"Impact of Malnutrition in the First 1,000 Days on a Child's Health in Rural Ethiopia"

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