Infants and young children need diets high in nutrient density and diversity to meet the requirements of rapid growth and development. Our aim was to evaluate sociodemographic, agricultural diversity, and women's empowerment factors associated with child dietary diversity and length-for-age z-score (LAZ) in children 6-23 months using data collected as part of the Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study baseline survey in May-June 2016. We here present a novel analysis using directed acyclic graphs (DAGs) to represent our assumptions about the causal influences between the factors of interest and the outcomes. The causal diagrams enabled the identification of variables to be included in multivariable analysis to estimate the total effects of factors of interest using ordinal logistic/linear regression models. We found that child dietary diversity was positively associated with LAZ with children consuming 4 or more food groups having on average an LAZ score 0.42 (95% CI [0.08, 0.77]) higher than those consuming no complementary foods. Household production of fruits and vegetables was associated with both increased child dietary diversity (adjusted OR 1.16; 95% CI [1.09, 1.24]) and LAZ (adjusted mean difference 0.05; 95% CI [0.005, 0.10]). Other factors positively associated with child dietary diversity included age in months, socio-economic status, maternal education, women's empowerment and dietary diversity, paternal childcare support, household food security, fruit and vegetable cultivation, and land ownership.LAZ was positively associated with age, socio-economic status, maternal education, fruit and vegetable production, and land ownership.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

No abstract

IntroductionImproving complementary feeding in Ethiopia requires special focus on dietary diversity. The Sustainable Undernutrition Reduction in Ethiopia (SURE) programme is a government-led multisectoral intervention that aims to integrate the work of the health and agriculture sectors to deliver a complex multicomponent intervention to improve child feeding and reduce stunting. The Federal Ministries of Health and Agriculture and Natural Resources implement the intervention. The evaluation aims to assess a range of processes, outcomes and impacts.Methods and analysisThe SURE evaluation study is a theory-based, mixed methods study comprising impact and process evaluations. We hypothesise that the package of SURE interventions, including integrated health and agriculture behaviour change communication for nutrition, systems strengthening and multisectoral coordination, will result in detectable differences in minimum acceptable diet in children 6–23 months and stunting in children 24–47 months between intervention and comparison groups. Repeated cross-sectional household surveys will be conducted at baseline and endline to assess impact. The process will be assessed using observations, key informant interviews and focus group discussions to investigate the fidelity and dose of programme implementation, behavioural pathways of impact and contextual factors interacting with the intervention. Pathways of impact will also be explored through statistical analyses.Ethics and disseminationThe study has received ethics approval from the scientific and ethical review committees at the Ethiopian Public Health Institute and the London School of Hygiene and Tropical Medicine. The findings will be disseminated collaboratively with stakeholders at specified time points and through peer-reviewed publications and presentations.

BackgroundAlthough breastfeeding is almost universal in Ethiopia, only 52% newborns benefited from early initiation in 2011. Early initiation is one of the recommended interventions for saving newborn lives but its potential seems not yet realized for Ethiopian newborns and there is a need for continued efforts to increase coverage. To do so, it is also relevant to focus on consistent and accurate reporting of coverage in early initiation.WHO recommends the question “how long after birth did you first put [name] to the breast?” in order to assess coverage in early initiation. It is designed to measure the time after birth when the mother attempted to initiate breastfeeding regardless of whether breast milk had arrived or not. However, it is unclear how mothers perceive this question and what their responses of time refer to. In this study, we assessed Ethiopian mothers’ perception about the question assessing early initiation.MethodsCognitive interviews were conducted between April and May 2013 with eligible mothers in Basona and Debrebirhan woredas (districts), 120 km away from Addis Ababa, Ethiopia.ResultsA total of 49 mothers, most from Basona (n = 36) and the rest from Debrebirhan woredas (n = 13) were interviewed. No probes or follow on questions were required for mothers to understand what the WHO recommended question was about. However, further probing was needed to ascertain what maternal responses of time refer to. Accordingly, mothers’ response about the timing of early initiation was related to the first time the newborn received breast milk rather than their first attempt to initiate breastfeeding. In addition, considerable probing was required to approximate and code responses of time based on the WHO coding format because some mothers were unable to assess time in minutes or hours.ConclusionThe existing question is not adequate to identify intended attempts of mothers to initiate breastfeeding. We recommend revising the question as “how long after birth did you first put [name] to the breast even if your breast milk did not arrive yet?” Standard probes or follow on questions are required to avoid subjective interpretation of the indicator.

BackgroundEthiopia is among seven high-mortality countries which have achieved the fourth millennium development goal with over two-thirds reduction in under-five mortality rate. However, the proportion of neonatal deaths continues to rise and recent studies reported low coverage of the essential interventions saving newborn lives. In the context of low uptake of health facility delivery, it is relevant to explore routine practices during home deliveries and, in this study, we explored the sequence of immediate newborn care practices and associated beliefs following home deliveries in rural communities in Ethiopia.MethodsBetween April-May 2013, we conducted 26 semi-structured interviews and 2 focus group discussions with eligible mothers, as well as a key informant interview with a local expert in traditional newborn care practices in rural Basona woreda (district) near the urban town of Debrebirhan, 120 km from Addis Ababa, Ethiopia.ResultsThe most frequently cited sequence of newborn care practices reported by mothers with home deliveries in the rural Basona woreda was to tie the cord, immediately bath then dry the newborn, practice ‘Lanka mansat’ (local traditional practice on newborns), give pre-lacteal feeding and then initiate breastfeeding. For ‘Lanka mansat’, the traditional birth attendant applies mild pressure inside the baby’s mouth on the soft palate using her index finger. This is performed believing that the baby will have ‘better voice’ and ‘speak clearly’ later in life.ConclusionCoverage figures fail to tell the whole story as to why some essential interventions are not practiced and, in this study, we identified established norms or routines within the rural communities that determine the sequence of newborn care practices following home births. This might explain why some mothers delay initiation of breastfeeding and implementation of other recommended essential interventions saving newborn lives. An in-depth understanding of established routines is necessary, and community health extension workers require further training and negotiation skills in order to change the behaviour of mothers in practicing essential interventions while respecting local values and norms within the communities.