Comparison of Child Nutritional Status Between Positive Deviance/Hearth (PD/Hearth) Intervention and Non-Intervention Areas in Jeju District, Arsi Zone, Oromia Regional State

Master's Thesis, 2013

90 Pages, Grade: Good










1.1. Significance of the Study
1.2. Statement of the Problem
1.3. Research Objectives
1.4. Research Question

2.1. Causes of Malnutrition & Country Situation
2.2. Common Approaches of Nutrition Intervention
2.3. The Positive Deviance/Hearth (PD/Hearth) approach
2.3.1. The Positive Deviance (PD) approach
2.3.2. The Hearth approach

3.1. Description of the Study Area
3.2. Research Design
3.3. Study Period
3.4. Source Population
3.5. Study Population
3.6. Sampling
3.7. Variables
3.8. Instruments
3.9. Data Collection
3.10. Data Analysis
3.11. Ethical Consideration

4.1. Demographic and Socioeconomic Characteristics of the Households
4.2. Child Nutritional Status
4.3. Child Feeding and Care Practices
4.4. Hygiene and Health Seeking Behaviors
4.5. Limitations and Strength



7.1. Consent & Data Collection Forms (English version)
7.2. Consent & Data Collection Forms (Afan Oromo version)


I lovingly dedicate this thesis manuscript to my wife, who supported me each step of the way.


First of all, I am thankful to my almighty God. I would also like to thank my advisors Dr Mesfin Beyero and Ms Getenesh Berhanu for their guidance and supports in preparation of this thesis. I would thank the Jeju District Health and Administration Offce management, the HEWs and the KA cabinets of Angodeche, Weshebabereket, Arjokere and Shedare KAs, the whole staff of World Vision Ethiopia, Jeju ADP and the participants of the study for their sincere cooperations. I would finally gratefully acknowledge the input and review provided by Soo-kyung Lee (PhD, RD) from Inha University, Department of Food and Nutrition, South Korea and Mr Yadessa Gedefa from World Vision Ethiopia as well as Ms Hiwot Abebe, Dr Pragya Singh and the other Applied Human Nutrition Department and INFST staff, for their useful contributions for the quality of the study.


Abbildung in dieser Leseprobe nicht enthalten


1. Mean family size and ages of participant children 6-59 months and their parents, Jeju District, Oromia Regional State, 2012

2. Socio-demographic characteristics of the households, Jeju District, Oromia Regional State, 2012

3. Nutritional status of children, Jeju District, Oromia Regional State, 2012

4. Association of religion and drinking water source to child nutritional status, Jeju District, Oromia Regional State, 2012

5. Duration and frequency of breastfeeding practices pertaining to under 24 months children, Jeju District, Oromia Regional State, 2012

6. Complementary feeding pertaining to under 24 months children, Jeju District, Oromia Regional State, 2012

7. Complementary feeding practices and participation in feeding and education programs pertaining to under 24 months children, Jeju District, Oromia Regional State, 2012

8. Hygiene and Health Seeking behaviors pertaining to the under 24 months children Jeju District, Oromia Regional State, 2012


1. Nutritional status of Children of Jeju District, Oromia Regional State,

2. Nutritional Status of Children by Age Category Jeju District, Oromia Regional State,

3. Percentage of mothers introducing identified complementary foods to children below 24 months, Jeju District, Oromia Regional State, 2012


1. Cluster selection using PPS for Angodeche & Weshebabereket KAs

2. Cluster selection using PPs for Arjokere & Shedare KAs

3. Anthropometric Data Collection Form

Comparison of Child Nutritional Status between Positive Deviance/Hearth (PD/Hearth) Intervention and Non-intervention Areas in Jeju District, Arsi Zone, Oromia Regional State

By Negassa Kinfu

Advisors: Mesfin Beyero (MD, MPH), Getenesh Berehanu (MSc)


World Vision Ethiopia had implemented a two years Essential Nutrition Promotion (ENP) Project, using the Positive Deviance/Hearth (PD Hearth) approach, in two Kebeles of Jeju District from June 2007 to September 2009. The PD Hearth approach identifies those behaviors practiced by the mothers or caretakers of well-nourished children from poor families and transfers such positive practices to others in the community with malnourished children. The study investigated whether there are improvements sustained three years after the program was terminated. A Cross-sectional survey was administered to a total of 249 children, 123 of them randomly selected from two Kebeles that had previously participated in the program and 126 children from a neighboring comparison two Kebeles. All the sample children 6-59 months of age were measured, and mothers of children under 24 months interviewed. The children born after the completion of the program in the intervention area were significantly better nourished than those in the comparison area, with adjusted mean weight-for-age Z scores of -0.963 versus -1.308 (p < 0.05), respectively. More intervention area mothers of under 24 months children were currently breastfeeding, at the time (100%) as compared with comparison area mothers (94.2%, p < 0.05). Frequency of complementary feeding to the 6-24 months children was better among the intervention area mothers as compared to their counterparts, 4.24 versus 3.83 per day, respectively (p < 0.05). Intervention area mothers reported that they often washed their hands before feeding their children (97.6% vs. 89.4%, p < 0.05). More intervention area mothers (97.0%) also reported that their family members use pit latrines rather than open defecation as compared to the comparison families (89.3%) (p < 0.05). The PD behaviors practiced through the hearth sessions might have sustained years after program completion, and and might have contributed to better nutritional status of the children.

Key Words: Hearth, positive deviance, malnutrition, nutrition, World Vision Ethiopia, Essential Nutrition Promotion, Jeju, Kebele


Malnutrition is implicated in more than half of all child deaths worldwide (CORE Group, 2003). In Ethiopia, infant mortality rate is 59 deaths per 1,000 live births and the overall under-5 mortality rate 88 deaths per 1,000 live births (CSA, 2012). The high mortality and morbidity due to malnutrition leads to the loss of the economic potential of the children. The prevalence of malnutrition, therefore, imposes significant costs on the Ethiopian economy as well as society (Save the Children, 2009).

Nationally, 44 percent of children under age five are stunted, and 21 percent of children are severely stunted. Overall, 10 percent of Ethiopian children are wasted, and 3 percent are severely wasted. Twenty nine percent of children under age five are underweight (have low weight-for-age), and 9 percent are severely underweight. The proportion of underweight children generally increases with each age cohort (CSA, 2012).

In Ethiopia, only 52 percent of children under-6 months (aged 0-5 months) were exclusively breastfed. In addition to breast milk, 19 percent of infants under 6 months were given plain water only, while 14 percent were given milk other than breast milk and 4 percent given non-milk liquids and juice. Furthermore, 10 percent of infants under 6 months were given complementary foods. By age 6-9 months, 51 percent of infants were given complementary foods. Sixteen percent of infants under 6 months were fed using a bottle with a nipple, a practice that is discouraged because of the risk of illness to the child (CSA, 2012).

About 27% of newborns received prelacteal food. Only 51.5 % of them were put to breast within one hour of birth. Only 51 % of children at 6-9 months of age are consuming complementary foods. Among all households, only 15.6 percent had salt with the recommended level of iodization. Child vitamin A supplementation also remains low, with only 53.1 percent of children between the ages of 6 and 24 months of age having received it (CSA, 2012).

1.1. Significance of the Study

Until recently, focus was placed on addressing food security as the primary means to address nutritional insecurity and the broad multi-sectoral factors contributing to malnutrition had been insufficiently emphasized (Save the Children, 2009). There are, infact, different approaches being utilized to tackle malnutrition in different parts of the World. The traditional nutrition interventions include growth monitoring, counseling and the provision of supplemental foods and micronutrients such as Vitamin A. These approaches to nutrition interventions tend to look only for problems in the community that need to be solved (CORE Group, 2003).

A Positive Deviance/Hearth (PD/Hearth) Nutrition Program is a home-based and neighborhood based nutrition program for children who are at risk for protein-energy malnutrition in developing countries. The PD/Hearth process looks for and taps into local wisdom for successfully treating and preventing malnutrition and spreads that wisdom throughout the community (CORE Group, 2003).

Different studies, elsewhere around the globe, have indicated that the PD/Hearth approach was effective in improving child malnutrition (Bolles et al., 2002; Mackintosh et al., 2002; Hidayat, 2009; Nishat & Batool, 2011). It has enabled hundreds of communities to reduce current levels of childhood malnutrition and to prevent malnutrition years after the program’s completion, in different countries (CORE Group, 2003).

1.2. Statement of the Problem

World Vision Ethiopia, Jeju Area Development Program (Jeju ADP) has been operating in 14 of the total 29 Kebele Administrations (KAs) of Jeju District, Oromia Regional State, for the last nine years. In order to improve the nutritional status of children in the area, the ADP had implemented a two years Essential Nutrition Promotion (ENP) Project in 2 KAs of the District, through the PD/Hearth approach, from June 2007 to September 2009. However, no baseline or impact evaluation was done for the project and, therefore, no information is available about the effectiveness of the program.

The purpose of this study is to investigate whether there are differences in nutritional status of children between the PD/Hearth intervention and non-intervention areas in the District. There was no similar study conducted in the area, and since the PD/Hearth intervention is a relatively new approach in Ethiopia, there is no enough information available about its effectiveness in the country’s context. The study is, therefore, designed to initiate further studies in the area to address this knowledge gap.

1.3. Research Objectives

The overall objective of the study:

- To assess and compare the nutritional status, feeding and care practices of under 5 children between the June 2007 and September 2009 PD/Hearth Program intervention Kebele Administrations (KAs) (Angodeche & Weshebabereket) and non-inntervention KAs (Arjokere and Shedere) in Jeju District of Arsi Zone, Oromia Regional State.

The specific objectives:

- To assess and compare the nutritional status of children in the former PD/Hearth Program intervention area with that of non intervention areas.
- To determine whether the mothers/caretakers in the intervention area are practicing better child feeding and care practices, compared to their counterparts in the non intervention area.

1.4. Research Question

- Are the June 2007 to September 2009 PD/Hearth Program Interventions area (Angodeche and Weshebabereket KAs) children better nourished than the non-intervention area (Arjokere and Shedere KAs) of Jeju District, Oromia Regional State?


The following section consists of literature review relating to the causes of malnutrition, Ethiopian situation on under-five malnutrition and some of the approaches of nutritional intervention emphasizing on the PD/Hearth approach.

2.1. Causes of Malnutrition & Country Situation

The immediate causes of malnutrition and child death are mutually reinforcing conditions of inadequate dietary intake and infectious disease. The underlying causes are household food insecurity, inadequate maternal and child care, and inadequate health services and health environment. And the basic causes include formal and non-formal institutions, political, economic, and ideological structures and systems representing the perennial political, economic, and institutional conflicts that public nutrition programs must work within (UNICEF, 1990 cited in Benson, 2005).

A community based survey was conducted on 622 mother-child pairs of 0-59 month old children in Mecha and Wenberma Woredas of West Gojam Zone, Northern Ethiopia between May and June 2006. The study was done to determine the magnitude and determinants of stunting in children under- five years of age in food surplus region of Ethiopia. The findings of this study led to the realization that inappropriate feeding practice is the principal risk factor which brought about nutritional deprivation among under-five children in food surplus areas of Ethiopia. The study also showed that the risk of stunting increases with age. Children in the age group 13-24 months were at significantly higher risk of stunting compared with children in the youngest age category (<7 months) (Beka et al., 2009).

A case-control study was conducted to determine the risk factors for severe acute malnutrition in children under the age of five years, among the admitted children in Gondar University Hospital. The study revealed that parental illiteracy and larger family size were associated with an increased risk of SAM (Solomon & Zemene, 2006).

Data collected from nine regions and two city administrations using stratified cluster sampling method by the Ethiopian Demographic Health Survey (EDHS) 2005, were used to study the practice and determinants of EBF countrywide. Analysis was based on children whose age were less than six months and alive at the time of interview that was extracted from the women’s database. A range of maternal and child health attributes such as marital status, economical status and child age were found to influence the practice of EBF in Ethiopia (Tewodros et al., 2005).

Data representing countries from four regions: 26 in sub-Saharan Africa, seven in the eastern Mediterranean, five in south and south-east Asia, and nine in Latin America and the Caribbean was analysed. In almost all countries investigated, stunting and wasting disproportionately affected the poor. However, socioeconomic inequality in wasting was limited and was not significant in about one third of countries. After correcting for the concentration index’s dependence on mean malnutrition, there was no clear association between average stunting and socioeconomic inequality (Ellen Van de Poel et al., 2008).

2.2. Common Approaches of Nutrition Intervention

Several donors, including USAID, have funded the development or refinement of various interventions to improve child nutritional status during the past decade at both the facility and community level. These include the Essential Nutrition Actions (ENA), Baby-Friendly Hospitals and mother-to-mother support groups for breastfeeding, Integrated Management of Childhood Illnesses (IMCI) for care of the sick child and Community-IMCI with a focus on key family practices, micronutrient supplementation and fortification (CORE Group, 2004).

The reduction in deaths related to stunting and lost Disability Adjusted Life Years (DALYs) that could result from implementation of interventions in the 36 countries in which 90% of the world’s stunted children live were estimated by reviewing interventions that affect maternal and child undernutrition and nutrition-related outcomes. A cohort model was used to assess the potential effect of these interventions on mothers and children in the 36 countries that have 90% of children with stunted linear growth. The model showed that existing interventions that were designed to improve nutrition and prevent related disease could reduce stunting at 36 months by 36%; mortality between birth and 36 months by about 25%; and DALYs associated with stunting, severe wasting, intrauterine growth restriction, and micronutrient deficiencies by about 25%. To eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women’s empowerment (Bhutta et al., 2008).

A study on Dietary counseling in the management of moderate malnourishment in children was done by collecting information from 10 United Nations agencies or donors, 20 international non-governmental organizations, 3 pediatric associations, and 6 national programs about the dietary advice they give to caregivers of moderately malnourished children. The study revealed that there was a greater emphasis on providing food supplements for rehabilitation than on utilizing family foods. Dietary recommendations were mostly vague and unlikely to be effective (Ashworth & Ferguson, 2009).

A study aimed to assess the impact of nutrition education on the nutritional status of children living in resource-limited environments was conducted in Pakistan. Nutrition education was found to be successful in reducing undernutrition in food insecure households (Khan et al., 2013).

The experiences of 63 countries during 1970–96 were studied. Women’s education was found to have the strongest impact on child malnutrition. It is followed closely in strength of impact by per capita food availability. As the amount of food available per person increases, however, its power to reduce child malnutrition weakens (Smith & Haddad, 2000).

Effect of integrated child nutrition intervention on the complementary food intake of young children in rural north Viet Nam was studied. Young rural children exposed to intervention program consumed intervention-promoted and any foods more frequently, ate a greater quantity of any food, consumed more energy, and were more likely to meet their daily energy requirements than comparison children. Some effects were only observed during the intensive intervention period; others persisted into or were evident only at the 12-month follow-up, approximately four months after program completion. Based on the mothers’ reports, the intervention did not apparently compromise breastfeeding prevalence or frequency. The intervention improved children’s food and energy intake and protected them from declining as rapidly as comparison children in meeting their energy requirements (Pachón et al., 2002).

2.3. The Positive Deviance/Hearth (PD/Hearth) approach

A PD/Hearth Nutrition Program uses the “positive deviance” approach to identify those behaviors practiced by the mothers or caretakers of well-nourished children from poor families and to transfer such positive practices to others in the community with malnourished children (CORE Group, 2003).

A cohort study, to monitor a community-based nutrition activities from the first cycle, of 50 program children and 55 comparison children in Leogane, Haiti indicated that children continued to gain weight as fast as or faster than the international standard median six months, after participating in a Hearth program (Bolles et al., 2002).

Analysis of primary data from project internal database was done to assess the implementation of Positive Deviance Approach in Aceh Besar District of Indonesia. The study showed that, out of the 894 children participated, 38.1% of them gained catch-up growth and 28.6% gained normal growth (Hidayat, 2009).

A cohort of 700 children, all with second or third degree malnutrition, participated in the Hearth program, by Save the Children/US in Vietnam, in 1991. Follow-up two years later showed that of these same children, only 3% were still second and third degree malnourished. Fifty-nine percent of all Hearth participants were rehabilitated to normal and 38% to first-degree malnutrition. This initial level of improvement was observed 14-23 months after participation in the Hearth (CORE Group, 2003).

A cross-sectional survey was administered to 46 randomly selected households in four former PD program communities and 25 households in a neighboring comparison community, in Viet Nam, two years after a Save the Children program based on PD had ceased. The study revealed that former program children and their younger siblings born after the project completion were better nourished than counterpart children in communities that never had the program. Moreover, former program mothers reported applying PD practices learned in the program to the younger children. It appeared that the promise of the PD approach for acceptability, affordability, and sustainability had been successful (Mackintosh et al., 2002).

Lapping et al. (2002) also compared the findings from a small sample PD inquiry to a large sample case control study in the same population of Afghan refugees in Pakistan. The case control study confirmed many of the PD inquiry findings, satisfactorily indicating that the PD methods were sound.

Another comparative cross sectional study, on the effect of “Positive Hearth Deviance” on feeding practices and underweight prevalence among children aged 6-24 months, was conducted in Quetta district of Pakistan, participating 200 mothers. It also indicated that feeding practices were significantly better and underweight prevalence was significantly less in hearth mothers compared to non hearth mothers (Nishat & Batool, 2011).

A systematic review of 10 peer reviewed intervention trials and 14 grey literature evaluation reports of child malnutrition programs using the PD⁄Hearth approach done in Walden University, Minneapolis, USA indicated that the PD⁄Hearth approach may have a role in preventing malnutrition, not just rehabilitation (Piroska & Bisits, 2011).

A pre-post evaluation using independent cross-sectional samples of a total of 371 pregnant women, to measure the impact of a positive deviance approach to improve an iron supplementation program among rural Senegalese pregnant women, showed that the positive deviance approach contributed to improving the effectiveness of iron supplementation during pregnancy, lowering the effects of anemia on pregnancy outcome (Ndiaye et al., 2009).

The quality of the two-week, volunteer-facilitated, caregiver-child rehabilitation “hearth,” or nutrition education and rehabilitation program (NERP), sessions in Save the Children’s integrated nutrition program in Viet Nam was evaluated. Despite imperfect implementation, the NERP’s active-learning and local problem-solving helped achieve measurable impact on growth, diet, morbidity, and empowerment despite uncommon program challenges, such as uncharacteristically low baseline levels of malnutrition and high population dispersion. Regular quality monitoring may enhance impact even further (Dickey et al., 2002).

A study was conducted in Nsanje district in Malawi to find out the potential of locally available resources in coming up with sustainable nutrition interventions. 60% of malnourished children had their nutrition status improved within twelve days of feeding on locally available foods (Nanchukwa, 2008).

A cross-sectional assessment was conducted, using qualitative methodologies, to compare self-reported changes in identified empowerment domains among 17 program health volunteers and 20 mothers involved in a child nutrition intervention and among five Women’s Union leaders and five mothers in a non-intervention comparison commune. In this study we found that the relative increases in empowerment were greater for mothers than for health volunteers. Intervention mothers reported more sharing of information on child care with neighbors. Health volunteers developed closer relationships with community members than Women’s Union leaders. The increased information sharing has positive implications for spread of key messages to families that did not directly participate in intensive feeding and the sustainability of the intervention’s impact (Hendrickson et al., 2002).

Identification of model newborn care practices through a positive deviance inquiry to guide behavior-change interventions was conducted in Haripur, Pakistan. PD individuals, families, and/or birth attendants modeled good maternal care and immediate, routine and special newborn care. Communities enthusiastically committed to change behavior and form neighborhood support groups for better newborn care, including a demand for hygienic delivery. The PD approach for the newborn is more complex than for child nutrition. Yet this pilot-test proposed a conceptual framework for household newborn care, suggested tools and methods for information gathering, identified PDs in two settings of different risk, galvanized SC staff to the potential of the approach, mobilized communities for better newborn health, and drafted a newborn PD training curricula (Marsh et al., 2002).

Positive Deviance/Hearth is an effective community mobilization tool, galvanizing communities into action by involving different strata of the community to work together to solve a problem and discover the solution from within. It focuses on maximizing existing resources, skills and strategies to overcome a problem and makes extensive use of participatory methodologies and the Participatory Learning and Action process (CORE Group, 2003).

PD/Hearth can be an entry point to mobilize communities to address malnutrition or an intervention for rehabilitating large numbers of malnourished children identified through routine growth monitoring and promotion (GMP) programs. PD/Hearth is, in essence, a “mop-up” program to eliminate the pool of ever-malnourished children not usually affected by more generalized programs, not only through rehabilitation but also by permanent behavior changes in their families which prevent malnutrition in future siblings.

PD/Hearth will be most successful in contributing to overall reductions in child malnutrition and improvements in child health if the program is linked to other health and nutrition interventions for all families within the target communities. Complementary programs include breastfeeding promotion and support, maternal nutrition, growth monitoring and promotion, immunizations, micronutrient supplementation and de-worming, general health and nutrition education, water and sanitation, and income generation or food security interventions such as promotion of home gardens and small animal production. PD/Hearth, with its strong community focus, can be included as part of the Essential Nutrition Actions strategy, and be a logical companion project within a Community Integrated Management of Childhood Illness (IMCI) strategy. Before entering the Hearth, families are required to take children to the health facility for de-worming, micronutrient supplementation, and needed immunizations. PD/Hearth volunteers reinforce continued use of health services through referrals and counseling. If a growth monitoring program did not exist previously in the community, the PD/Hearth program must work with the health facility to establish one (CORE Group, 2005).

The PD/Hearth Program combines the ‘Positive Deviance’ and the ‘Hearth’ approaches proven to successfully reduce child malnutrition and promote the normal development of the child at the community level (CORE Group, 2003).

2.3.1. The Positive Deviance (PD) approach

Positive Deviance is one developmental approach that seeks to identify and optimize existing resources and solutions within the community to solve community problems, without brining in “alien” handouts developed without communities socio-cultural and economic considerations. This approach, identifies people or groups within communities who share in the same resources with the rest of the community, but are however able to uniquely enhance a more better and sustainable standard of living (Iorungwa & Terhemba, 2009).

Positive Deviance is based on the premise that some solutions to community problems already exist within the community and just need to be discovered. Because behaviors change slowly, most public health practitioners agree that the solutions discovered within a community are more sustainable than those brought into the community from the outside.

Positive Deviance is a “strength-based” or “asset-based” approach based on the belief that in every community there are certain individuals (“Positive Deviants”) who’s special, or uncommon, practices and behaviors enable them to find better ways to prevent malnutrition than their neighbors who share the same resources and face the same risks. Through a dynamic process called the Positive Deviance Inquiry (PDI), program staff invites community members to discover the unique practices that contribute to a better nutritional outcome in the child. The program staff and community members then design an intervention to enable families with malnourished children to learn and practice these and other beneficial behaviors (CORE Group, 2003).

2.3.2. The Hearth approach

The “Hearth” or home is the location for the nutrition education and rehabilitation sessions. In the Hearth approach, community volunteers and caregivers of malnourished children practice new cooking, feeding, hygiene and caring practices shown to be successful for rehabilitating malnourished children. The selected practices come from both the findings of the PDI and emphasis behaviors highlighted by public health experts. Volunteers actively involve the mother and child in rehabilitation and learning in a comfortable home situation and work to enable the families to sustain the child’s enhanced nutritional status at home. The Hearth session consists of nutritional rehabilitation and education over a twelve-day period followed by home visits to the caregivers by volunteers.

The Hearth approach promotes behavior change and empowers caregivers to take responsibility for nutritional rehabilitation of their children using local knowledge and resources. After two weeks of being fed additional high-calorie foods, children become more energetic and their appetites increase. Visible changes in the child, coupled with the “learning by doing” method, results in improved caregiver confidence and skills in feeding, child care, hygiene and health-seeking practices. This approach successfully reduces malnutrition in the target community by enabling community members to discover the wisdom of PD mothers and to practice this wisdom in the daily Hearth sessions (CORE Group, 2003).

In summary, from review of these literatures we can see that the PD/Hearth Program is a proven, easy and effective program to tackle child malnutrition, especially in developing countries. The peculiarity of the program, which is the possible cause of its effectiveness, is the fact that it utilizes the locally available knowledge, practices and resources in solving the nutritional problems of the children in the community. The behavioral changes attained during the practical sessions of the program were found to be sustainable, affecting the growth of even the future children of the mothers. The program has also well organized guidelines, which is easily available and could be easily utilized. However, the approach is not yet much utilized in Ethiopia. It is only recently introduced to the country, and therefore, literatures on its effectiveness in the country’s context were found to be rare. The purpose of this study is therefore, to fill this gap of knowledge on its effectiveness in the country’s context.


3.1. Description of the Study Area

Jeju District is located in Arsi zone of Oromia Regional State, at 186 km south of Addis Ababa and at a distance of 125 km North of Asella the capital of Arsi zone. The District covers an area of 770 km2 and according to the estimates of CSA (2012) has a total population of 127,745 yielding an overall density of 150 people per km2. This constitutes 64,511 (50.5%) male and 63,234 (49.5%) female. The specific study area population was the total population of Angodeche, Weshebaberakat, Shedare and Arjokere KAs of the District, estimated to be more than 15,000. The estimation of the total 0-59 months children of the study area was 2,250, calculated from the total population with 15% proportion (JWHO, 2012).

The agro-ecological features of the District includes: highland, midland, and lowland covering 47%, 33% and 20% respectively. The altitude of the District ranges from 1150 - 3200 m.a.s.l. The annual rainfall ranges from 824 mm to 1450 mm. Rainfall distribution in the mid land and high land is of bi-modal nature, which is the “Belg” small rainy season and “Meher” the main rainy season. The temperature of the area ranges from 8oc to 36oc.

The total land area of the District is estimated to be 770 square kilo meters, of which 67% cultivable land 14.2% grazing land, 5.5% shrubs, bush & forest, 5.5 waste land 5.4 % used for settlement and 2.4 %others. The area has relatively irrigation potentials and needs feasibility study to increase the coverage.

The mainstay of the rural population of the District is agriculture (crop production and livestock husbandry). The average landholding is 2.5 ha/household though it can vary from 0.25 ha – 5 ha. The main crops that are produced in the District are wheat, barley, oats, maize, teff, sorghum, haricot bean, broad bean, pea and flax. According to the District agriculture and rural development office, since recently, production of vegetables like cabbages, tomato, beetroots, and pepper are introduced and gradually taking impetus. The crops that are considered as cash crops are flax, haricot beans, chat, coffee, teff, onion and other vegetables.

Even though there is shortage of grazing land, the farmers raise different types of livestock such as bovines, equines, shoats and poultry, which is currently numbering to 310,042 heads. Cattle constitute about 38% of the total number of the livestock. They mostly keep them for sale, traction power, transportation and home consumption.

Concerning social infrastructures, the District has 1 health centre, 8 health posts, and 4 clinics. There is formal public transport, but the main road that detour from Adama – Assela road to the District center, Arboye town, is of poor quality. The District has 40 schools (37 elementary schools, two junior secondary schools and one senior secondary school) (JDFEDO, 2012).

3.2. Research Design

The study employed a comparative cross sectional study with quantitative data collection methods.

3.3. Study Period

From July 2012-January 2013

3.4. Source Population

The source population for the survey was the total 6-59 months old children and mothers of <24 months children of Angodeche, Weshebaberakat, Shedare & Arjokere KAs of Jeju District, Arsi Zone, Oromia Regional State.

3.5. Study Population

The study populations were sampled 6 to 59 months children and mothers (caregivers) of under 24 months children in the sample areas.

3.6. Sampling

Sample size: The sample size was calculated by using the formula:

n = Abbildung in dieser Leseprobe nicht enthalten

n= the required sample size

Abbildung in dieser Leseprobe nicht enthalten= confidence level at 95% (standard value of 1.96)

Abbildung in dieser Leseprobe nicht enthalten= the z-score corresponding to power (standard value of 0.84)

Abbildung in dieser Leseprobe nicht enthalten= estimated prevalence of stunting in the comparison area (0.5)

Abbildung in dieser Leseprobe nicht enthalten= estimated prevalence of stunting in the intervention area (0.25)

Abbildung in dieser Leseprobe nicht enthalten= Abbildung in dieser Leseprobe nicht enthalten

According to the data taken from national statistics on malnutrition, it is estimated that nearly half 46% (~0.5=Abbildung in dieser Leseprobe nicht enthalten) of the children in rural Ethiopia suffer from chronic malnutrition (stunting). And the goal of the World Vision ENP project was to reduce this proportion to 25% (0.25=Abbildung in dieser Leseprobe nicht enthalten) for the intervention area.

Using the values above, the calculation for n resulted in 58 children. And since the survey was designed as a cluster sample, to correct for the difference in design, it was multiplied by design effect (DE) of 2 and resulted in 116 children. In addition, after adding 5% contingency for non-response or recording error, the sample size for the intervention group (Angodeche & Weshebabereket) KAs resulted in 122 children. Another 122 children were also randomly selected from the non-intervention KAs (Shedere & Arjokere), as a comparison group, which in total gave a sample size of 244 children.

Cluster selection: Clusters were selected from 4 rural KAs of Jeju District: 2 of them, Angodeche & Weshebabereket KAs, the previous PD/Hearth project intervention KAs (intervention group) and another 2, Shedare & Arjokere KAs, selected from the remaining 37 non-PD/Hearth intervention KAs (comparison group). Similarity in geographic and some socioeconomic characteristics with the intervention KAs was considered in selection of the comparison KAs. The PD/Hearth intervention KAs are the KAs where mothers of the study children had participated in the 12 days Hearth sessions. In the Hearth sessions, new cooking, feeding, hygiene and caring behaviors are practicesed to rehabilitating the malnourished children. These behaviors mainly come from the findings of the PDI, complemented by some emphasis highlights by public health experts. Implementations of the other national programs were similar in both the intervention and comparison areas (JWHO, 2012). In order to minimize the effect of possible cross contamination of the nutrition information, the intervention and comparison communities were selected to be, as much as possible, geographically apart. There is another non intervention KA named Gure Kabino between the two areas.

Each village/Gare within each KA was considered a cluster and 20 clusters, 10 for each of the intervention and comparison groups, were sampled using probability proportional to size (PPS) (Appendix Tables 1&2). The sample size was then further rounded up to 260 to match it well with the cluster number, so that 13 children per each cluster will be measured.

Within the selected clusters, to select the first house to survey and in moving from house to house, the data collectors used the EPI method. The EPI method was used since there was no sampling frame (up-to-date child or HH list) and also the the HHs are not arranged in any kind of logical order, to use either of simple or systematic random sampling methods. It was also difficult to do census, due to time and financial limits.

Following the EPI method, the data collectors went to the center of the selected clusters and randomly chose a direction by spinning a pencil or pen on the ground and noting the direction in which it points when it stops. They then walked in the direction indicated by the pen, from the center to the edge of the village, counting the number of houses on the way. They drew a random number between 1 and the number of houses counted on the line. The house matching the randomly selected number is the first house to be included in the survey. Within selected households, all children 6-59 months were measured and mothers/caregivers of under 24 months children interviewed. Mothers of 24-59 months children were not interviewed since their above 24 months children have the possibility of being cared for by other secondary caregivers due to possible subsequent pregnancies or berths. Subsequent households were chosen by proximity or in villages where the houses were closely packed together, choosing the next house on the right. And in villages less densely inhabited, choosing the house with the door closest to the last house surveyed, whether it is on the right or left. The sampling continued the same way in each cluster until the required number of children had been enrolled in the survey.

Inclusion and Exclusion Criteria

Inclusion Criteria

- All children, 6-59 months, living permanently in the study area.

Exclusion Criteria:

- Severely ill children and involuntary mothers

3.7. Variables

Dependent Variables

- Nutritional Status of the Children in terms of levels of underweight, stunting and wasting;
- Child feeding and care practices of the community: breastfeeding, complementary feeding, hygiene behaviours and health seeking practices.

Independent Variables

- Permanently residence in the PD/Hearth program intervention or non-intervention area.
- Socio-demographic characteristics: Like age, sex, education, occupation, marital status of the HH head and the primary caregiver as wel as their relationship with the child, their drinking water source and latrine utilization.

3.8. Instruments

Structured questionnaires were prepared in English and then translated to the local language (Afan Oromo); and utilized to interview the sample mothers in the HHs. Pilot testing of data collection equipments, forms and questionnaires was done in villages not selected to be part of the larger survey. This was to ensure that the data collectors and respondents understand the questions and that the data collectors follow correct protocols of taking the measurements in the survey area.

3.9. Data Collection

Data Collectors: - Prior to the data collection, ten enumerators and 5 team leaders and two supervisors were selected from the survey area and trained for two consecutive days on nutrition assessment techniques: data collection procedures, interview and anthropometric measurement techniques. The two supervisors were also trained along with the data collectors on how to supervise during the data collection. During the training, the data collectors were also organized into five teams, each of them consisting of three members, one team leader and two enumerators. A village/Gare leader or a community volunteer from each village had also participated in guiding the data collectors from house to house, during the data collection.

Data Collection Method: - The enumerators went house to house, and using the structured questionnaires conducted interviews with the children’s mothers/caregivers. The information collected includes: socio-demographic status, child-feeding practices (specifically, breastfeeding, and time of introduction and variety of complementary food), prevalence and management of childhood illnesses, immunization status, hygiene and sanitation conditions and practices, feeding program information like Targeted Supplementary Feeding program (TSFP) and Outpatient Therapeutic Program (OTP), participation in the PD/Hearth program, contact with local health and nutrition workers. These enumerators also measured the height and weight of children 6-59 months of age. Heights of children aged 6-23 months were measured in a recumbent position to the nearest 0.1 cm using a board with an upright wooden base and a movable headpiece. Heights of children 24 months and older were measured in a standing-up position to the nearest 0.1 cm. Each subject was weighed with salter scale, hanged from a stick held on the shoulders of two people, put in salter trousers with minimum clothing and no foot wear. The nutritional status of the study children was assessed using the indicators weight-for-age, weight-for-height, and height-for-age, according to the WHO reference standard taking –2SD as the cut-off point indicating malnutrition (under weight, stunting, and wasting).

Quality Control: - Two supervisors were closely supervising the team throughout the survey period. The data was reviewed and necessary edition was conducted at the field level. The UNICEF (SALTER) weighing scales and the EHNRI length/height boards were used for anthropometric measurements. The weighing scales were checked every morning by a standard 5 kg weight. Daily checking was conducted on each questionnaire and data sheet prior to the data entry which was done every night. Feedbacks were also provided every morning by the supervisors.

3.10. Data Analysis

The data entry and analysis was done using the ENA 2011 and SPSS version 20 software programs. The ENA software automatically flags abnormal values as anthropometric data are entered. It is designed to automatically present all important data in standard format under standard section headings. The Z scores were determined by the ENA software using WHO standard of 2006. Plausibility check was also run for each group data using the ENA software and the overall data quality was found to be acceptable for the intervention group and good for the comparison group. The socioeconomic and demographic characteristics were compared among the intervention and the comparison participants using SPSS. Comparison of differences between the groups was done using chi-squares and logistic regressions for proportions and Student’s t-test for means. P values less than or equal to 0.05 were considered statistically significant.

3.11. Ethical Consideration

Ethical approval was obtained from the ethical approval committee, Hawassa University, before the survey was conducted. The District Health Office and the District Administration Office were informed about the background, purpose, objectives and methods for the survey. The authorities were requested to officially inform the communities that will be involved in the assessment, and official permission letters obtained.

Each participant was informed about the study, and informed consent was obtained before starting the data collection. All the information collected was treated as strictly confidential. The data was used only for the purpose of the study.


4.1. Demographic and Socioeconomic Characteristics of the Households

The intervention and comparison communities were similar in most of the household variables. Mixed farming was the primary occupation of most parents surveyed in both communities; 98(97.0%) for intervention area and 97(95.1%) for comparison area (p=0.77). Family size was found to be 5.72 ± 2.01 and 5.78 ± 2.15 (p=0.83) for intervention and comparison areas, respectively (table 1). All of the caregivers of the intervention area children and 99(97.1%) of those of the comparison area children were married (p=0.40). Regarding educational status, 78(79.6%) and 83(80.6%) of the caregivers of the intervention and comparison area children, respectively had no formal education (p=0.86) (table 1). And the relationship of the caregivers with the children was found to be 98(97.1%) and 103(100.0%) mothers, respectively for the intervention and comparison children (p=0.31).

However, more IC families were found to be Muslims (OR=1.94, 95% CI 1.00-3.77), less IC families use pipe water (OR=0.41, 95% CI 0.22-0.75) and more IC families use pit latrines with a platform rather than unsanitary methods (OR=3.9, 95% CI 1.06-14.4) than their counterparts (table 2). The association of these variables with the nutritional status of the children, however, was found to be non-significant.

The anthropometric data was collected from a total of 249 children of ages 6-59 months, 123 and 126 from the intervention and comparison areas, respectively. The sex distributions of the samples were found to be 63(51.2%) boys and 60(48.8%) girls for the intervention group and 61(48.4%) boys and 65(51.6%) girls for the comparison group (table 2). The mean age of the intervention and comparison area children were 27.65(±14.04) and 28.72(±14.90) months, respectively (table 1). A total of 204 mothers/caregivers of children <24 monhs were also interviewed, 101 from the intervention area and 103 from the comparison area.

TABLE 1: Mean family size and ages of participant children 6-59 months and their parents, Jeju District, Oromia Regional State, 2012

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The ages of the younger (6-36 months) children in both study groups were balanced; 19.31± 7.5 months and 19.62± 8.0 months for intervention and comparison area, respectively (p = 0.793). But, even though it is not statistically significant, the older (36-59 months) children of the intervention area tended to be younger than those of the comparison area 44.97 ± 6.4 months (intervention) versus 46.91± 6.3 months (comparison), (p = 0.169) (table 3). The age categorization 6 to 36 and 36 to 59 was used so as to be able to compare the impacts of the program between the program children and the children born after completion of the program.

TABLE 2: Socio-demographic characteristics of the households, Jeju District, Oromia Regional State, 2012

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4.2. Child Nutritional Status

Levels of underweight, stunting and wasting were found to be 12.2%, 29.3% and 6.5% for the intervention area children; and 22.2%, 42.1% and 4.8% for the comparison area children, respectively (figure 1). Odds Ratio for WAZ & HAZ indicated that 2.06 (95% CI 1.04-4.08) and 1.76 (95% CI 1.04-2.97) times more IC children, respectively have normal weight & height (table 3).

TABLE 3: Nutritional status of children, Jeju District, Oromia Regional State, 2012

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The intervention area children in the younger age group (6-36 months) were found to have better mean weight for age Z score than their counterparts (mean weight-for-age Z score (WAZ) -0.963 versus -1.308, respectively (p = 0.024) OR=3.393 (95% CI 1.35-8.54). The difference in mean WAZ of the intervention older (36-59 months) children, however, was found to be -1.265 Z, and -1.417 Z for their counterparts, which was statistically not significant (p = 0.430) (table 3).

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Figure 1: Nutritional status of Children of Jeju District, Oromia Regional State, 2012

Odds Ratio for HAZ by age category also indicated that the younger intervention group had 2.49 (95% CI 1.11-5.59) times more children who were better nourished than their older age group. There was no significant difference in nutritional status between the younger and older comparison children (table 3).

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Figure 2: Nutritional Status of Children by Age Category Jeju District, Oromia Regional State, 2012

The levels of underweight and stunting were, therefore, found to be lower among the PD/Hearth intervention area children, compared to those of the comparison area. This indicates that the under five children of the intervention area were relatively better nourished than those of the comparison area. The intervention of the PD/Hearth Program seems to have brought better child feeding behaviors in the intervention area resulting in better child nutritional status, even after the completion of the program. The level of wasting, however, is slightly higher among the intervention area, even though it is not statistically significant, which could be attributed to the smaller sample size.

The association of drinking water source and the type of latrines they used with nutritional status of the children were not found to be significant in this study (table 5). Hygiene and sanitation were found to be associated with child malnutrition in previous studies in Indonesia and Vietnam (Hidayat. 2009, Mackintosh et al., 2002).

TABLE 4: Association of religion and drinking water source to child nutritional status, Jeju District, Oromia Regional State, 2012

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Family size, caregiver’s education and marital status and age and sex of the children all showed a non-significant difference between the intervention and comparison groups. These factors, however, were found to be associated with nutritional status of children in the results of other studies conducted in the country (Solomon & Zemene, 2006; Tewodros et al., 2005). The similarity of these factors between the groups, in this study, supports the fact that the study groups had similar demographic and socioeconomic characteristics.


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Comparison of Child Nutritional Status Between Positive Deviance/Hearth (PD/Hearth) Intervention and Non-Intervention Areas in Jeju District, Arsi Zone, Oromia Regional State
Hawassa University  (Institute of Nutrition, Food Science and Technology)
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Hearth, positive deviance, malnutrition, nutrition, World Vision Ethiopia, Essential Nutrition Promotion, Jeju, Kebele
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Negassa Kinfu (Author), 2013, Comparison of Child Nutritional Status Between Positive Deviance/Hearth (PD/Hearth) Intervention and Non-Intervention Areas in Jeju District, Arsi Zone, Oromia Regional State, Munich, GRIN Verlag,


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