Accelerating Nutrition Improvements
in sub-Saharan Africa (ANI)
Report of the baseline and end-line
perception surveys in
ten countries
Accelerating Nutrition Improvements in sub-Saharan Africa (ANI)
Report of the baseline and end-line perception surveys in
ten countries
Accelerating nutrition improvements in sub-Saharan Africa (ANI): report of the baseline and end-line perception surveys in ten countries
ISBN 978-92-4-151208-4
© World Health Organization 2017
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REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES
Contents
Acknowledgements vii
Abbreviations viii
Executive Summary iv
I. Introduction 1
II. Methods 2
Survey tools 2
Timing of surveys 2
Implementation of surveys in countries 3
Global level analyses 3
Assessment of the ANI PMF indicators 3
PMF Intermediate outcome 1300: Awareness of the country’s nutrition situation 3 PMF Immediate outcome 1120: Government capacity for nutrition surveillance 3 PMF Immediate outcome 1220: Health workers’ capacity to deliver nutrition
interventions 5
PMF Intermediate outcome 1100: Health workers’ capacity and confidence to
do nutrition surveillance 5
III. Results 6
Responses 6
Perception of the nutrition situation and priorities in countries 6 Awareness of Global Nutrition Target-related problems in countries 6 Awareness of nutrition problems and causes beyond the Global Nutrition Targets 8
Government priority for nutrition 15
Perception of nutrition surveillance 17
Government capacity for nutrition surveillance 17
Nutrition data being collected 20
Use of nutrition data 20
Perception of health worker capacity for delivering nutrition services and performing
nutrition surveillance 20
Health workers’ capacity to deliver nutrition interventions 20
Health worker training 24
Health workers’ capacity and confidence to do nutrition surveillance 26
Summary of survey results 27
IV. Discussion and conclusion 29
V. References 30
iv
ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
List of Tables
Table 1. Questionnaire tools, target groups and recommended sample sizes per country 2 Table 2. Country data related to the 2025 Global Nutrition Targets: prevalence and year 4 Table 3. Cut-off values used to determine country-relevant nutrition problems 5
Table 4. Number of respondents by respondent group 7
Table 5. Summary of baseline and end-line values for ANI PMF perception indicators 28 List of Figures
Figure 1. Indicator 1300: Awareness of a majority of country-relevant problems
related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media,
by country (n= 450 at baseline, 298 at end-line) 8
Figure 2. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development
practitioners and media, by country (n= 450 at baseline, 298 at end-line) 9 Figure 3. Problems related to the Global Nutrition Targets as perceived by respondents
representing government at national and district level, development practitioners and media, by type of respondent (n= 450 at baseline, 298 at
end-line) 10
Figure 4. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development
practitioners and media (n= 450 at baseline, 298 at end-line) 11 Figure 5. Problems related to child undernutrition, undernutrition in women, overweight
and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development
practitioners and media, by country (n= 450 at baseline, 298 at end-line) 12 Figure 6. Causes of nutrition problems as perceived by respondents representing
government at national and district level, development practitioners and
media (n= 450 at baseline, 298 at end-line) 13
Figure 7. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and
media, by country (n= 450 at baseline, 298 at end-line) 14 Figure 8. Government priority for nutrition as perceived by all respondents in ten
countries at baseline and in three countries at end-line (n=767 at baseline,
167 at end-line) 15
Figure 9. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by country
(n=767 at baseline, 167 at end-line) 16
Figure 10. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by type of respondent
(n=767 at baseline, 167 at end-line) 16
Figure 11. Health workers’ perception of priority given to nutrition by decision-makers and by themselves in their daily work in ten countries at baseline and in three
countries at end-line (n=317 at baseline, 61 at end-line) 17
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES Figure 12. Indicator 1120: Perceived “high” or “very high” government capacity for
nutrition surveillance as reported by respondents representing government at national and district level and development practitioners, by country
(n=395 at baseline, 298 at end-line) 17
Figure 13. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development
practitioners, by country (n=395 at baseline, 298 at end-line) 18 Figure 14. Government capacity for nutrition surveillance as perceived by respondents
representing government at national and district level and development
practitioners, by type of respondent (n=395 at baseline, 298 at end-line) 19 Figure 15. Government capacity for various aspects of nutrition surveillance as perceived
by respondents representing government at national and district level and
development practitioners (n=395 at baseline,298 at end-line) 19 Figure 16. Collection of Global Nutrition Target indicators as reported by government
respondents at national and district levels and health workers (n=615) 20 Figure 17. Collection of 2025 Global Nutrition Target indicators as reported by government
at national and district levels and health workers, by country (n=615) 21 Figure 18. Uses of nutrition data collected as reported by government respondents
at national and district levels (n=298) 21
Figure 19. Perception of nutrition information as reported by media respondents (n=55) 22 Figure 20. Indicator 1220: Correct knowledge on at least six out of eight questions
related to the delivery of nutrition services among health workers in the three
scale-up countries, by country (n=115 at baseline, 79 at end-line) 22 Figure 21. Correct knowledge on delivery of various nutrition services, as reported health
workers in the three scale-up countries, by country (n=115 at baseline,
79 at end-line) 23
Figure 22. Training and perceived training needs among health workers in ten countries
at baseline (n=317) 24
Figure 23. Health worker knowledge of and confidence to carry out IYCF intervention
in ten countries at baseline, by breastfeeding training status (n=317) 25 Figure 24. Health worker knowledge of and confidence to manage SAM in ten countries at
baseline, by SAM management training status (n=317) 26
Figure 25. Indicator 1100: Confidence in most or every aspect of implementing four nutrition surveillance activities as perceived by health workers in ten countries,
by country (n=317) 26
Figure 26. Confidence in implementing four nutrition surveillance activities as perceived by health workers in ten countries, by nutrition surveillance training status (n=317) 27 Figure 27. Health worker knowledge about WHO Growth Standards in ten ANI countries,
by nutrition surveillance training status (n=317) 27
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES
Acknowledgements
The development of the perception surveys and preparation of this report were led by Ms Kaia Engesveen with technical inputs and support from Dr Hana Bekele, Dr Férima Coulibaly-Zerbo and Dr Elisa Dominguez. Appreciation is extended to the larger WHO team, including Ms Monika Bloessner, Dr Francesco Branca, Dr Mercy Chikoko, Dr Chizuru Nishida, Dr Mercedes de Onis, Dr Adelheid Onyango and Ms Krista Zillmer, as well as to the WHO interns who supported the development of the survey tools and preparation of the report including Ms Ana Elisa Pineda, Ms Einat Schmutz, Ms Paula Veliz and Ms Line Vogt. WHO gratefully recognizes the work of Dr Jessica Fanzo (Johns Hopkins Bloomberg School of Public Health) who developed guidance for using the Performance Monitoring Framework of the project.
Special thanks are also due to the WHO country office colleagues and their national counterparts who led the surveys:
■
■ Burkina Faso: Dr Fousséni Dao (WHO), Ms Bertine Ouaro Dabiré and Mr Saidou Kabore (Ministère de la Santé)
■
■ Ethiopia: Ms Etsegenet Assefa, Dr Kemeria Barsenga and Mr Getahun Teka Beyene (WHO), Ms Mulu Gebremedhin (John Snow, Inc.), Ms Yordanos Giday Hagos and Mr Birara Melese Yalew (Federal Ministry of Health)
■
■ Mali: Dr Seybou Guindo (Ministère de la Santé), Dr Mohamed Ibrahim (Ministère de la Santé) and Dr Attaher Houzeye Toure (WHO)
■
■ Mozambique: Dr Marla Amaro (Ministry of Health) and Dr Daisy Trovodada (WHO)
■
■ Senegal: Dr Maty Diagne Camara (Ministère de la Santé et de l’Action Sociale), Mr Ndiaye Djibril (consultant) and Dr Fatim Tall (WHO)
■
■ Sierra Leone: Dr Aminata Shamit Koroma and Dr Solade Pyne-Bailey (Ministry of Health and Sanitation) and Ms Hannah Yankson (WHO)
■
■ Uganda: Dr Baku Agnes Chandia and Dr Mwebembezi Edmond (Ministry of Health), Dr Priscilla Ravonimanantsoa (WHO), Mr Ssesanga Steven (MOH), Dr Bakunzi Maureen Tumusiime (Office of the Prime Minister) and Dr Florence Turyashemererwa-Biko (WHO)
■
■ United Republic of Tanzania: Dr Isiaka Stevens Alo (WHO), Ms Mwashiga Augustino (Save the Children Fund Tanzania), Mr Gilagister Gwarassa (Tanzania Food and Nutrition Center), Mr Juma Peter Kaswahili (Ministry of Health and Social Welfare), Ms Rachel Alice Makunde (Save the Children Fund Tanzania), Mr Samson Ndimaga (TFNC)
■
■ Zambia: Ms Agnes Aongola (Ministry of Health), Ms Chipo Misodzi Mwela (WHO) and Ms Dorothy Sikazwe (Ministry of Health)
■
■ Zimbabwe: Mr Admire Chinjekure and Dr Trevor Kanyowa (WHO), Mr Joshua Katiyo (Ministry of Health) and Mr Nyadzayo Tasiana (Ministry of Health)
viii
ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
Abbreviations
ANI Accelerating Nutrition Improvements in sub-Saharan Africa CSO Civil society organization
DHS/EDS Demographic and Health Survey/Enquête Démographique et de Santé IYCF Infant and young child feeding
MAM Moderate acute malnutrition MICS Multiple Indicator Cluster Survey NGO Nongovernmental organization PMF Performance Monitoring Framework SAM Severe acute malnutrition
SMART Standardized Monitoring and Assessment of Relief and Transitions
UN United Nations
WHO World Health Organization
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES
Executive Summary
The Accelerating Nutrition Improvements in sub-Saharan Africa (ANI) project, implemented during the period 2013–2016, focused on strengthening nutrition surveillance in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe). The project was supported by Global Affairs Canada and was implemented in close collaboration between the ministry of health, the World Health Organization (WHO) and local partners in respective countries.
The progress of the ANI project was assessed using a Performance Monitoring Framework (PMF), which was developed in the beginning of the project. The PMF consisted of a set of quantitative and qualitative indicators with specific project performance targets to be reached during the implementation period. Four of the qualitative indicators were related to the perceptions and capacities of stakeholders:
1. Stakeholders’ awareness of the country’s nutrition situation (target: 50%) 2. Government capacity to collect and analyse nutrition data (target: 70%) 3. Health workers’ capacity to deliver nutrition interventions (target: 75%)
4. Health workers’ capacity and confidence to carry out nutrition surveillance (target: 50%).
Information on these four indicators was gathered through “perception surveys” at the beginning and end of the project by each of the country teams. Five questionnaires were used to assess the perceptions of national and district level government representatives, development practitioners, health workers and media. Algorithms were created for aggregating the perception survey results into one indicator value per country.
This report presents the results of 767 baseline and 498 end-line interviews in ten countries, and the level of achievement of the project performance targets on the four perception and capacity indicators. Rwanda was not included in the analysis, due to the timing of their interventions.
The results of the perception surveys show that important perception and capacity changes can be achieved among government officials, health workers and other stakeholders in a relatively short but intense period. For instance, seven out of ten countries attained the project performance target related to awareness of the country’s nutrition situation. While stakeholders were most familiar with the problems of stunting and wasting, the awareness of problems related to anaemia, low birth weight, overweight and low rates of exclusive breastfeeding increased over the project period.
Health workers’ perceptions of their capacity for delivering nutrition services and performing nutrition surveillance also increased over the project period. In all three countries supported to implement scaling-up of nutrition actions (Ethiopia, Uganda and the United Republic of Tanzania), health workers’ capacity to deliver nutrition interventions, such as infant and young child feeding counselling and the management of severe acute malnutrition, was strengthened. Furthermore, in seven out of ten countries, health workers’ capacity and confidence to perform nutrition surveil- lance increased.
On the other hand, no country reached the project performance target concerning government capacity for nutrition surveillance. This may be attributable to the fact that the survey assessed
x
ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
stakeholders’ perceptions of government capacity rather than the government’s actual capacity to conduct nutrition surveillance. Overall, government capacity for undertaking surveys was perceived higher than the capacity for conducting routine data collection.
The perception surveys can serve as important tools for assessing stakeholders’ understanding and views on nutrition problems being faced in their communities, districts or countries as well as their capacity to address those problems. This, in turn, will help to identify required actions to guide the delivery of nutrition interventions.
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES
I. Introduction
The Accelerating Nutrition Improvements in sub-Saharan Africa (ANI) project, implemented during the period 2013–2016, had three components:
■
■ strengthening of nutrition surveillance in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe);
■
■ carrying out nutrition surveys in four countries (Rwanda, Sierra Leone, Zambia and Zimbabwe);
and
■
■ scaling up nutrition interventions in three countries (Ethiopia, Uganda and the United Republic of Tanzania).
The ANI project was supported by Global Affairs Canada and was implemented in close collaboration between the ministry of health, the World Health Organization (WHO) and local partners in respective countries.
The progress of the ANI project was assessed using a Performance Monitoring Framework (PMF), developed in the beginning of the project implementation period. The framework consists of a set of quantitative and qualitative indicators, of which four concern the perceptions and capacities of different stakeholders:
1. Policy-makers, development practitioners, and media with awareness of the country’s nutrition situation, and an understanding/conviction that nutrition is a national priority for investment.
2. Government capacity to collect and analyse nutrition data collected from the surveys (those who perceive they have the knowledge and skills to collect and analyse the data).
3. Health workers’ capacity to deliver nutrition interventions to women and children in ANI districts (who perceive that their knowledge and skills have improved).
4. Health workers’ perception of their capacity (and confidence) to carry out nutrition surveillance.
Information on these indicators was collected through surveys at baseline and end-line of the project. Ten of the eleven ANI countries performed the full survey at baseline and an abbreviated version at end-line. One country, Rwanda, carried out the baseline survey in October 2015 after having implemented various capacity building activities and thus did not conduct an end-line survey.
This report presents the results of the surveys, hereafter referred to as “perception surveys”, in ten countries.
2
ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
II. Methods
The perception surveys were developed based on the WHO Landscape Analysis country assessment tools and methodology,1 which have been applied in 19 countries2 to date. A detailed description of the methodology, including sampling and interview techniques, can be found in the ANI PMF Guide (WHO, 2014).
Survey tools
The survey tools consisted of five questionnaires (Table 1), with corresponding data entry sheets.
All five questionnaires were used to collect data at baseline, while shorter versions of four of the questionnaires3 were used at end-line. Recommended sample sizes remained the same at baseline and end-line.
Table 1. Questionnaire tools, target groups and recommended sample sizes per country
QUESTIONNAIRE TOOL EXAMPLE OF TARGET GROUP RESPONDENTS RECOMMENDED SAMPLE SIZE 1. National level government Director of Nutrition Programme, Director of
Health Promotion Department, Director of Food
Security and Nutrition, School Health Manager 10–15 2. Development practitioners UN, NGOs, CSOs and donors 10 3. Media Journalists, writers, television and radio
producers/creators, press 5
4. District level government
District Health Manager, District Chief Health Officer, District Agriculture Extension Supervisor, local authorities involved in decisions on nutrition issues
10
5. Health workers Community health worker, midwife, child health
nurse 20
Timing of surveys
The baseline perception surveys were conducted between April 2014 and February 2015, and the end-line surveys between May and October 2016. As far as possible, the baseline perception surveys were carried out through integration into other planned surveys or activities to avoid creating an additional burden for the countries. For example, in Uganda and the United Republic of Tanzania, they were conducted in conjunction with district assessments, and in Ethiopia. they were carried out along with a pilot coverage survey and a surveillance gap assessment.
1 http://www.who.int/nutrition/landscape_analysis/country_assessment_methodology/en/
2 http://www.who.int/nutrition/landscape_analysis/country_assessments_summaries/en/
3 Questionnaires 1,2,4 and 5. Questionnaire 3, directed towards media, was not repeated as none of the countries implemented specific activities addressing media in the context of the ANI project.
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES
Implementation of surveys in countries
In all countries, the assessment team was led by national government staff and supported by WHO and partners. Country teams adapted the tools to suit the local health services and infrastructure as well as the public administrative realities, selected target respondents and sites, trained data collection teams, collected the data and performed country analyses and reporting. Many countries also presented the results at national stakeholder meetings.
Global level analyses
Data from all countries were cleaned, harmonized and merged at the global level by WHO headquarters. Analyses included descriptive statistics and assessment of the four ANI PMF indicators, which were subsequently included in the ANI PMF baseline and end-line reports.
Assessment of the ANI PMF indicators
Assessing the four perception indicators required creating algorithms for aggregating the rich perception survey datasets into one indicator value per country.
PMF Intermediate outcome 1300: Awareness of the country’s nutrition situation
Awareness of the country’s nutrition situation was assessed through open-ended questions to national and district level stakeholders. Responses were coded straightaway into previously defined categories related to nutrition problems and their immediate, underlying and basic causes.
Perceptions related to the priority given to nutrition by the government were also assessed.
This indicator was defined as the proportion of stakeholders surveyed who are aware of the nutrition situation, and had a target of 50% (WHO, 2014). The algorithm to estimate the indicator was defined as the proportion of stakeholders who mentioned more than half of the existing Global Nutrition Target-related nutrition problems in their country. In other words, awareness around any one Global Nutrition Target was only considered if this constituted a problem in the country. To determine whether a country had a Global Nutrition Target-related problem or not, data from the most recent national surveys available in countries were assessed against established cut-off values (for stunting, wasting and anaemia), cut-off values derived from the global target (overweight and exclusive breastfeeding), or those used in previous similar analyses (low birth weight) (Table 2 and Table 3). Individual responses were analysed to count the number of existing Global Nutrition Target-related problems mentioned in their countries, and the ANI PMF indicator was calculated as the proportion of stakeholders who mentioned more than half of these problems.
PMF Immediate outcome 1120: Government capacity for nutrition surveillance
The survey questionnaires explored various aspects of capacity for conducting nutrition surveillance at national, district and health facility levels. Information was gathered on data collection, flow between different levels, reporting and use in routine surveillance and in surveys. Respondents were also asked how they perceived and would rate government capacity to collect, analyse and report nutrition survey and routine data.
This indicator was defined as the proportion of government respondents who have the capacity to do surveillance, and had a target of 70% (WHO, 2014). However, clearly not all individual government respondents at national and district levels need to have skills to collect and analyse nutrition data.
Therefore, rather than focusing on individual capacity, the algorithm was defined as the proportion of high or very high ratings of government capacity to perform any of the aspects of nutrition surveillance.
4
ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
Ta bl e 2 . Co un tr y d at a r el at ed t o t he 2 02 5 G lo ba l N ut riti on T ar ge ts : pre va le nce a nd y ea r
Red colour indicates that the value is within the cut-off level used for indicating a nutrition problem. Burkina FasoEthiopiaMaliMozambiqueSenegalSierra LeoneUgandaUnited Republic of TanzaniaZambiaZimbabweBas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Bas elin e
End -lin e
Stunting31.5% (2013)30.2% (2015)44% (2011)38.4% (2016)27.5% (2013)23.1% (2016)43% (2011)43% (2011)18.7% (2013)19.4% (2014)34.1% (2010)28.8% (2014)33.4% (2011)34.0% (2011)42% (2010)34.0% (2015)40% (2013)40.0% ZAM32% (2010–2011)27% (2015) Anaemia49.5% (2010)61.9% (2014)17% (2011)23% (2016)51.4% (2012)51.4% (2012)52.4% (2011)52.4% (2011)54% (2013)54% (2013)45% (2008)45% (2013)23% (2011)23% (2011)40 % (2010)45 % (2015)29.2% (2011)29.2% (2011)28% (2010–2011)27% (2015) Low birth weight10.3% (2013)9.8% (2014)
11% (2011)
11% (2018% 16% 14%14%1.3% 1.3% 11% 7% 10.2%10.2 %7%7% 9%9%10%10% 11)(2010)(2012)(2011)(2011)(2014)(2014)(2008)(2013)(2011)(2011)(2010)(2015)(2013)(2013)(2010–2011)(2015) 2% 1% 1.7%2.8%4.7% 4.7% 7.1%7.1%1.4% 0.3% 8.4% 7.5% 3.4%3.4%5%4%1%1%6%6% Overweight (2014)(2015)(2011)(2016)(2010)(2010)(2011)(2011)(2013)(2016)(2008)(2013)(2011)(2011)(2010)(2015)(2013)(2013)(2010–2011)(2015) Exclusive 47.2% 46.7% 52% breastfeeding(2013)2015)(2011)
58% (2033% 33% 41%41%38% 33% 32% 58% 63%63%50%59%73%73%31% 16)(2012)(2012)(2011)(2011)(2013)(2015)(2010)(2014)(2011)(2011)(2010)(2015)(2013)(2013)(2010–2011)
48% (2015) 8.2% 10.4% 10%9.9%8.6% 11.5% 6.7%6.7%8.7% 5.8% 6.9% 4.7% 4.7%4.7%4.8%4.5%6%6%3%3% Wasting (2013)(2015)(2011)(2016)(2013)(2016)(2011)(2011)(2013)(2014)(2010)(2014)(2011)(2011)(2010)(2015)(2013)(2013)(2010–2011)(2015) Data sources: Burkina Faso: Stunting, overweight, wasting, exclusive breastfeeding from Standardized Monitoring and Assessment of Relief and Transitions (SMART) surveys 2013, 2104 and 2015; anaemia among women of reproductive age from Demographic and Health Survey (DHS – Enquête démographique et de santé (EDS)) 2010 and from Iodine and anaemia nutrition survey (Enquête nutritionnelle iode et anémie Burkina Faso (ENIAB)) 2014; low birth weight from annual statistic bulletin (annuaire statistique) 2013 and 2014. Ethiopia: DHS 2011, DHS 2016. Mali: Stunting, wasting from SMART surveys 2013 and 2016; anaemia among women of reproductive age and exclusive breastfeeding from DHS 2012; low birth weight from Multiple Indicator Cluster Survey (MICS) 2010 and DHS 2012; overweight from DHS 2010. Mozambique: DHS 2011. Senegal: Stunting, low birth weight, overweight, wasting from continuous DHS (EDS continue) 2013 and 2014 and ANI sentinel surveillance 2016; anaemia among women of reproductive age from National survey on food security and nutrition (Enquête nationale sur la sécurité alimentaire et la nutrition (ENSAN)) 2013; exclusive breastfeeding from continuous DHS (EDS continue) 2013 and 2015. Sierra Leone: Stunting, exclusive breastfeeding and wasting from Sierra Leone Nutrition Survey (SLNS) 2010 and 2014; anaemia among women of reproductive age, low birth weight and overweight from DHS 2008 and 2013. Uganda: DHS 2011 except for anaemia which is prevalence estimate for 2011 published by WHO (2015): The global prevalence of anaemia in 2011. United Republic of Tanzania: DHS 2010, DHS 2015. Zambia: DHS 2013. Zimbabwe: DHS 2010-11, DHS 2015.
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES PMF Immediate outcome 1220: Health workers’ capacity to deliver nutrition
interventions
To assess health workers’ capacity to deliver nutrition interventions in the three countries that were supported to scale up nutrition actions, the survey explored health workers’ knowledge of and confidence to deliver essential nutrition actions, their training and their perceived adequacy of time to provide nutrition services.
This indicator was defined as the proportion of health workers surveyed who perceive that they have the knowledge to deliver nutrition services, and had a target of 75% (WHO, 2014). The algorithm for this indicator was set as the proportion of health workers who answered correctly a minimum of six out of eight knowledge questions, concerning the delivery of micronutrient supplementation to pregnant women, early initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding, HIV and breastfeeding, timely introduction of complementary feeding, hospital-based management of severe acute malnutrition (SAM), and promotion of healthy diets and lifestyles.
PMF Intermediate outcome 1100: Health workers’ capacity and confidence to do nutrition surveillance
Health workers’ capacity and confidence to do nutrition surveillance was assessed by their knowledge of and confidence around growth monitoring and anthropometry, their training and their perceived adequacy of time to conduct nutrition surveillance.
This indicator was defined as the proportion of health workers who feel confident to do nutrition surveillance, and had a target of 50% (WHO, 2014). The algorithm for this indicator was set as the proportion of health workers who feel confident about most or every aspect of carrying out conventional nutrition surveillance activities, for example taking anthropometric measurements, plotting and interpreting growth charts, completing child health cards and analysing nutrition data.
Table 3. Cut-off values used to determine country-relevant nutrition problems
GLOBAL NUTRITION
TARGET CUT-OFF
VALUE USED SIGNIFICANCE/REASON REFERENCE
Stunting ≥ 20% Level of public health significance (WHO, 1995)
Anaemia ≥ 20% Moderate or severe problem (WHO, 2008)
Low birth weight ≥ 10% Used in previous similar analyses (WHO, 2013) Child overweight ≥ 7% Represents a higher rate than the global level
baseline (WHO, 2014)
Exclusive
breastfeeding < 50% Represents a non-attainment of global target (WHO, 2014)
Wasting ≥ 5% Unacceptable level (WHO, 1995)
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ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
III. Results
Responses
A total of 767 baseline and 498 end-line interviews were conducted with stakeholders at national, district and facility levels (Table 4). Nine countries reached most of the recommended sample sizes described at baseline (three countries met all), whereas six countries met most of the recommended sample sizes at end-line (five countries met all). The higher number of interviews at baseline was mainly due to very large sample sizes among district officials and health workers in two countries (Uganda and Zambia); these were more than four times the recommended sample sizes.
Perception of the nutrition situation and priorities in countries Awareness of Global Nutrition Target-related problems in countries
At baseline, four countries (Ethiopia, Mali, Mozambique and the United Republic of Tanzania) had already reached the target of 50% or more of respondents being aware of more than half of the relevant Global Nutrition Target-related problems in their countries, while at end-line this had increased to seven countries (Burkina Faso, Ethiopia, Mali, Senegal, Sierra Leone, the United Republic of Tanzania and Zambia) (Figure 1). Awareness more than doubled in three countries (Burkina Faso, Sierra Leone and Zambia), whereas in four countries (Mali, Mozambique, Uganda and Zimbabwe) there was a decrease in awareness of country-relevant problems.
Stunting was perceived as a problem by a majority of respondents in all countries at both baseline and end-line (Figure 2), including in Senegal where national stunting rates were just below the 20%
cut-off value for public health significance. Wasting was mentioned as a problem by a majority of respondents in most countries at both baseline and end-line. Exceptions were Uganda, the United Republic of Tanzania and Zimbabwe where the wasting rates were below the 5% cut-off value for acceptable prevalence. At end-line, a majority of respondents in four countries (Ethiopia, Sierra Leone, the United Republic of Tanzania and Zambia) reported anaemia as a key problem in their countries. Low birth weight and overweight were perceived as nutrition problems by fewer than 25% of respondents in most countries at baseline and in many countries at end-line. Anaemia, low birth weight, overweight and exclusive breastfeeding were perceived as problems more than twice as often at end-line compared to baseline in four countries (Burkina Faso, Ethiopia, Sierra Leone and Zambia).
All respondent groups interviewed at both baseline and end-line (government, development practitioners and district level stakeholders) mentioned more problems related to the Global Nutrition Targets at end-line than baseline (Figure 3). Low birth weight, overweight and exclusive breastfeeding were mentioned more than twice as often by government and district officials at end-line than at baseline; mention of wasting remained stable. Media respondents, who were only interviewed at baseline, generally mentioned problems related to the Global Nutrition Targets less frequently than other respondents.
REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES
Table 4. Number of respondents by respondent group
Green colour indicates that the recommended sample size was reached.
1. GOVERNMENT 2. DEVELOPMENT PRACTITIONER 3. MEDIA 4. DISTRICT 5. HEALTH WORKER TOTAL
BASELINE
Burkina Faso 17 10 6 10 20 63
Ethiopia 12 16 5 8 12 53
Mali 13 11 6 11 20 61
Mozambique 8 10 4 7 15 44
Senegal 18 11 5 9 18 61
Sierra Leone 11 15 5 13 22 66
Uganda 6 8 5 39 71 129
United Republic of Tanzania 5 0 5 16 32 58
Zambia 1 9 8 55 82 155
Zimbabwe 6 7 6 33 25 77
Baseline subtotal 97 97 55 201 317 767
END-LINE
Burkina Faso 24 11 – 12 22 69
Ethiopia 10 10 – 10 20 50
Mali 10 10 – 10 20 50
Mozambique 3 5 – 5 7 20
Senegal 10 9 – 10 19 48
Sierra Leone 11 15 – 13 22 61
Uganda 5 10 – 13 34 62
United Republic of Tanzania 10 11 – 12 25 58
Zambia 4 7 – 11 11 33
Zimbabwe 5 7 – 15 20 47
End-line subtotal 92 95 – 111 200 498
Grand Total 189 192 55 312 517 1 265
8
ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)
Figure 1. Indicator 1300: Awareness of a majority of country-relevant problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line)
Awareness of nutrition problems and causes beyond the Global Nutrition Targets
Among all respondents in all the countries, problems related to child undernutrition were most commonly mentioned, followed by vitamin and mineral deficiencies and by undernutrition among women (Figure 4). Whereas 96% of respondents mentioned child undernutrition as a problem in their countries, they generally referred to stunting and wasting. Only 19% specified low birth weight at baseline; this increased to 43% at end-line. Similarly, whereas more than 50% of respondents mentioned undernutrition among women as a problem in their countries, they generally referred to anaemia or underweight. Short stature in women was only mentioned by 6% of respondents at baseline, which increased to 18% at end-line. Reference to low birth weight, short stature among women, overweight in children and adults, iodine deficiency and vitamin A deficiency more than doubled between baseline and end-line.
Perception of all main problem groups (child undernutrition, undernutrition among women, overweight and obesity, and vitamin and mineral deficiencies) increased in five countries (Burkina Faso, Ethiopia, Sierra Leone, the United Republic of Tanzania and Zambia) from baseline to end- line (Figure 5). The proportions more than doubled for overweight and obesity in four countries (Burkina Faso, Ethiopia, Sierra Leone and Zambia), for undernutrition in women in three countries (Ethiopia, the United Republic of Tanzania and Zambia) and for vitamin and mineral deficiencies in two countries (Burkina Faso and Zambia).
The most commonly mentioned causes of nutrition problems were food insecurity, lack of knowledge, inadequate infant and young child feeding (IYCF) and caring practices, disease burden, poverty and insufficient health services or unhealthy environments (Figure 6 and Figure 7).
Perception of a causal relationship between nutrition problems and the lack of recommended breastfeeding practices, inadequate sanitation, inadequate hygiene, unclean water, increasing food prices, malaria and disasters increased by more than two-fold between baseline and end-line.
13
40% 54% 54% 66% 42% 41% 41% 69% 47% 29%
98% 97% 50% 46% 62% 97% 29% 97% 100% 26%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Burkina Faso
(n=43; 47) Ethiopia
(n=41; 30) Mali (n=41;
30) Mozambique (n=29; 13) Senegal
(n=43; 29) Sierra Leone
(n=44; 39) Uganda
(n=58; 28) United Republic of
Tanzania (n=26; 33)
Zambia
(n=73; 22) Zimbabwe (n=52; 27)
Baseline End-‐line
