Summary of Nutrition Baseline Surveys For The BMZ

Summary of Nutrition Baseline Surveys for the BMZ financed Global
Programme Food and Nutrition Security and Enhanced Resilience

Gina Kennedy, Gudrun Keding, Esther Evang, Lars Scheerer, Giulia Rota Nodari
16 September 2016
Table of contents
Survey methods
Country overview
Definitions of Key Indicators
Results
Key indicators
Availability and access to food
Water, Sanitation and Health
Care practices and MAD
Dietary intake of women and children
Preliminary Logistic regression results
Conclusions
Recommendations
2
Bioversity International\S. Collins
Survey methods
Sample size needed was calculated at

n=347, sample size of the NBS ranged
from 396-487 with the exception of India
(n=803)
Data from 4700 women-child pairs
Selection criteria: Respondents were

women (15-49 yrs) who also had at least
one child (6-23 months)
Bioversity International\J. Lauderdale
Country overview: Africa
Ethiopia
Mali
GDP per capita* (World Bank,

2015): 744.3
Human Development Index
(UNDP, 2014): 0.419
Prevalence of stunting (UNICEF,
2013): 39%
Kenya
Burkina Faso

2015): 619.1
(UNDP, 2014): 0.442
2013): 44%

2015): 613
(UNDP, 2014): 0.402
2013):33%
Zambia
Togo

2015): 1376.7
(UNDP, 2014): 0.548
2013): 35%
GDP per capita* (World Bank, 2015):

548
Human Development Index (UNDP,
2014): 0.484
2013): 30%
Benin

2015): 779.1
(UNDP, 2014): 0.480
2013): 45%

2015): 1307.8
(UNDP, 2014): 0.586
2013):46%
Malawi

2015): 381.4
(UNDP, 2014): 0.445
2013): 48%
*current US$
Country overview: Asia
India

2015): 1581.6
(UNDP, 2014): 0.609
2013): 48%
Cambodia

2015): 1158.7
(UNDP, 2014): 0.555
2013): 41%
*current US$
5
Definitions of Key Indicators of the Program

Individual Dietary Diversity Score Women of Reproductive age IDDS-W - and Minimum Dietary Diversity Women of reproductive
age - MDD-W
Minimum Acceptable Diet - MAD (6-23 months of age)
MDD (Minimum Dietary Diversity)
MMF (Minimum Meal Frequency)
Food Insecurity Experience Scale-Household - FIES-H

Individual Dietary Diversity Score and MDD-W
IDDS-W: is the sum of ten food groups consumed
over the past 24 hours by women 15-49 years of
age.
MDD-W: is the proportion of women 15-49 years of
age who consumed food items from at least 5 out of
10 defined food groups the previous day or night.
Interpretation: Higher prevalence of MDD-W is a
proxy for better micronutrient adequacy among
women of reproductive age in the population
Photo credit: Klaus Wohlmann

Food groups for women
Grains, white roots/tubers, plantains
Eggs
Pulses (beans, peas and lentils)
Dark green leafy vegetables
Nuts and seeds
Other vitamin A-rich fruits &
Dairy
Meat, poultry and fish
vegetables
Other vegetables
Other fruits

Minimum Acceptable Diet (MAD)
Minimum Dietary Diversity (MDD)
Minimum Meal Frequency (MMF)
Minimum acceptable diet (MAD): Proportion of children 6-23 months of age who receive a minimum
acceptable diet which is a composite indicator of minimum dietary diversity and minimum meal frequency
during the previous day
Minimum dietary diversity (MDD): Proportion of children 6-23 months of age who receive foods from 4
or more food groups out of seven
Interpretation: proxy for adequate micronutrient-density of foods and liquids other than breast milk
Minimum meal frequency (MMF): Proportion of breastfed and non-breastfed children 6-23 months of
age who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children)
the minimum number of times or more.
Source, WHO, 2008
Interpretation: proxy for energy intake from foods other than breast milk
9
Food Insecurity Experience Scale-H (FIES-H)

Prevalence of Experienced Food Insecurity at moderate or severe levels (FImod+sev)
Prevalence of Experienced Food Insecurity at severe levels (FIsev)
Interpretation: estimates of the proportion of the population facing difficulties in
accessing food, at levels of moderate and severe food insecurity During the last 4 weeks, was there a time when:
1.
You or others in your household worried you would run out of food because of a lack of money or other resources?
2.
You or others in your household were unable to eat healthy and nutritious food because of a lack of money or other resources?
3.
You or others in your household ate only a few kinds of foods because of a lack of money or other resources?
4.
You or others in your household had to skip a meal because there was not enough money or other resources to get food?
5.
You or others in your household ate less than you thought you should because of a lack of money or other resources?
6.
Your household ran out of food because of a lack of money or other resources?
7.
You or others in your household were hungry but did not eat because there was not enough money or other resources for
food?
8.
You or others in your household went without eating for a whole day because of a lack of money or other resources?
10
Source: FAO, Voices of the Hungry, 2016
Results according to the UNICEF Framework

Nutritional Status
(Prevalence of stunting, underweight, overweight
and micronutrient deficiencies)
Food Intake
Health Status
MAD (MDD and MMF) in children 6-23 mo
Prevalence of diarrhea
MDD-W of women 15-49 years

Land access. Crop diversity,
Home gardening, Livestock keeping, Access to fruit trees
Prevalence of moderate and severe food insecurity (FIES-H)
Care Environment
Access to nutrition counselling
Presence of soap in household,Use of soap for hand-
Knowledge about prevention of
washing, Access to improved sanitation facility, Access to
malnutrition
improved water
Education
11
Health Services and WASH
Womens education level
Results: Presentation of the Nutrition Baseline Survey

results
In order to summarize visually
different percentages across
the ten countries, a dashboard
categorization was used.
Red: Very Poor
Yellow: Poor
Green: Better
12
0-32%
Very low/poor
33-66%
Low
67-100%
Better
The inverse percentages used for Food

Insecurity as increasing percentage
reflects a worse situation
Results: Summary of Key Indicators of the Program

Country
FIES-H
MAD
MDD-W
Kenya
87
15
12
Malawi
86
34
27
Mali
55
11
Togo
55
33
28
Zambia
41
34
57
Benin
32
26
34
Cambodia
24
41
53
Ethiopia
23
19
Burkina Faso
22
38
38
India
18
18
20
FIES-H here refers to moderately and severely food insecure

Numbers represent %
Many patterns are consistent

(Kenya, Togo, Zambia, Benin)
Households experience of
moderate and severe food
insecurity is relatively low in
Ethiopia and India, however MAD
and MDD very low.
14
Results: Female education

Benin
Some
school
20%
Burkina
Cambodia Ethiopia
Faso
33.6%
90.4%
45%
India
Kenya
Malawi
Mali
Togo
Zambia
51%
100%
87%
33.6%
56%
69%
Very large range across countries in female education (20-100%)

According to MDG for sub-Saharan Africa in 2000, 60% of all children were enrolled in
primary school (MDG report of the United Nations, 2015). 5 out of 8 project sites in Africa are
below this benchmark.
Keep the level of education in mind when designing and implementing interventions
Results: Availability and access to food - access to land

Burkina
Cambodia Ethiopia
Faso
Benin
Access to
land for
agriculture
97%
81%
85%
95%
India
Kenya
Malawi
Mali
Togo
Zambia
71.5%
21%
90%
78%
92%
99%
Access to land for agriculture is OK for all countries except Kenya.

Kenya reports a low access to land; it should be noted that the survey area in Kenya
represents an area where the population is mainly pastoral and practice a nomadic lifestyle.
Keep the level of access to land in mind for agriculture interventions, especially INDIA
and KENYA
15
Results: Availability and access to food - Main crops grown

(% of households growing the crop)
Benin
Burkina
Faso
Cambodia
Ethiopia
India
Kenya
Malawi
Mali
Togo
Zambia
Maize
94
Maize
97
Rice
95
Maize
70
Wheat
93
Maize
88
Maize
91
Rice
88
Maize
98
Maize
100
Sorghum
75
Millet
78
Cassava
15
Teff
60
Mustard
66
Maize
19
Manioc
94
Groundnuts
67
Soya
76
Groundnuts
63
Beans
8
Barley
50
Sesame
56
Soya
20
Millet
19
Beans
66
Sunflower
57
Yams
77
Red sorghum
61
Legumes
43
Bengal
gram
55
Rice
20
Groundnuts
58
Legumes Groundnuts
74
45
Red circles indicate potentially interesting crops for

diversifying diet of women and children
16
17
Comparison of production and consumption

Countries with
red circle
indicate more
attention to
consumption of
own production
needed
Results: Availability and access to food - households with

home gardens, access to fruit and livestock
India, Kenya and Togo
twenty percent or fewer
hh had home gardens.
1/3 of hh or fewer with
access to fruit in
Ethiopia, India, Kenya
and Mali
Fifty percent or more of
all hh keep livestock,
except Malawi
Photo: Kuldeep Singh Jadon
18
Results: Availability and access to food - food insecurity

experience scale (FIES-Household)
Country
Kenya
Malawi
Mali
Togo
Zambia
Benin
Cambodia
Ethiopia
Burkina Faso
India
19
FImod+sev (%)
86.6
86.1
54.8
54.6
41.4
31.7
23.8
22.7
21.9
17.7
FIsev (%)
46.5
35.8
29.7
2.5
10
12.8
0.09
0.8
4.7
8.4
Prevalence rates are

representative of project area
(not national).
Within the surveyed areas
food insecurity is greatest in
Kenya, followed by Malawi,
Mali and Togo.
Results from Ethiopia are
better than expected given
one of the lowest MDD-W and
MAD.
Results: Health - drinking water and sanitation

West Africa
East Africa
Asia
Southern Africa
100
100
100
100
90
90
90
90
80
80
80
80
70
70
70
70
60
60
60
60
50
50
50
50
40
40
40
40
30
30
30
30
20
20
20
20
10
10
10
10
Ethiopia
Kenya
Access to improved sanitation

Access to improved water Wet
season
Access to improved water Dry
season
Benin
Burkina
Faso
Mali
Togo
Malawi
Zambia
2015 MDG targets

for sub-Saharan
Africa 74% access
to safe water and
62% access to safe
sanitation.
Water goal met in at
least one season for
six project areas in
Africa.
Cambodia
India
Sanitation in nearly
every project area is
very far away from
goal.
Results: Care - Maternal knowledge compared to prevalence of

MAD
What should we do to prevent malnutrition in
children?
21
Gap between knowledge and

practice is high in Kenya and
Ethiopia. WHY? Research on
barriers (economic, culture,
gender) needed
Knowledge and practice are
similar for other countries, so
behavior change communication
a plausible strategy.
Results: Dietary Intake Women (15-49 years)

Country
IDDS-W
MDD-W (%)*
Ethiopia
3.1
Kenya
3.2
12
Mali
3.2
India
3.6
20
Malawi
3.9
27
Togo
3.9
28
Benin
4.1
34
Burkina
Faso
4.2
38
Cambodia
4.6
53
Zambia
4.7
57
22
The IDDS-W ranged from 3.1 (0.9)

(Ethiopia) to 4.7 (1.3) (Zambia) with
percent of women achieving MDD
ranging from 6.8 % in Ethiopia to 57 %
in Zambia.
The relationship between IDDS
and MDD-W is very consistent.
Could recalculate your target
IDDS now (add 0.5 to the
baseline)
Results: Dietary intake children 6-23 months

Mali
MAD
MDD
MMF
Kenya
Ethiopia
India
Benin Togo Malawi Zambia
Burkina
Cambodia
Faso
11
15
17
18
26
33
34
34
38
41
27
22
19
23
33
43
43
55
50
47
57
71
66
58
67
71
70
77
63
93
MMF higher than MDD for all countries, focus needed on diversification.
Important to also disaggregate results by breastfeeding and age
Results are presented for full sample not by breastfed/non-breastfed as >75% of children breastfed yesterday
Results: Preliminary testing of hypotheses

Hypothesis 1: Womens dietary diversity, measured by the Individual Dietary
Diversity Score Women (IDDS-W) or Minimum Dietary Diversity Women (MDD-W),
is higher for households with a more diverse agricultural production pattern and a
better knowledge of adequate nutrition.
Hypothesis 2: Children aged 6-23 months are more likely to receive a minimum
acceptable diet (MAD) the more diverse the households agricultural production and
the higher the households level of nutrition knowledge.
24
Results: Preliminary testing of hypotheses IDDS-W and MDD-W

In 9 out of 10 country models at least one and max. three agricultural variables have
a causal positive effect on women's dietary diversity:
(crop diversity, home garden, access to fruit/fruit production in homestead, yearround vegetable production, vegetable diversity, fruit diversity)
Nutrition counselling was significant in some but not all countries
Other significant predictors are very country specific and do not occur consistently
amongst countries
(secondary education, geographical location, ethnicity, income score)
Results: Preliminary testing of hypotheses: Minimum acceptable

diet
In 5 out of 10 country models at least one and max. two agricultural variables
have causal positive effect on infants MAD (vegetable diversity, crop diversity,
home garden)
In some country models under 5 child clinic visits positively and significantly
influence MAD
Within countries district was also often a significant predictor
Results seem to confirm the programs hypotheses of relationships between

agriculture production and particularly womens dietary diversity.
For Minimum acceptable diet, have a close look at MDD and MMF across age groups
and breastfeeding status
Conclusions
1.
The project sites represent vulnerable areas and are appropriate sites for the proposed
interventions.
2.
The chosen key indicators of IDDS-W and MAD match well with the program intervention
packages in most countries.
3.
There are plausible impact pathways to achieve the objectives of the program given the
combination of interventions in most countries.
4.
Note: Those countries focusing on sanitation and hygiene will need to think how to measure
change as no change in MAD or IDDS-W is expected based on improvements in sanitation
and hygiene
27
Recommendations for the program

General
Try to assess level and intensity of participation in interventions (see RAIN impact evaluation)
Own production was a big focus of the NBS but market and market access was not, more
exploration of market access and food availability in markets could be undertaken at mid-term
Seasonal fluctuations in food availability should be further explored and addressed when
designing interventions
Divergence between access to fruit and vegetables and consumption should be explored
using qualitative methods (see supplementary slides)
28

Gender
All projects should undertake qualitative research with women and men of different age groups
to understand food and nutrition security dynamics within the household:
Who controls the income that determines what food is purchased?

Who decides what food to grown in the homegarden? (mother in law/older female in HH, male
member of hh, or mother of the young child?)
Who decides on a daily basis the food prepared for the family (mother in law/older female, male
member of hh, or mother of the young child)
Who decides on a daily basis the food prepared for the child (6-23 months) ?* there could be a
difference between decision making for family and young child
Who decides if it is OK to feed the child a new food (e.g. fruit, vegetable, egg)
29

Care
Country specific qualitative data collection is needed to understand divergence in knowledge

and practice of dietary diversity for children in Ethiopia and Kenya
Most knowledge questions were based on maternal recall of general topics, the uptake of
program specific messaging should be tested
Assess different channels of communication for uptake of messages
Health/WASH
Advocate especially access to sanitation
30
Thank you
Gina Kennedy
g.kennedy@cgiar.org
www.bioversityinternational.org/subscribe
@BioversityInt

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Summary of Nutrition Baseline Surveys for the BMZ financed Global

Programme Food and Nutrition Security and Enhanced Resilience

Bioversity International\S. Collins

Sample size needed was calculated at

Data from 4700 women-child pairs

Selection criteria: Respondents were

Country overview: Africa

GDP per capita* (World Bank,

GDP per capita* (World Bank,

GDP per capita* (World Bank,

GDP per capita* (World Bank,

GDP per capita* (World Bank, 2015):

GDP per capita* (World Bank,

GDP per capita* (World Bank,

GDP per capita* (World Bank,

Country overview: Asia

GDP per capita* (World Bank,

GDP per capita* (World Bank,

Definitions of Key Indicators of the Program

Food Insecurity Experience Scale-Household - FIES-H

Definitions of Key Indicators

Definitions of Key Indicators

Grains, white roots/tubers, plantains

Pulses (beans, peas and lentils)

Dark green leafy vegetables

Nuts and seeds

Other vitamin A-rich fruits &

Definitions of Key Indicators

Definitions of Key Indicators

Food Insecurity Experience Scale-H (FIES-H)

Source: FAO, Voices of the Hungry, 2016

Results according to the UNICEF Framework

MAD (MDD and MMF) in children 6-23 mo

MDD-W of women 15-49 years

Availability and access to food

Presence of soap in household,Use of soap for hand-

Knowledge about prevention of

washing, Access to improved sanitation facility, Access to

Health Services and WASH

Womens education level

Results: Presentation of the Nutrition Baseline Survey

The inverse percentages used for Food

Results: Summary of Key Indicators of the Program

FIES-H here refers to moderately and severely food insecure

Many patterns are consistent

Results: Female education

Very large range across countries in female education (20-100%)

Results: Availability and access to food - access to land

Access to land for agriculture is OK for all countries except Kenya.

Results: Availability and access to food - Main crops grown

Red circles indicate potentially interesting crops for

Comparison of production and consumption

Results: Availability and access to food - households with

Results: Availability and access to food - food insecurity

Prevalence rates are

Results: Health - drinking water and sanitation

Access to improved sanitation

2015 MDG targets

Results: Care - Maternal knowledge compared to prevalence of

Gap between knowledge and

Results: Dietary Intake Women (15-49 years)

The IDDS-W ranged from 3.1 (0.9)

Results: Dietary intake children 6-23 months