Category Archives: Malnutrition

South Ethiopia Network of Universities in Public Health II (SENUPH II)

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The SENUPH II project represents a network of three universities in southern Ethiopia as well as the University of Bergen. The focus is on public health. Based on history of 20-year collaboration, we aim to strengthen the existing collaboration so to enhance efforts to improve capacity building, research, building independent senior researchers, and collaborate with the Ministry of Health with the relevant health information to improve the health of peoples in southern Ethiopia.

Project’s particular importance

Even if there has been a substantial economic growth in Ethiopia, the country remains among the 20 poorest countries. The population is in a transition with declining fertility, increasing life expectancy, heavy burdens of poverty-related diseases and increasing load of non-communicable diseases. Thus, the country needs evidence-based healthcare to improve health policy and improve the health of the population.

This project focuses on health challenges and priority setting. We believe universities in southern Ethiopia, can produce relevant information for policymakers to enhance public health work. By focusing on infectious diseases, malnutrition and the emerging burden of non-communicable diseases, we aim to build capacity in higher education both at universities and at the Ministry of health.

By the end of the project and through building strong research groups, we expect to have nine independent researchers capable of research leadership, supervising future PhD students, mentoring post docs, that further can develop their institutions when this project ends. Furthermore, we expect to have strengthened two PhD programs that would be sustainable in an Ethiopian context.

Building on a previous joint PhD degree programme between Hawassa University and the University of Bergen, and strengthening research at Dilla and Arba Minch University, we plan through PhD and post doc research, linked to training at the master’s level, strengthen the ownership, capability, and sustainability of the universities and of the Ministry of health to carry out evidence-based healthcare. The teaching, research, and implementation work will be interdisciplinary and integrated and involve disciplines such as epidemiology, medicine, priority setting and health economics, household economy, essential laboratory disciplines for emerging and existing epidemics.

Project goals

Through this six-year project, we aim to strengthen the institutional capacity for teaching, supervision and research by developing teams of researchers consisting of both senior (post docs) and junior researchers (PhD students and PhD holders) and thereby obtaining a critical mass needed for future sustainability of the institution. This will also focus on enhancing leadership capability of researchers so that they become independent researchers.

We shall strengthen research groups on thematic areas such as communicable diseases (malaria, emerging and re-emerging infections, and tuberculosis), nutrition, and priority setting on non-communicable diseases and health economics.

Relevant SDGs in the project

This project will deal with several of the sustainable development goals. The main goal is good health and well-being (SDG3). However, a large proportion of the efforts will be to reduce hunger in an area where chronic malnutrition is highly prevalent (SDG2). Our program will be based on quality teaching (DG4), and gender equality (SDG5).

Partner institutions

In Ethiopia, Hawassa University, Arba Minch University, and Dilla University, and the University of Bergen

New article: Can we measure household Food Insecurity?

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Kabalo, Bereket Yohannes, Seifu Hagos Gebreyesus, Eskindir Loha, and Bernt Lindtjørn. “Performance of an Adapted Household Food Insecurity Access Scale in Measuring Seasonality in Household Food Insecurity in Rural Ethiopia: A Cohort Analysis.” BMC Nutrition 5, no. 1 (2019/11/20 2019): 54. https://doi.org/10.1186/s40795-019-0323-6

Background  Seasonality poses a considerable food security challenge in Ethiopia. Yet, measuring seasonal variations in food insecurity, particularly the dimension of food access, lacks an adequately validated tool. We therefore evaluated the performance of an adapted Household Food Insecurity Access Scale (HFIAS) to estimate seasonal variations in food insecurity (FI) among subsistence villagers in Ethiopia.

Methods  We employed a cohort study design using a panel of four repeated measurements taken in June, September, and December in the year 2017, and in March 2018. The study recruited 473 villagers from the drought-affected Wolaita area in southwest Ethiopia. The performance of the HFIAS was evaluated via internal consistency (Chronbach’s alpha values) and criterion validation techniques. The set of criteria include: parallelism between affirmative responses to FI questions and wealth strata; dose-response relationship between FI and dietary intake; and also FI severity and household wealth status.

Results  This study revealed that the HFIAS had satisfactory performance in four repeated measurements. The likelihood of affirmative responses to questions about FI decreased with ascending wealth quintiles. We observed an inverse dose-response relationship between FI and wealth status, and between FI and household dietary diversity.

Conclusions  The HFIAS showed an acceptable potential for measuring seasonal variations in FI in the study area. Our findings complement efforts to evaluate the scale’s applicability in various settings, in order to promote cross-culture monitoring and comparisons. However, it required a careful adaption for contextual and cultural sensitivities.

Reducing poverty

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Intervention studies, and especially randomised controlled trials, has been in the health tool box for many years. In medicine, we usually examine one intervention and look at one outcome. About 20 years ago, economists, furthermore, began to use these powerful methods.

Now, this year’s Nobel prize in economics gives an outstanding recognition to Abhijit Banerjee, Indian born professor at Massachusetts Institute of Technology, to Esther Duflo, a French born professor also at MIT, and to Michael Kremer, professor at Harvard University.

Their great achievements are that they introduced randomised controlled trials to obtaining reliable answers about the best ways to fight poverty. They divided the question of reducing poverty into smaller and more manageable, questions – for example, the most effective interventions for improving educational outcomes or child health. They show by doing so, questions are generally best answered via carefully designed experiments among the people who are, for the most part, affected.

In the research that we do, we frequently find that poverty is an underlying cause of a health problem, as can be seen by for example malnutrition. Now, the challenge is to identify smaller steps that could reduce poverty and subsequently malnutrition using their novel concept of breaking the problems into tinier and manageable proportions.

I hope that development agencies and governments, in collaboration with universities, will use such tools to improve their work.

Taye Gari’s PhD thesis: Malaria, anaemia and undernutrition in Ethiopia

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Taye Gari. Malaria, anaemia and undernutrition in a drought-affected area of the Rift Valley of Ethiopia: Experiences from a trial to prevent malaria.  PhD. University of Bergen, 2018. Bergen

Summary of PhD thesis

Background: In Ethiopia, malaria, anaemia and undernutrition are common childhood health problems. The country is planning to reduce these conditions to a level where they are not a public health problem. Meanwhile, for the success of this aim, a description of the occurrence and interaction of malaria, anaemia and undernutrition could help contribute to design tailored, efficient and effective control strategies. This study was done in the context of malaria prevention trial, which aimed to measure the effect of combining long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) in reducing the malaria incidence compared to LLINs or IRS alone. The study area was affected by a serious drought and famine during the first year of the study.

Objectives: The overall aim of this thesis is to improve our understanding of the effect of malaria prevention on anaemia, and to assess the association between malaria, anaemia and undernutrition among children in a drought-affected area in south-central, Ethiopia.

Methods: A cohort of 5309 residents was followed-up for 16 weeks to measure the variations in malaria incidence among villages (Paper I), and the results were used as a baseline to calculate the sample size needed for the trial. We followed a cohort of children aged 6 to 59 months for one year to describe anaemia and changes in haemoglobin (Hb) concentration (Paper II). A cohort of 4468 children was followed-up for 89 weeks to measure the relationship between malaria and undernutrition (Paper III). Weekly home visits and patient self-referral were also used to identify malaria cases. We conducted Hb concentration (once a year) and anthropometry (twice a year) surveys.

Results: In Paper I, we observed a variation in malaria incidence among villages. On the other hand, the insecticide-treated nets ownership was low (27%), with the distance from the lake or river and younger age being the main risk factors for malaria. The findings of this study were used as a baseline to calculate the sample size for the trial. In Paper II, despite the malaria prevention effort in the community, we observed an unexpected increase in anaemia prevalence over the period of a year, which could be due to the drought and famine that affected the area. A higher incidence of anaemia was observed among children with stunting, malaria infection, young age and in poor families. However, no significant difference in anaemia prevalence was observed among the different trial arms (LLIN+IRS, LLINs alone, IRS alone and routine arm). In Paper III, malaria infection was a risk factor for stunting and wasting, although undernutrition was not a risk for malaria infection. Furthermore, an increase in the prevalence of stunting, but no significant change in a prevalence of wasting was observed over time.

Conclusions: We showed a large variation in malaria incidence among villages. Conducting trials in a drought-prone area may bring an unexpected challenge. We observed an unexpected increase in anaemia prevalence over a year. There was no significant difference in anaemia prevalence among the trial arms. Moreover, a close follow-up of the nutritional status of children with malaria infection may be needed. There could hence be a need to prioritize villages nearer to the main mosquito breeding sites for malaria control.

Trial registration: PACTR 201411000882128 (8 September, 2014)

The Thesis can be downloaded here

Malaria, anaemia and undernutrition

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On Friday June 22, 2018 Taye Gari Anaya will defend his PhD thesis at the University of Bergen. 

The title of his thesis is: “Malaria, anaemia and undernutrition in a drought-affected area of the Rift Valley of Ethiopia: Experiences from a trial to prevent malaria”.

Malaria, anaemia and malnutrition are interconnected, and often coexist in prevalent areas such as in sub-Saharan Africa, including Ethiopia. Although individuals in all ages of life are affected by these conditions, children under the age of 5 represent the most vulnerable group. Ethiopia is planning to reduce these conditions to a level where they are not public health problems Meanwhile, for the success of this aim, a description of the occurrence and interaction of malaria, anaemia and undernutrition could help to design tailored, efficient and effective control strategies.  

This thesis measures the effect of malaria prevention on anaemia reduction, and assesses the association between malaria, anaemia and undernutrition among a cohort of children aged 6 to 59 months old followed in a drought-affected rural area in south-central, Ethiopia.

The study showed a large variation in malaria incidence among villages in the same district. Despite community wide malaria prevention effort, an unexpected increase in anaemia prevalence was observed over a year. Malaria infection was a risk factor for undernutrition, although undernutrition was not a risk for malaria infection. There could be a need to prioritise villages nearer to the main mosquito breeding sites for malaria control. Moreover, a close follow-up of the nutritional status of children with malaria infection may be needed. 

Biographical

Taye Gari Ayana is from Hawassa in south Ethiopia. He completed Master degree in Public Health from Addis Ababa University in Ethiopia. From 2013 he has been affiliated with the Centre for International Health as a PhD candidate. Now he is a lecturer at the School of Public Health, at Hawassa University in Ethiopia. His supervisors were Professor Bernt Lindtjørn, Dr Eskindir Loha and Dr Wakgari Deressa. 

Malaria increases the risk of stunting and wasting

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Gari T, Loha E, Deressa W, Solomon T, Lindtjørn B (2018) Malaria increased the risk of stunting and wasting among young children in Ethiopia: Results of a cohort study. PLoS ONE 13(1): e0190983.

Abstract
Introduction  Given the high prevalence of malnutrition in a malaria-endemic setting, improving nutritional status could serve as a tool to prevent malaria. However, the relationship between the two conditions remains unclear. Therefore, this study assessed the association between under-nutrition and malaria among a cohort of children aged 6 to 59 months old.

Methods  Two cohorts of children were followed for 89 weeks in a rural Rift Valley area of Ethiopia. In the first approach (malaria-malnutrition), a cohort of 2,330 non-stunted and 4,204 non-wasted children were included to assess under-nutrition (outcome) based on their previous malaria status (exposure). In the second approach (malnutrition–malaria), a cohort of 4,468 children were followed-up to measure malaria (outcome), taking under-nutrition as an exposure. A weekly home visit was carried out to identify malaria cases. Four anthropometry surveys were conducted, and generalized estimating equation (GEE) method was used to measure the association between undernutrition and malaria.

Results  The prevalence of stunting was 44.9% in December 2014, 51.5% in August 2015, 50.7% in December 2015 and 48.1% in August 2016. We observed 103 cases with 118 episodes of malaria, 684 new stunting and 239 new wasting cases. The incidence rate per 10,000 weeks of observation was 3.8 for malaria, 50.4 for stunting and 8.2 for wasting. Children with malaria infection, [Adjusted Odds Ratio (AOR) = 1.9; 95% Confidence Interval (CI), 1.2–2.9)] and younger age (AOR = 1.3; 95% CI, 1.1–1.5) were more likely to be stunted. Furthermore, children with malaria infection (AOR = 8.5; 95% CI, 5.0–14.5) and young age group (AOR = 1.6; 95% CI, 1.2–2.1) were more likely to be wasted. However, stunting and wasting were not risk factors of subsequent malaria illness.

Conclusions  Malaria infection was a risk factor for stunting and wasting, but stunting or wasting was not associated with subsequent malaria illness. As our study shows that malaria is a risk factor for stunting and wasting, a close follow-up of the nutritional status of such children may be needed.

Maternal depression symptoms are highly prevalent among food-insecure households in Ethiopia

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Gebreyesus SH, Endris BS, Hanlon C, Lindtjorn B: Maternal depression symptoms are highly prevalent among food-insecure households in Ethiopia. Public Health Nutr 2017:1-8.

Objective: We aimed to evaluate the association between household food insecurity and maternal depression in Ethiopia.

Design/Setting/Subjects: In 2014, we conducted a cross-sectional study in southern Ethiopia, including 591 food-secure and 2500 food-insecure households. We measured depression status of women using the Patient Health Questionnaire-9 validated for Ethiopia, with a cut-off of ≥5. We evaluated household-level food insecurity using a validated Household Food Insecurity Access Scale. We applied Bayesian modelling to evaluate the relationship between food insecurity and maternal depression accounting for other observed characteristics.

Results: Among the analytic sample, 80·8 (95 % CI 79·4, 82·2) % of women were living in food-insecure households. The overall prevalence of probable depression (mild and moderate forms) was 4·7 (95 % CI 4·1, 5·6) %. All individual depressive symptoms had a significantly higher prevalence in the food-insecure group, except for suicidal ideation (but small numbers; P < 0·001). In the Bayesian model adjusting for paternal characteristics, there was a significant dose–response linear relationship (trend) between household food insecurity and maternal depression (P<0·01). The adjusted OR (95% Bayesian credible interval) for depression for differing levels of food insecurity were: mild food insecurity, 3·29 (1·63, 6·18); moderate, 3·82 (1·91, 7·45); severe, 12·50 (3·38, 32·70).

Conclusions: The study documented a high burden of depression among women who lived in food-insecure households. Given this finding, we recommend integrating mental health in the livelihood programmes in areas suffering from food insecurity.

Anaemia, drought and malaria in Ethiopia

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Gari T, Loha E, Deressa W, Solomon T, Atsbeha H, Assegid M, Hailu A, Lindtjørn B. (2017) Anaemia among children in a drought affected community in south-central Ethiopia. PLoS ONE 12(3): e0170898. doi:10.1371/journal.pone.0170898

Introduction  As part of a field trial (PACTR201411000882128) to provide evidence on the combined use of long-lasting insecticidal nets and indoor residual spray for malaria prevention, we measured haemoglobin values among children aged 6 to 59 months. The aim of this study was to estimate the prevalence of anaemia, and to determine the risk factors of anaemia and change in haemoglobin value in Adami Tullu district in south-central Ethiopia.

Methods  Repeated cross-sectional surveys among 2984 children in 2014 and 3128 children in 2015; and a cohort study (malaria as exposure and anaemia as outcome variable) were conducted. The study area faced severe drought and food shortages in 2015. Anaemia was diagnosed using HemoCue Hb 301, and children with haemoglobin <11 g/dl were classified as anaemic. Multilevel and Cox regression models were applied to assess predictors of anaemia.

Results  The prevalence of anaemia was 28.2% [95% Confidence Interval (CI), 26.6–29.8] in 2014 and increased to 36.8% (95% CI, 35.1–38.5) in 2015 (P<0.001). The incidence of anaemia was 30; (95% CI, 28–32) cases per 100 children years of observation. The risk of anaemia was high (adjusted Hazard Ratio = 10) among children with malaria. Children from poor families [Adjusted Odds Ratio (AOR); 1.3; 95% CI, 1.1–1.6)], stunted children (AOR 1.5; 95% CI; 1.2–1.8), and children aged less than 36 months (AOR; 2.0; 95% CI, 1.6–2.4) were at risk of anaemia compared to their counterparts. There was no significant difference in risk of anaemia among the trial arms.

Conclusions  Young age, stunting, malaria and poverty were the main predictors of anaemia. An increase in the prevalence of anaemia was observed over a year, despite malaria prevention effort, which could be related to the drought and food shortage. Therefore, conducting trials in settings prone to drought and famine may bring unexpected challenges.

Clustering of chronic malnutrition among Ethiopian children

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journal-pone-0170785-g001Hagos S, Hailemariam D, WoldeHanna T, Lindtjørn B (2017) Spatial heterogeneity and risk factors for stunting among children under age five in Ethiopia: A Bayesian geo-statistical model. PLOS ONE 12(2): e0170785. doi: 10.1371/journal.pone.0170785

Background  Understanding the spatial distribution of stunting and underlying factors operating at meso-scale is of paramount importance for intervention designing and implementations. Yet, little is known about the spatial distribution of stunting and some discrepancies are documented on the relative importance of reported risk factors. Therefore, the present study aims at exploring the spatial distribution of stunting at meso- (district) scale, and evaluates the effect of spatial dependency on the identification of risk factors and their relative contribution to the occurrence of stunting and severe stunting in a rural area of Ethiopia.

Methods  A community based cross sectional study was conducted to measure the occurrence of stunting and severe stunting among children aged 0–59 months. Additionally, we collected relevant information on anthropometric measures, dietary habits, parent and child-related demographic and socio-economic status. Latitude and longitude of surveyed households were also recorded. Local Anselin Moran’s I was calculated to investigate the spatial variation of stunting prevalence and identify potential local pockets (hotspots) of high prevalence. Finally, we employed a Bayesian geo-statistical model, which accounted for spatial dependency structure in the data, to identify potential risk factors for stunting in the study area.

Results  Overall, the prevalence of stunting and severe stunting in the district was 43.7% [95%CI: 40.9, 46.4] and 21.3% [95%CI: 19.5, 23.3] respectively. We identified statistically significant clusters of high prevalence of stunting (hotspots) in the eastern part of the district and clusters of low prevalence (cold spots) in the western. We found out that the inclusion of spatial structure of the data into the Bayesian model has shown to improve the fit for stunting model. The Bayesian geo-statistical model indicated that the risk of stunting increased as the child’s age increased (OR 4.74; 95% Bayesian credible interval [BCI]:3.35–6.58) and among boys (OR 1.28; 95%BCI; 1.12–1.45). However, maternal education and household food security were found to be protective against stunting and severe stunting.

Conclusion  Stunting prevalence may vary across space at different scale. For this, it’s important that nutrition studies and, more importantly, control interventions take into account this spatial heterogeneity in the distribution of nutritional deficits and their underlying associated factors. The findings of this study also indicated that interventions integrating household food insecurity in nutrition programs in the district might help to avert the burden of stunting.

 

 

New information about malnutrition in Ethiopia

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Seifu-thesis coverNew PhD: On September 16, Seifu Hagos Gebreyesus from Ethiopia, shall defend his PhD work at the University of Bergen:

Spatial variations in child undernutrition in Ethiopia: Implications for intervention strategies

Summary

Background: Ethiopia is one of the countries with the highest burden of undernutrition, with rates of stunting and underweight as high as 40% and 25%, respectively. National efforts are underway for an accelerated reduction of undernutrition by the year 2030. However, for this to occur, understanding the spatial variations in the distribution of undernutrition on a varying geographic scale, and its determinants will contribute a quite a bit to enhance planning and implementing nutrition intervention programmes.

Objectives: The aim of this thesis was to evaluate the large- and small-scale spatial variations in the distribution of undernutrition indicators, the underlying processes and the factors responsible for the observed spatial variations.

Methods: We used nationally available climate and undernutrition data to evaluate the macro-scale spatial pattern of undernutrition and its determinants. We applied a panel study design, and evaluated the effect of growing seasonal rainfall and temperature variability on the macro-scale spatial variations (Paper I). We conducted a repeated cross- sectional survey to assess the performance of the Household Food Insecurity Access Scale (HFIAS) developed internationally to measure household food insecurity. The results from this validation work were used to modify the HFIAS items for subsequent papers (Papers III and IV). We conducted a census on six randomly selected kebeles to evaluate the spatial patterns of undernutrition on a smaller scale (Paper III). For Paper IV, we conducted a cross-sectional survey on a representative sample, and employed a Bayesian geo-statistical model to help identify the risk factors for stunting, thereby accounting for the spatial structure (spatial dependency) of the data.

Results: In Paper I, we demonstrated spatial variations in the distribution of stunting across administrative zones in the country, which could be explained in part by rainfall. However, the models poorly explained the variation in stunting within an administrative zone during the study period. We indicated that a single model for all agro-ecologic zones may not be appropriate. In Paper II, we showed that the internal consistency of the HFIAS’ tools, as measured by Cronbach’s alpha, was adequate. We observed a lack of reproducibility in HFIAS score among rural households. Therefore, we modified the HFAIS tool, and used it for subsequent surveys in this thesis (Papers III and IV). In Paper III, spatial clustering on a smaller scale (within a kebele) was found for wasting and severe wasting. Spatial clustering on a higher scale (inter-kebele) was found for stunting and severe stunting. Children found within the identified cluster were 1.5 times more at risk of stunting, and nearly five times more at risk of wasting, than children residing outside this cluster. In Paper IV, we found a significant spatial heterogeneity in the distribution of stunting in the district. Using both the local Anselin Moran’s I (LISA) and the scan statistics, we identified statistically significant clusters of high value (hotspots) and a most likely significant cluster for stunting in the eastern part of the district. We found that the risk of stunting was higher among boys, children whose mother or guardian had no education and children who lived in a food-insecure household. We showed that including a spatial component (spatial structure of the data) into the Bayesian model improved the model fit compared with the model without this spatial component.

Conclusion: We demonstrated that stunting and wasting exhibited a spatial heterogeneity, both on a large and small scale, rather than being distributed randomly. We demonstrated that there is a tendency for undernourished cases (stunting and wasting) to occur near each other than to occur homogeneously. We demonstrated a micro-level spatial variation in risk and vulnerability to undernutrition in a district with a high burden of undernutrition. Identifying such areas where a population at risk lives is central in assisting a geographical targeting of intervention. We recommend further study, possibly using a trial design or implementation research approach, to help evaluate the feasibility and benefits of geographically targeting nutritional interventions.

The thesis can be downloaded here.