A Nutrition and Food Security Assessment of the Dry Zone of Myanmar, - - PowerPoint PPT Presentation

A Nutrition and Food Security Assessment

• f the Dry Zone of Myanmar,

June 24th - July 18th 2013

January 16th 2014

OBJECTIVES

• 1. Estimate the prevalence of indicators
• f undernutrition in the Dry Zone, and

three different agroecological zones within

• 2. Estimate infant and young child

feeding practice rates

• 3. Assess the differences in the nutrition

situation by agroecological zone and the likely reasons, examining the associations between nutrition and

• ther indicators
• 4. Make recommendations for

programming, policy and advocacy

Agroeco logical zone number Agroecological zone name Characteristics

1 Dry land farming

• 1. Low land, not flood prone, no

irrigation

• 2. Suitable soil for cultivation
• 3. Only single or double

cropping possibilities

2 High land with sloping agriculture

• 1. High land (greater than 300

meters)

• 2. Soil suitable for orchards,

plantations, forest

• 3. Sloping/ shifting cultivation

agriculture practiced

3 Flood plains and irrigated areas

• 1. Flood plain with good soil

fertility

• 2. Irrigated land
• 3. Multi-cropping possibilities

year round

METHODS (1/5): DESIGN

A cross sectional, two stage, random, cluster survey of rural villages, with 3 strata (agroecological zones) Stage 1: Random selection of 50 village clusters per zone Stage 2: Random selection of 40 households per village (12 households with children under 5 for nutrition/IYCF data and 13 (minimum 10) households with/without children under 5 for food security/HH data)

A household: “ a person or group of

people eating and sleeping in the same compound four nights weekly and sharing resources, not including those who may have migrated”

METHODS (2/5) SAMPLE SIZE

Nutrition:

• 1,800 children 0-59 months

Infant and Young Child Feeding:

• 522 0-24 month olds

Mothers:

• All of the children 0-59 months

Food security, wealth/poverty and Water Sanitation and Hygiene (WASH):

• 1,500 households (with/without U5s)
• Including 560 households with child

nutrition and household food security data

METHODS (3/5): QUESTIONNAIRES

• Village profile: Population (for weighting);

crop production; market, clinic and water source access and distance by season; and common diseases affecting children

• Household: Written consent and

household demography

• Mother: Anthropometry; ANC/PNC; 24

hour diet recall

• Household Food Security,

wealth/poverty, WASH

• Child under 5: Anthropometry; recent

sickness; supplementation and vaccination status and hygiene practices

• Child under 2: Infant and Young Child

Feeding practices

METHODS (4/5): MEASUREMENTS

• Children: weight, height/length, Mid Upper Arm

Circumference (MUAC) and check for oedema. Date of birth

• Mothers: weight, height and MUAC. Age
• Salt iodisation test at household level

METHODS (5/5): FIELD LOGISTICS

• 64 staff (10 from DRD), 9

teams, 8 supervisors

• 2 weeks training, including

practice anthropometry & village pilot

• 3.5 weeks field work

NUTRITION RESULTS

Maximum achieved sample sizes Dry land farming zone (1) Highland farming zone (2) Flood plains/ irrigated zone (3)

Dry Zone total

Planned sample size Villages 51 50 51

152

150 Households with children U5 601 607 600

1808

ND Households with OR without children U5 617 574 612

1803

1500 Children U5 687 689 600

2037

1800 Children U2 290 289 243

822

522 Mothers (children U5) 591 598 599

1789

ND

SAMPLE SIZE ACHIEVED:

% Wasted / acutely malnourished (0-59 month olds)

0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 5 1 0 1 5 2 0 2 5

A g e (m o n th s) P r e v a le n c e o f G lo b a l A c u te M a ln u tr itio n %

Z one 1 Z one 2 Z one 3

Zo n e 1 Zo n e 2 Zo n e 3 Ag g re g ate d 5 10 15 20

A g roecolog ical Z ones

P r e v a le n c e o f G lo b a l A c u te M a ln u tr itio n %

M oderate S evere

A cce p ta b le P o o r H igh C ritical P ublic H ealth S ignificance

% Stunted/chronically malnourished (0-59 month olds)

0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 1 0 2 0 3 0 4 0 5 0

A g e (m o n th s) P r e v a le n c e o f S tu n tin g %

Z one 1 Z one 2 Z one 3

Zo n e 1 Zo n e 2 Zo n e 3 Ag g re g ate d 10 20 30 40 50

A groecological Zones

P r e v a le n c e o f S tu n tin g %

M oderate S evere

Low M edium H igh V ery high P ublic H ealth S ignificance

Weight for Height Z-score (WHZ) and Height for Age Z-score (HAZ) distributions

.1 .2 .3 .4 .5

• 6
• 5
• 4
• 3
• 2
• 1

1 2 3 4 5 6

Weight-for-length z-score

.1 .2 .3 .4

• 6
• 5
• 4
• 3
• 2
• 1

1 2 3 4 5 6

Height-for-age z-score

<-2 = wasted <-2 = stunted

Zo n e 1 Zo n e 2 Zo n e 3 Ag g r e g a te d 1 0 2 0 3 0 4 0

A g ro e c o lo g ic a l Z o n e s

P re v a le n c e o f L o w B irth w e ig h t %

% Babies born Low Birth Weight (<2500g)

% Undernutrition in mothers

M U A C < 2 1 0 c m B M I < 1 8 .5 k g /m 2 5 1 0 1 5 2 0 2 5

In d ic a to r P re v a le n c e o f m o th e rs ' u n d e rn u tritio n %

Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

• Mean MUAC

pregnant/lactating mothers: 26.0cm

• Mean MUAC non-

pregnant/lactating mothers: 26.8cm

DISEASE AND PUBLIC HEALTH

% Child sickness (previous two weeks)

F e v e r C

• u

g h D i a r r h

• e

a M e a s l e s O t h e r F e v e r C

• u

g h D i a r r h

• e

a M e a s l e s O t h e r F e v e r C

• u

g h D i a r r h

• e

a M e a s l e s O t h e r 5 1 0 1 5 2 0

P re v a le n c e o f M o rb id ity %

Z o n e 1 Z o n e 2 Z o n e 3

Dry Zone sickness prevalence: 28.0%

Health caring practices: Care of children with diarrhoea

m o r e flu id s m o r e fo o d O R S H o m e O R S Zin c ta b le t Zin c s yr u p 2 0 4 0 6 0 8 0

D ia rrh o e a c a r e P ro p o rtio n %

Health caring practices: Hygiene practices

H a n d w a s h in g a fte r c h ild d e fa e c a te d H a n d w a s h in g a fte r c h ild d e fa e c a te d (w ith s o a p ) H a n d w a s h in g p r io r to fo o d p r e p a r a tio n fo r c h ild r e n H a n d w a s h in g p r io r to fo o d p r e p a r a tio n fo r c h ild r e n (w ith s o a p ) D is p o s a l

• f fa e c e s

in to ile t 5 0 1 0 0

H y g ie n e p ra c tic e s P ro p o rtio n %

Z o n e 1 Z o n e 2 Z o n e 3

Household latrine access

F lu s h la tr in e P it la tr in e V e n tila te d im p r o v e d P it la tr in e w ith s la b P it la tr in e w ith o u t s la b N o la tr in e

• p e n d e fe c a tio n

2 0 4 0 6 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

T u b e w e l l / b

• r

e h

• l

e H a n d d u g w e l l P

• n

d T u b e w e l l / b

• r

e h

• l

e H a n d d u g w e l l P

• n

d T u b e w e l l / b

• r

e h

• l

e H a n d d u g w e l l P

• n

d 5 0 1 0 0

W a te r s o u rc e s % o f v illa g e s Z o n e 1 Z o n e 2 Z o n e 3

Village main water source

Households with access to protected water year round: 64.5%

DIET

5 0 1 0 0 E x c lu s iv e b r e a s tfe e d in g T im le y in itia tio n o f b r e a s tfe e d in g C o n tin u e d b r e a s tfe e d in g a t 1 ye a r C o n tin u e d b r e a s tfe e d in g a t 2 ye a r s E v e r b r e a s tfe d B o ttle fe e d in g T im e ly c o m p le m e n ta r y fe e d in g T im e ly in tr o d u c tio n o f s o lid , s e m is o lid , o r s o ft fo o d s M in im u m d ie ta r y d iv e r s ity M in im u m m e a l fr e q u e n c y (b r e a s tfe d c h ild r e n ) M in im u m a c c e p ta b le d ie t (b r e a s tfe d c h ild r e n ) C o n s u m p tio n o f ir o n -r ic h o r ir o n -fo r tifie d fo o d s C o n s u m p tio n o f fo r tifie d fo o d s C o n s u m p tio n o f M N P

P ro p o rtio n (% ) C o m p le m e n ta ry fe e d in g B re a s tfe e d in g

Infant and Young Child Feeding practices

Mean dietary diversity scores (child, mother, household)

C h ild re n 6 - 2 3 m o n th s A ll No -p re g n a n t n o -la c ta tin g P re g n a n t

• r la c ta tin g

Ho u s e h o ld s 2 7 1 2

D ie ta ry d iv e rs ity s c o re (ID D S & H D D S )

Z one 2 Z one 3 Z one 1 A g greg ated

M others * *

• Individual Dietary

Diversity Score non-pregnant/ lactating mothers: 4.4

• Individual Dietary

Diversity Score pregnant/ lactating mothers: 4.2 4 4 7 9 12

QUESTIONS / COMMENTS?

HOUSEHOLD FOOD SECURITY, WEALTH AND POVERTY

POTENTIAL CAUSES OF UNDERNUTRITION:

Using: Descriptive analysis

• Q1: What indicators are

inadequate?

• Q2: What patterns exist

between agroecological zones? And Exploration of associations and risk factors NOTWITHSTANDING THE LIMITATIONS OF THE CROSS SECTIONAL DATA…

Season

Months of food gap

J u n J u l A u g S e p O c t N o v D e c J a n F e b M a r A p r M a y

1 0 2 0 3 0 4 0 5 0

M o n th P ro p o rtio n (% )

Seasonal timing places the survey in the hunger gap, impacting on the ‘high’ rates of acute malnutrition, and other indicators (e.g. diet diversity, sickness) – worst case scenario (acute malnutrition)?

Undernutrition in children and mothers

1. Wasting more likely in stunted children (a risk factor), and vice versa 2. Birth weight determines later nutrition status (and LBW is a risk factor for stunting) 3. Mother’s nutrition status (BMI) determines child’s nutrition status (WHZ) (and low BMI is a risk factor for wasting)

Inadequate diets

1. Late and non-exclusive breastfeeding 2. Poor dietary diversity and meal frequency for children during the complementary feeding period 3. Low diet diversity diets for mothers, particularly pregnant/breastfeeding – affects their nutrition and the nutrition

• f their baby

4. Diet diversity of mother a determinant of child’s diet, regardless of HH economic status, suggesting need to tackle poverty and/or increase knowledge and change attitudes around IYCF/diets

Recent sickness/age Wasting/age

0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 2 0 4 0 6 0

A g e (m o n th s) P re v a le n c e o f M o rb id ity %

Z one 1 Z one 2 Z one 3

0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 0 -5 6 -1 7 1 8 -2 9 3 0 -4 1 4 2 -5 3 5 4 -5 9 5 1 0 1 5 2 0 2 5

A g e (m o n th s) P re v a le n c e o f G lo b a l A c u te M a ln u tr itio n %

Z one 1 Z one 2 Z one 3

Disease and poor public health environment, including WASH

• 1. Sickness – similar trends as wasting and stunting

Disease and poor public health environment, including WASH

2. Inappropriate care of sick children 3. Poor hygiene practices, particularly hand washing 4. Poor latrine access 5. Use of unprotected water sources 6. Poor drinking water treatment practices

Household food insecurity

• 1. Low contribution of household

subsistence production to household food needs (livestock ownership and land access determinants of mothers BMI)

• 2. Reliance on market purchase for

food access (due to small landholdings/high landlessness; limited irrigation/low yields; small stocks) (poor economic access to food)

• 3. Challenges in accessing market

may impede food access

• 4. Potentially, poor intrahousehold

food allocation

Household incomes/expenditure

1. Low incomes from limited sources, agriculture- focused so vulnerable to climatic and economic shocks 2. Typicality of loan taking / credit purchase, for many,

• n unfavourable terms;

i.e entrenched indebtedness 3. Poor economic access to food: high proportionate spends on food needs, much on rice (driving poor diversity of diets)

A ll fo o d R ic e P a d d y p u r c h a s e

• n c r e d it

2 0 4 0 6 0 8 0

F o o d e x p e n d itu re (% o f to ta l e x p e n d itu re ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

* *

Challenges of physical access – affecting causes of undernutrition through different pathways?

• As the highest rates of sickness are in zone 2 it could be that factors

associated with the zones could be ‘causing’ malnutrition, particularly poor infrastructure/ service access.

R a in y s e a s o n S u m m e r s e a s o n W in te r s e a s o n R a in y s e a s o n S u m m e r s e a s o n W in te r s e a s o n R a in y s e a s o n S u m m e r s e a s o n W in te r s e a s o n 1 0 2 0 3 0 4 0

S e a s o n T ra v el tim e fo r a ro u n d trip to m a rk e t (h rs ) Z o n e 1 Z o n e 2 Z o n e 3

CONCLUSIONS

• 1. The nutrition situation in the Dry Zone is more concerning

than expected. Both acute and chronic malnutrition require attention, as well as the nutrition status of mothers, particularly pregnant and lactating mothers

• 2. Zone 3 (irrigated/flood plains) is generally better off, but the

situation in the whole Dry Zone warrants attention. The population of Zone 2 (highland farming) may be particularly vulnerable due to access issues as well as poorer food security

• 3. Children’s nutrition status is associated with mother’s

nutrition status and may be poor from birth, so a life cycle approach is vital

• 4. Individual explanatory variables explain only a small

proportion of variance of nutrition indicators. This highlights that a multisector approach is needed

• 5. Sickness is a key driver of undernutrition, particularly in
• lder children and in zone 2
• 6. Deficiencies in the water, sanitation and hygiene

environment are implicated

• 7. Poor diets are an important driver of undernutrition, in

children and mothers

• 8. The relationship of nutrition with household economy /

poverty is not clear, but widespread low incomes, high debts and insecure livelihood need to be tackled to improve diets and nutrition

QUESTIONS / COMMENTS?

Spare slides in case of questions about some specifics

Key preventative health interventions (children)

B e d n e t u s e (6 - 5 0 m o n th s ) M e a s le s v a c c in a tio n (1 2 - 2 3 m o n th s ) An tih e lm in th c o v e r a g e (1 2 - 5 9 m o n th s ) V ita m in A s u p p le m e n ta tio n (6 - 5 9 m o n th s ) T B v a c c in a tio n b y B C G s c a r (0 - 5 9 m o n th s ) 5 0 1 0 0

P re v e n ta tiv e H e a lth C a re P ro p o rtio n %

Z o n e 1 Z o n e 2 Z o n e 3

*

5 0 1 0 0 D o c to r N u r s e M id w ife A u x ilia r y m id w ife T r a d itio n a l b ir th a tte n d a n t O th e r P ro p o rtio n (% )

Z o n e 2 Z o n e 3 Z o n e 1

Ante-natal Care provision

5 0 1 0 0 P o s tp a r tu m V it A V ita m in B 1 Ir o n d u r in g p r e g n a n c y P ro p o rtio n (% )

Z o n e 2 Z o n e 3 A g g re g a te d Z o n e 1

Mother’s micronutrient supplementation

5 0 1 0 0 1 - 2 tim e s a m o n th 1 - 2 tim e s a w e e k 3 - 4 tim e s a w e e k 5 d a y s a w e e k P ro p o rtio n (% )

5 days a week

Drinking water treatment

B o ilin g C lo th filtr a tio n L e a v in g it to s e ttle N o filtr a tio n O th e r

2 0 4 0 6 0 8 0 1 0 0

P roportion (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

5 0 1 0 0 S ta r c h y s ta p le s F a ts /o ils L e g u m e s O th e r V ita m in A r ic h fr u its a n d v e g s O th e r fr u its a n d v e g e ta b le s F is h a n d m e a t D a r k g r e e n le a fy v e g e ta b le s E g g s M ilk a n d d a ir y p r o d u c ts O r g a n m e a t P ro p o rtio n (% )

Z o n e 2 Z o n e 3 Z o n e 1

Food group consumption (mothers, 24 hour recall)

Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 5 0 1 0 0

A g ro e c o lo g ic a l Z o n e s P ro p o rtio n %

A d e q u a te (H D D S > 4 ) M o d e ra te (H D D S 3 -4 ) S e v e re (H D D S < 3 )

Zo n e 1 Zo n e 2 Zo n e 3 A g g re g a te d 2 0 4 0 6 0 8 0 1 0 0

A g ro e c o lo g ic a l Z o n e s P ro p o rtio n %

A d e q u a te (F C S > 3 8 .5 ) B o rd e rlin e (F C S 2 4 .6 -3 8 .5 ) P o o r (F C S < 2 4 .6 )

*

L a n d le s s < 2 2 - 4 5 - 1 0 > 1 0 1 0 2 0 3 0 4 0 5 0

A c re s o f la n d a c c e s s ib le to th e h o u s e h o ld P ro p o rtio n o f h o u s e h o ld s (% )

Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d H o u s e h o ld s e n g a g e d in a g ric u ltu re

2 0 4 0 6 0 8 0

L a n d le s s < 2 2 - 4 5 - 1 0 > 1 0 1 0 2 0 3 0 4 0 5 0

A c re s o w n e d b y th e h o u s e h o ld P ro p o rtio n o f h o u s e h o ld s (% )

Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

2 0 4 0 6 0 P ro p o rtio n o f a c c e s s e d la n d irrig a te d (% )

*

2 0 4 0 6 0 8 0 1 0 0

% H o u s e h o ld s w ith s ta p le s to c k s Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

5 1 0 1 5 2 0 2 5

M e d ia n d a y s o f s to c k a v a ila b le p e r h o u s e h o ld Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

< 1 1 - < 2 2 - < 3  3 2 0 4 0 6 0 8 0

M o n th s w o rth o f s to c k P ro p o rtio n o f h o u s e h o ld s (% )

Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

*

2 0 4 0 6 0 8 0 1 0 0

% H o u s e h o ld s w ith io d is e d s a lt Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

R e p o rte d p ro b le m s to m e e t fo o d n e e d s in th e la s t 1 2 m o n th s R e p o rte d p ro b le m s to m e e t fo o d n e e d s in th e la s t 7 d a ys D a ily c o p in g 1 0 2 0 3 0 4 0 5 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

N o h u n g e r H H S < 1 M o d e ra te h u n g e r H H S 2 -3 S e v e re h u n g e r H H S 4 -6 5 0 1 0 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

A d e q u a te C S I < 3 M o d e ra te C S I 3 -3 .4 S e v e re C S I > 3 .4 5 0 1 0 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

N o in c o m e 1 in c o m e 2 in c o m e s 3 + in c o m e s 1 0 2 0 3 0 4 0 5 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

N o in c o m e < 2 5 U S D 2 5 -5 9 U S D 5 0 -7 5 U S D 7 5 -9 9 U S D > 1 0 0 U S D

1 0 2 0 3 0 4 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

W a g e la b o u r a g r ic u ltu r a l W a g e la b o u r n o n -a g r ic u ltu r a l S e llin g p a d d y S e llin g p u ls e s /b e a n s

5 1 0 1 5 2 0 2 5

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

A ll fo o d R ic e P a d d y p u r c h a s e

• n c r e d it

2 0 4 0 6 0 8 0

F o o d e x p e n d itu re (% o f to ta l e x p e n d itu re ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

* *

T o ta l F o o d N o n -fo o d E d u c a tio n A d u lt h e a lth C h ild h e a lth T r a n s p o r t

5 0 ,0 0 0 1 0 0 ,0 0 0 1 5 0 ,0 0 0 2 0 0 ,0 0 0 2 5 0 ,0 0 0

E x p e n d itu re (k y a t) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

* *

L a s t m o n th e x p e n d itu re L a s t 6 m o n th s e x p e n d itu re

< 1 0 0 U S D 1 0 0 -2 0 0 U S D 2 0 0 -3 0 0 U S D

2 0 4 0 6 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

B e lo w n a tio n a l p o v e r ty lin e B e lo w fo o d p o v e r ty lin e

1 0 2 0 3 0 4 0

P ro p o rtio n (% ) Z o n e 2 Z o n e 3 Z o n e 1 A g g re g a te d

* *

METHODS (2/5) MORE ON SAMPLE SIZE

Nutrition and IYCF: 1,800 children 0-59 months, including 522 0-24 month olds:

• For anthropometric indices: using stunting 39% in 0-59 month olds, precision 5%, power

90%, design effect 1.5, 10% refusal = 426 0-59 month olds per zone (9 per village cluster)

• For IYCF: exclusive breastfeeding 8% in 0-5 month olds, precision 5%, power 90% = 80

infants per zone, * 4 and design effect of 1.5 = 480 0-24 month olds

• Estimate 8.8% U5s (2.6% U2s) in Dry Zone, and 31% HH with a child U5 = 12 children U5

in 39 households, of which 3 U2 And their mothers Food security, wealth/poverty and WASH: 1,500 households (with/without U5s), including 560 HH with child nutrition and household food sec data

• Prevalence 50%, precision 10%, power 90%, design effect 5 = 340 HH per zone (7 per

village cluster), BUT 7HH=2U5. Increase pragmatically to 13 (10 minimum) households

METHODS: DATA MANAGEMENT AND PROCESSING

• Anthropometry data double entered & processed in ENA for SMART

(2011)

• Other data entered in Excel / SPSS
• Data entry complete September
• Datasets merged & analysed in ‘svy’ in STATA (12.0)
• Data weighted at cluster & strata level for child/mother/household

level estimates, & strata level for analysis of village data

Undernutrition Child stunting (HAZ score / <-2 HAZ (y/n)), wasting (WHZ score / <-2 WHZ (y/n)) Maternal undernutrition (BMI score / < 18.5 (y/n)) Inadequate diet IYCF practices: exclusively breastfed (y/n), meal frequency / min meal freq (y/n), dietary diversity score** / min diet diversity (y/n), min adequate diet (y/n) Mother’s dietary diversity score** Disease Recent morbidity (y/n) Household food insecurity Travel time to market Household Dietary Diversity Score** Food Consumption Score, including adequacy (y/n)** Income amount Food expenditure and food expenditure amounts HH subsistence production (y/n)** Livestock ownership (y/n)** Household poverty and demography Probability of falling below national poverty line Sex of household head (m/f) Number of people in the household Dependency ratio Labour migration (y/n)

Inadequate care environment

Poor public health environment Antihelminth (y/n); Vitamin A supplementation (y/n) Hand washing wiih soap Child’s faeces disposal in latrine (y/n) Drinking water on the premise (y/n) Clinic in village (y/n) and time to travel to the clinic Latrine access (y/n)**

Detecting significant associations

Requires variability in the population, as well as a sufficiently powered sample. No evidence of association or risk does not mean no association

• r risk exists….

e.g. poverty

Significant associations

Nutrition indicators as explanatory variables

• Outcome HAZ, explanatory variable

birthweight, R2 = 13.1% (0.1, 0.4)

• Outcome WHZ, explanatory variable

birthweight, R2 = 7.8% (0.1, 0.3)

• Outcome WHZ, explanatory variable

mother’s BMI, R2 = 1.4% (0.0, 0.1)

• Outcome stunting, explanatory

variable wasting, OR 1.68 (1.16, 2.42)

• Outcome stunting, explanatory

variable low birth weight, OR 10.66 (2.47, 45.98)

• Outcome wasting, explanatory

variable mother’s BMI, OR 0.93 (0.87, 0.98) Diet indicators as explanatory variables

• Outcome HAZ, explanatory variable

adequate HDDS, R2 = 2.2 (0.1, 1.3)

• Outcome HAZ, explanatory variable

adequate FCS, R2 = 1.8 (0.1, 0.7)

• Outcome BMI, explanatory variable

mother’s IDDS, R2 = 1.3 (0.5, 0.0)

• Outcome stunting, explanatory

variable Minimum Meal Frequency, OR 1.73 (1.07, 2.8)

• Outcome wasting, explanatory

variable Minimum Adequate Diet, OR 3.24 (1.06, 9.9) Public Health environment as explan

• Outcome BMI, explanatory variable

latrine access, R2 = 3.4 (-0.7, 0.0)

More regression results

Household food security indicators as explanatory variables

• Outcome BMI, explanatory variable

HH livestock ownership, R2 = 2.3 (- 0.0, 0.0)

• Outcome BMI, explanatory variable

HH subsistence production, R2 = 1.9 (1.8, 0.0)

• Outcome stunting, explanatory

variable adequate HDDS, OR 0.43 (0.18, 0.99)