcoAgriculture •Distribution of Plumpy'Nut Phase 2: Pilot •Education of pregnant women •Education of farmers •Rural implementation/ dissemination of leaf powder microenterprise •Vitamin distribution to bakers in urban settings •Nutrition Education Phase 3: Assessment and Scaling Up •Post-pilot assessment •Scaling up •Policy development with CAB support
  • 11. Pregnancy Education Model Curriculum Concepts Relevant Health Belief Model Constructs Importance of providing colostrum to babies within first hour of birth for immune system + nutrition benefits Perceived benefits Breastfeeding is free and can be done in the home Self-efficacy, reduced perceived barriers Breastfeeding promotes bonding between mother and child Perceived benefits Breastfeeding should be done exclusively for 6 months, and paired with food afterwards Maternal malnutrition during pregnancy occurs in 25% of Ethiopian women and leads to low birthweight, delayed development, stunting, and increased child mortality Perceived severity, susceptibility
  • 12. Improved Farming Practices • Develop drought-tolerant seeds • Prioritize local-led breeding and knowledge of plants • Good farm management • Crop rotation • Crop diversification • Effective Irrigation systems • Low water waste systems • Below average rainfall risk management • Possible public policy promotion • Practices to reduce crop waste
  • 13. Necessary Vitamins for Immunity and Neonatal Development • Zinc- supports number and function of immune cells, categorized byWHO as essential for the immune system • Vitamin E, C- Work on the cellular level to quench free radicals and support cellular health Also supports the function of immune cells throughout your body • Vitamin E- inactivate harmful free radicals • Vitamin A- phytonutrients works on cellular level to promote immunity and protect DNA • Selenium, Manganese, Magnesium- all minerals support immunity http://www.airbornehealth.com/how-it-works
  • 14. Agricultural Byproducts for Better Health http://www.cimmyt.org/wheat-crp/ Barley Leaf • Zn++, Ca++, Folic Acid, K+, Mg+, Fe++, Cu++, P, Mn++, ß- Carotene, B1, B2, B6, Folic Acid, Pantothenic Acid Wheatgrass • Mg++, Ca++, Vitamin A, C, E • Chlorophyll, antioxidants, amino acids Sweet Potato Leaf • Ca++, Fe, Vitamin A, E,C, K, Carotene • Comparable to spinach
  • 15. Source Recommended Daily Intake (Infants, Adults) Nutritional Value Powder Required (Infants, Adults) Vitamin A Wheatgrass 1000 IU, 3000 IU 500 IU/g 2 g,6 g Folic Acid Barley leaves 150 mcg, 600 mcg 1.06 mcg/g 159 g, 566 g Calcium Barley leaves, wheatgrass, Sweet potato leaves 700 mcg, 1000 mcg 5 mg/g 0.35 g, 0.5 g Iron Barley leaves, wheatgrass, sweet potato leaves 7 mg, 27 mg 3 mg/g 2.3 g,9 g Table 1. Nutrition supplements recommended to avoid malnutrition and adverse birth outcomes with amount of powder needed to reach recommended Daily Intake (Core Group, 2004). http://nutritiondata.self.com/facts/custom/900675/2
  • 16. Rural Intervention 1.Allocate microloans to community members 2.Training of recipients 3.Building leaf dryers and supplying leaf product 4.Production and sale of leaf powder 5.Uptake by community 6.Return on investment and recycling of loans
  • 17. Microfinance in Rural Districts 200 loans at $500 each Entrepreneur receives loan and training (ex. solar leaf dryers) Business is established Product distributed Food fortified Repayment of loans
  • 18. Urban Intervention 1. Fortification of bread and other locally manufactured foodstuffs using commercially supplied vitamins 2. Incentivizing company involvement through grants 3. Encourage responsible civic engagement by businesses 4. Promote future policy to regulate fortification
  • 19. Nutrition Education Curriculum • Distributed in religious organizations, schools, and hospitals • Includes Amharic literature paired with detailed pictures • Target focus is older children and young adults • Education on foods needed to eat to avoid symptoms or maintain certain physiological functions • Incentivize use of powder by education on BENEFITS • Possible uses include: beverages, sprinkled on foods, baked into good
  • 20. Solar Leaf Dryer Construction
  • 21. Phase 3: Assessment and Scaling Up Phase 1: Community Engagement and Emergency Relief •Assessment and Training •Partnership with EcoAgriculture •Distribution of Plumpy'Nut Phase 2: Pilot •Education of pregnant women •Education of farmers •Rural implementation/ dissemination of leaf powder microenterprise •Vitamin distribution to bakers in urban settings •Nutrition Education Phase 3: Assessment and Scaling Up •Post-pilot assessment •Scaling up •Policy development with CAB support
  • 22. Target Population Evaluation Pregnant/Postnatal Women + Infants  Infant mortality  Infant birthweight  Comparison to baseline growth curve  Fundal height measures and key milestones  Attitude, self-efficacy, perceived behavioral control, and perceived norm changes Children + Young Adults  Number of Plumpy’Nut regimens administered  Number of children with access to nutrition materials  Long term health bureau collected development measures  Reduced mortality  Attitude, self-efficacy, perceived behavioral control, and perceived norm changes
  • 23. Intervention Delivery Evaluation • Number of microloans distributed • ROI of microenterprise • Number of cooperating foodstuff (bread) manufacturers • Internal content validity of educational training • Number of teachers/church leaders trained on nutritional education • Number of church leaders trained on breastfeeding/nutrition in pregnancy education • Breakdown of total fund allocation to proposed allocation
  • 24. Limitations and Possible Risks • Long term sustainability and community adoption • Region has serious political instability and community tensions • Region is facing a drought which presents additional challenges to farmers • Cultural resistance to introducing powdered vitamins • Long-term process with delayed visible results reduces community buy-in • Limited supply of materials
  • 25. Sustainability • Utilization of pre-existing NGO infrastructure • Microloans repaid and recycled within the community • Continued demand for product and need for renewal • Strong community interest in issue • Organizational body comprised of community members

Editor's Notes

  1. Sam
  2. Sam Serious health issues from stunting: Weakened immune systems, decreased ability to learn, higher risk for illnesses and premature death.
  3. Sam Major Crops Teff, barley, wheat, maize, beans, peas
  4. Sam East Gojjam region is 60% food insecure  Close proximity to urban region 
  5. Mugdha
  6. Mugdha There is a three phase intervention: phase one is community engagement and emergency relief, phase two is pilot, and phase three is assessment and scaling up.
  7. Mugdha
  8. Tiffany Based on the ideals of community based participatory research
  9. Tiffany
  10. Aaron IN AN INTERVENTION WITH LIMITED FUNDING, A STRONG AND EFFECTIVE PILOT WITH CYCLICAL AND ITERATIVE EVALUATION IS CRITICAL TO USING MONEY EFFICIENTLY.
  11. Aaron:  Important points are 1)when to breastfeed,2)how long to breastfeed,3)why it's important. Also, here are the relevant Health Belief Model constructs associated with each. For the first 40 days after birth in Amhara culture, woman and child are expected to stay at home
  12. Aaron We will also be supporting and supplementing these farming practices through the provision of seeds. While these goals will last during our limited intervention, we hope that these practices will inform future policy on improved farming practices. Formative research will hopefully inform other agriculture policy to combat inequity including land grabbing.
  13. Priyanka Pregnant women need vitamin A, folate, calcium, iron. Zinc is also necessary for a healthy immune system.  Good nutrition builds strong immune systems, supercharging children’s chances of survival and protecting them their whole lives  Detox lymph glands & blood cells ; may boost the immune system and lower the likelihood of infection 
  14. Priyanka Reason we chose these plants is for the nutrients
  15. Priyanka
  16. Tiffany
  17. Tiffany
  18. Tiffany
  19. Tiffany
  20. Aaron
  21. Aaron Measurement of Fundal Height Establish baseline of fundal height to the woman and see if her fundal height improves in next pregnancy after our intervention! Meet Key milestones(essentially 1 cm increase per week)
  22. Aaron
  23. Mugdha
  24. Mugdha