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The impact of supplementary feeding programmes on the nutritional status of beneficiaries in Addis Ababa
Teshome Demeke and Zewdie Wolde-Gabriel
Ethiopian Nutrition Institute, Addis Ababa, Ethiopia
During the last 30 years in various developing countries a large number of supplementary feeding programmes have been conducted, varying in content and methods of operation depending on the resources available and the objective for which they were established. These supplementary feeding programmes, operating with funds made available from local and international sources, varied from supplementary foodstuffs issued to mothers attending maternal and child health (MCH) centres, to Mothercraft Nutrition Centres, nutrition rehabilitation services, food assistance such as food-for-work, and emergency feeding programmes. Almost all of these programmes focused on delivery of fortified foods and in some cases were complemented with health and nutrition education.
Similarly, in recent years various types of supplementary feeding programmes have been undertaken in the city of Addis Ababa by philanthropic, religious, voluntary, and international organizations through clinics, day-care units, food and nutrition centres, and welfare institutions. Beneficiaries of these feeding programmes have been mainly children of preschool age from underprivileged families. Lactating and expectant mothers from the low socio-economic level of the population have also received food aid from some of the supplementary feeding programme centres.
Wide operational diversities existed among the various agencies charged with the responsibility for the implementation of these programmes. These included differences in the type and amount of food commodity distributed, frequency of distribution, selection of criteria for the vulnerable population, and procurement of information for programme evaluation. Among the main donors of the supplementary foods were the World Food Programme, the Christian Relief and Development Association, Catholic Relief Service, and UNICEF.
Realization of the magnitude of operational variations and lack of co-ordination among the different feeding programmes led the agencies involved to form a central body known as the International Co-ordinating Committee for Welfare and Development (ICC) in 1976. The main tasks of this committee include co-ordination, monitoring, and evaluation of the supplementary feeding programmes in Addis Ababa. The overall objectives of the feeding programmes operated by donor agencies, as stated in the report of a subcommittee of ICC in March 1979, were:
- to provide undernourished children, particularly those below the age of five years, with nutritionally balanced food to supplement their unbalanced staple diet, aimed at ensuring normal growth and preservation of health;
- to integrate health education with food and nutrition services; and
- to make the community eventually self-sufficient in meeting its nutritional needs.
The feeding programmes also focused on indirect strategies, including increasing MCH attendance, promotion of production and acceptance of low-cost but nutritious foods, and other related activities.
Among the several measures that the ICC has considered during its short span of operation to meet its objectives was its request to the Ethiopian Nutrition Institute to assess the impact and performance of the supplementary feeding programmes under its auspices, including feasibility of methods and techniques used in the execution of the programmes. It was with this background that the Institute embarked on this study of the impact of supplementary feeding programmes on the nutritional status of beneficiary children in Addis Ababa.
THE EVALUATION SURVEY
Supplementary feeding programmes have been in operation in Addis Ababa for some time. In July 1981 alone, a total of 71,236 beneficiaries, of whom 40,339 were preschool children and 30,897 were mothers, were registered in 42 feeding centres. Programmes were carried out through daycare centres, MCH clinics, and supplementary food distribution centres. Beneficiaries in welfare boarding institutions were not included in the study.
The purpose of the survey was to determine nutritional effects of the programmes as manifested in the growth and weight gain of preschool child beneficiaries. It was also intended to evaluate the effectiveness of the different feeding schemes in operation. The reason for the survey, as stated initially, was to help in decision-making for possible changes in operational strategies of the various feeding programmes.
TABLE 1. Study Centres and Their Operational Characteristics
|Category and Centre||Scheme Code||Type||Frequency||Food Ration per Child|
|Kef. 1 Keb. 08*||1||on-spot feeding||one meal per day||220 g faffa|
|Kolfe Clinic||2||take-home||daily||500 ml fresh milk|
|Supplementary food distribution centres|
|Kef.19 Keb.50*||3||take-home||monthly||1,000 ml oil, 3,000 g sorghum, 2,000 g dry milk, 3,000 g CSM|
|St. George's Church||4||take-home||fortnightly||500 ml oil, 1,500 g sorghum, 1,000 g dry milk, 1,500 g CSM|
|Medhanealem Church||5||take-home||weekly||250 ml oil, 750 g sorghum, 500 g dry milk, 750 9 CSM|
* Organizational units.
Before the main evaluation began, a preliminary survey was undertaken at all the feeding centres to obtain information required to design the principal survey. An array of information collected from each feeding centre included number and type of beneficiaries, criteria for their selection, type and amount of food commodities distributed, frequency of distribution, and type of feeding scheme. Based on the information obtained from the preliminary survey, supplementary food distribution centres were grouped into different categories (table 1). The supplementary feeding programmes studied use daily and monthly distribution schemes, reflecting the established practices in the respective sectors. However, fortnightly and weekly schemes were also included in the study for purposes of determining the effect of frequent handouts as opposed to the routine practices of the centres.
Population and Sample
Children under six years of age who were beneficiaries of the supplementary food programmes in Addis Ababa constituted the target population of the survey. A list of these children and other pertinent information, such as type and amount of food ration, frequency of distribution, and the usual practices in each centre were obtained from the preliminary survey on which the principal survey was based.
The sample size was determined for each centre, taking the following factors into consideration:
- prevalence of malnutrition (median minus 2 SD) among children under six years of age, 60 per cent;
- required precision for the estimate of change, +5 percent;
- width of confidence interval, 10 per cent.
A total of 1,174 children from 1,096 households were randomly selected out of 9,442 beneficiaries registered in five centres. The total population of beneficiary children and the sample size of each feeding scheme are given in table 2. (A small increase in sample size was allowed in some of the feeding centres to alleviate problems encountered at the start of the survey.) Age and sex distribution are also given in the table.
Age and sex distribution of the study children. The age of the children in the survey ranged from six months to six years, and a breakdown of this shows that more than two-thirds (70.8 per cent) were between one and four years (table 2). Those under one and those between four and six years of age accounted for 9.7 and 19.5 per cent of the total, respectively. A similar pattern was observed in schemes 3, 4, and 5 and in the control group. In scheme 1, however, all children studied were two years old and older, while in scheme 2 a large proportion (89.8 per cent) were less than two years old. Males slightly outnumbered females in the sample and in most of the schemes, but the difference was negligible.
TABLE 2. Total Population of Beneficiary Children, Sample Size, and Age and Sex Distribution (Percentage) by Feeding Scheme at the Start of the Study
|Scheme Code||Population||Sample Size||
Age in Months
Control group. A control group was not part of the original design of the evaluation survey. The plan was to study six different sites representing all the feeding practices, but one had to be dropped after two months because it ceased distributing food. Data collection at this centre was, however, continued as in the other sites because of its potential to serve as a control centre. A total of 401 beneficiaries were registered at the control centre, and among these 158 children from 108 households were randomly selected as control subjects.
Attrition of survey sample. Five children, all from scheme 1, did not complete the survey: three could not be traced because of moving to unknown addresses, and the other two died before the survey ended. In the control group two children could not be traced, another two dropped out because their parents were reluctant to co-operate, and one died during the survey.
Choice of Nutritional Status Indicators and Method of Data Collection
Anthropometry. The main type of malnutrition the supplementary food programmes intended to correct or prevent was protein-energy malnutrition. The survey was designed to indicate changes in nutritional status of children in each centre and among the different feeding schemes. Three indicators were compared among children at the different sites: weight for age, height for age, and weight for height.
Frequency of data collection. In order to obtain adequate data to show the pattern of change in indicators and to ensure greater precision of the estimated change, a longitudinal approach was chosen in data collection. Anthropometric data were therefore collected at the beginning of the survey and three months thereafter for one year.
Standardization of procedures and control of measurements. The collection of data and observations on food distribution according to the schemes shown in table 1 were carried out by temporarily employed staff. Both activities were regularly supervised by a nurse. Data collectors and the supervisor were trained in the techniques of measuring heights, lengths, and weights of infants and older children. A standardization test to determine precision and accuracy indicated satisfactory performance by the survey staff. The quantity of food commodities distributed was determined by measuring the volume of the utensils used to dispense the rations to obtain the approximate weight and volume of the ration.
Household Background Information
General household information on families of the children receiving the supplementary food was obtained along with other data at the beginning of the survey. Information collected included household characteristics such as age and sex composition of the families; occupation, marital status, and education of heads of households; and data on facilities such as latrines, lighting, water supply, ownership of residence, and number of rooms in the house. These data were intended to serve as indirect indicators of the socio-economic status of the study population, which was felt important for comparing the effectiveness of the different feeding schemes. The same information also provided an indication of the relationship between the prevalence of malnutrition and socio-economic factors.
Children under one and between one and four years constituted 6 per cent and 21.3 per cent of the total household members respectively. The male-to-female ratio was approximately 1: 1.2. The ages of family members of the recipient households in the survey ranged from 0.5 to 45+ years.
TABLE 3. Family Size, Marital Status, and Education of Head of Household (Percentages)-Families of Survey Subjects and Control Group
Subject N = 1,096 households; control-group N = 108 households
*Able to read and write.
TABLE 4. Occupation of Head of Household (Percentages)
Subject N = 1,096 households; control-group N = 108 households.
Family size, marital status, and education level of heads of households. Table 3 shows the size of the families of the children in the survey sample and the control group and the marital status and education of the heads of the households. The average family size in the sample population for all schemes was 5.4. Out of the total of 1,096 heads of households, 76.4 per cent were married; the highest percentage of married household heads appeared to be among those in scheme 2 and the lowest in scheme 1. The other most important factor in all schemes was education level of household heads. Data from these studies showed that 62.1 per cent of household heads in all schemes had some education, ranging from the ability to read to a grade level of eight or above. Data for the control population were not significantly different.
Occupational status of heads of households. Table 4 shows the occupations of heads of households. For the sample survey, 45.3 per cent of the heads of households were employed. The highest rate of employment was among those in scheme 3 (61.5 per cent) and the lowest in scheme 5, where only 38.5 per cent were employed. The majority of the unemployed heads of households in all schemes were day labourers, followed by craftsmen in schemes 1, 2, and 3 and welfare dependents in schemes 4 and 5. Only 1.9 per cent of the heads of households in the control group were employed, and a large majority (82.4 per cent) of the unemployed lived on welfare assistance.
Ownership of residence and housing conditions. Table 5 shows home ownership data and housing conditions. More than a third of the survey households did not own their homes. The highest percentage of ownership was observed in scheme 1, where it was about 85.5 per cent, while only 14.5 per cent in scheme 5 owned their homes. A little less than half of the families (43.9 per cent) of the control group also owned their homes. Of the households that did not own their homes, 83.5 per cent paid a monthly rent of Br 10 or less (1 birr = US$0.48). The difference in rental costs among households in the different schemes is negligible except in scheme 1, where fewer than half paid more than Br 10 per month. The 56.1 per cent of households in the control group who did not own their residence paid a monthly house rent of less than Br 10. Over 53 per cent of total households lived in a one-room private home, and a similar pattern is seen in most of the schemes and in the control group.
TABLE 5. Ownership of Residence, Rents, and Number of Rooms in Home (Percentages)
|Residence||Rent (Birr per Month)||Number of Rooms|
Subject N = 1,096 households; control-group N = 108 households.
TABLE 6. Sewage Disposal, Lighting, and Water Source (Percentages)
|Pit||Flush toilet||Field||Electricity||Oil lamp||Pipe||Well||River|
Subject N = 1,096 households; control-group N = 108 households
Sanitary facilities, electricity, and water supply. Table 6 shows the households' means of sewage disposal, use of electricity, and water source. Pit latrines were used by 82.2 per cent of the sample households, 14.9 used the field, and 2.9 per cent had flush toilets for disposal of waste, with minor differences among the different schemes. In the control group, however, pit latrine and field were used almost equally. About 94.3 per cent of both sample and control groups used electricity for lighting. The differences in the percentage of electric light-users among the schemes were not significant. More than 90 per cent of households in all schemes used pipe water; 10.6 per cent in scheme 3 and 4.6 per cent in scheme 2 depended on well water and river water respectively. Of those in the control group 13.9 per cent used well water.
Summary of data on socio-economic status of households. Baseline information such as that given above is intended to give a bird's-eye view of the socio-economic comparability of the households from which the study subjects were drawn. As can be seen from the data in tables 3-6, there were only small differences in the standard of living among households where survey children lived. Of all households surveyed, those from scheme 1 appeared to be relatively better off, as indicated by education and employment of household head, ownership of home, house rent, sanitary facilities, and water supply. These criteria applied to the control group showed that they had a slightly lower standard of living.
Assessment of Nutritional Impact
The measurement of the impact of supplementary feeding programmes on the nutritional status of the recipient children was based on data collected at the beginning of the survey and at its termination one year later.
As a measure of malnutrition, two arbitrarily chosen cut-off points-one and two standard deviations below the median of a reference population (Bulletin of the World Health Organization, vol. 55, no. 4  ) for each of the three anthropometric indicators of nutritional status-were used for comparative purposes. In the course of statistical analysis, however, 2 SD below the median was the only cutoff point used: malnutrition in this survey was defined as the level of nutritional status falling below the median minus 2 SD of the reference population.
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