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Adding ENAM to the intervention pot to improve young children's diets in rural

Ghana

Grace S. Marquis, Ph.D.

School of Dietetics and Human NutritionCentre for Indigenous Peoples’ Nutrition and Environment

McGill UniversityNovember 17, 2008

Esi ColecraftProject manager

Felix BoaduDriver

Grace MarquisUS PI

Owuraku Sakyi-DawsonGhana PI Lorna

ButlerManjuReddy

Helen Jensen

ElizabethLonergan

US Co-PIs

Anna Lartey

Ben Ahunu

Emmanuel Canacoo

Ghana Co-PIs

Selasie Agamah, Gymfiwah NikoiAdministrative officer

Mawunyo Timbo, Gifty Nyarko Data entry

Richard Tweneboah-Kodua, Aaron ChristianField supervisors / data management

Felicia KudomorWinneba

Dinah AmoahTechiman

Thomas KambongaNavrongo

10 sponsored MSc students

(8 U of Ghana, 2 McGill)

William Quarmine, Clifford MarquayeData analysis assistants

Consequences of poor child nutrition

Reduced early developmentPhysical Cognitive

Increased severity of illness/mortalityIncreased risk with reproduction Poor birth outcomes Diminished productivity in adulthoodLost potential for a nation

8. Develop a global partnership for development7. Ensure environmental sustainability6. Combat HIV/AIDS, malaria and other diseases5. Improve maternal health4. Reduce child mortality3. Promote gender equality and empower women2. Achieve universal primary education

Millennium Development Goals (MDGs)

1. Eradicate extreme poverty and hunger

In Sept., 2000, Millennium Declaration was signed by 189 countries

“to create an environment – at the national and global levels alike –which is conducive to development and the elimination of poverty”

Improving nutrition is key to achieving the MDGs

Child nutritional status in sub-Saharan Africa

Demographic & Health Surveys

http://www.prb.org/Articles/2008/stuntingssa.aspx/?p=1

0

10

20

30

40

Country Rural Urban

1988199319982003

Prevalence of stunting among Ghanaian children < 5 y old

UNICEF. Global Framework for Action. 2006

UNICEF conceptual framework for child growth

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ENAM Project

Enhancing child Nutrition through Animal source food Management

Enam = “animal-based products” (Twi)Active CRSPs• Aquaculture CRSP

– Oregon State University• BASIS CRSP

– University of Wisconsin• Bean/Cowpea CRSP

– Michigan State University• Global Livestock CRSP

– University of California - Davis• Integrated Pest Management CRSP

– Virginia Tech • PEANUT CRSP

– University of Georgia• Soil Management CRSP

– University of Hawaii at Manoa• Sorgum/Millet CRSP

– University of Nebraska• Sustainable Agriculture and Natural Resource Management CRSP

– Virginia Tech

Demment M 2008

Collaborative Research Support Program (CRSP)

Phase 2Implement an income-generation

and education/training intervention

Phase 3Transfer of activities to local agents

for sustainability

Phase 1Participatory process to develop

problem modelPhase 1

Participatory process to develop problem model for constraints on

animal source foods (ASF)Availability

AccessibilityUtilization

RegionsEcological zones

Experience in region

Upper East

Brong-Ahafo

Central

Inquiry selection site

CommunitiesMinistry assisted

1 rural & 1 semi-rural/zone

InterviewsRegional & national managers in agriculture and health ministries

Tracking ASF sources

Inquiry: “What are the constraints on ASF?”

Focus groupsNon-governmental organization staffExtension workersCommunity leadersChild caregivers

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ParticipantsResearchersMinistry of Food and Agriculture (MOFA)/Women in Agriculture and Development (WIAD)

Ghana Health Services (GHS)Commodity organizations Non-governmental organizationsCommunity residents

OutcomesAnalysis of research resultsDevelopment of problem modelList of intervention approaches

Stakeholders’ workshop Problem model for constraints on ASF

Income

Marketing linkages

Processing and storage

Feeding skills and nutrition knowledge

Household food allocation

Cultural beliefs and attitudes

ASF

Availability

Accessibility

Utilization

Financial services

Seasonality

Pests and diseases

Caregiver empowerment

Household size

Number of extension field staff

Stimulate income-generation activities (IGA)Provide access to micro-credit loansFood processing/storage trainingEntrepreneurship/marketing training

Nutrition education training for caregivers

Dialogue with leaders/communities to change commonly held beliefs and support women

Extension continuing educationMinistry and NGO staff

Suggested interventions to overcome constraints

Community level

Regional/country level

Sample18 organizations/institutions in ENAM study areas

MethodsSemi-structured interviews

Program administrators and implementersInformal discussions

Program participantsObservations of program activitiesReview of program documentation when available

What are the “best practices” for IGA in Ghana?

Best practicesIndividual IGABoth cash and input may be requiredLoan is guaranteed by groupSmall weekly payments Renewal of IGA upon community completion

What are the “best practices” for IGA?

Identified gapsLimited emphasis on ASF-specific IGAInconsistent involvement with market linkagesLimited emphasis on nutrition education & evaluation

Phase 1

Problem modelComponents of intervention

Best practices for IGAPartners

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Phase 2Implement an income-generation

and education/training intervention

Research question

Does the implementation of an intervention with micro-credit, entrepreneurship training, and nutrition educationimprove household food security, use of animal source foods for children, and children’s nutritional status in rural Ghana?

Upper East

Brong-Ahafo

Central

Study site selection

2 intervention and 2 control communities per region Nutrition indicators among Ghanaian children < 5 y of age, by study region in 2003

0 10 20 30 40

Central

Brong-Ahafo

UpperEast

WastedUnderweightStunted

Percent of children (%)

DHS STATCompiler

Animal source foods regularly used, by region

Guinea savannahTransitional/forestCoastal savannah

Colecraft et al., Ecol Food Nutr 2006

0

10

20

30

40

50

60

70

80

90

100

Fish Chicken Cattle Goats Bushmeat Guineafowl

Pigs Sheep Dog/cat Eggs Milk

ASF sources

% o

f Foc

us g

roup

s

Upper East

Brong-AhafoCentral

Develop list of IGA

Reviewed IGA suitability

Cash flow analysis

Consensus on IGA to support

Develop support packages forselected IGA

Promotion of selected IGA

Community ENAM Team Community

Intervention: (i) identify IGA

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Feasible IGA Fish smoking FishmongerPoultry egg productionSelling of foodstuffsSelling of cooked foodsProcessing & sale of foods

(shea butter, rice parboiling)

Solidaritygroup

Caregiver self-selection

Loan appraisal

Orientation training

Eligible caregivers for solidarity groups (3-5/group)

Loan requirements:Group conceptLoan cycleRepayment and savingsEducation

Future loans require:Meeting attendanceSavingsGroup appraisal

Solidaritygroup

Solidaritygroup

Solidaritygroup

Intervention: (ii) organize micro-credit

CSA leadership (1/village)PresidentTreasurerSecretaryOrganizer

Development of group rules and by-lawsMembership requirementsPenalties

Solidaritygroup

Solidaritygroup

Solidaritygroup

Solidaritygroup

Credit & Savings Association

(CSA)

Example of 16-wk package: poultry egg production

20510015

4050

GrantSource of funds

5050

Repayable loan

585150

15320100

Total (US$)

345Total Point-of-lay birdsMedication

15Equipment280Feeding 50Housing

Caregiver contribution

Support category

Women developed individual business planRepayment feasible within 16-wk loan cycle$22-$141/cycle

Example: training in fish smoking

Construction of improved smoking oven Demonstration oven

Fish handling Smoked fish preservation

Technical assistanceMOFA/WIAD

Central and Upper East regions

Intervention: (iii) provide IGA training

Central region (2005)–Technical assistance: U of Ghana–Avian Influenza halted

Brong-Ahafo and Upper East regions (2007-2008): –Technical assistance: Heifer Int’l-Ghana

• Coup construction and maintenance• Poultry health & feed management• Interactions with veteran poultry farmers• Marketing of poultry products

–University of California Avian Flu School

Example: training in poultry raising

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Weekly education sessions before loan/saving paymentsGroup dynamicsNutrition focus: cycles 1, 2, 4

Technical assistanceHealth promotion Unit of Ghana Health ServicesWomen in Agriculture Development (WIAD)

Intervention: (iv) nutrition education

ApproachesFlip chart lesson plans

• Growing well• Child feeding styles• Malnutrition signs• Benefits of ASF• Balanced plate• Hygiene

Food demonstrations & recipes

Cooking competition to reinforce nutrition education lessons

Hygiene

Evaluation of meal preparedRationale focused on childKnowledgeable about nutritional valueIncludes ASF and iodized saltPracticalAdequate portion size

Feeding style

Weekly education sessions before loan/saving paymentsGroup dynamicsEntrepreneurial focus: cycles 2, 3, 4

Technical assistanceWomen in Agriculture Development (WIAD)

ApproachesGroup lessons with manualSkits on lessons learned

Intervention: (v) Entrepreneurial education(i) 180 participants

Open to all women with 2-5 y old children; self-selectedReceived the intervention (education & IGA)

(ii) 144 non-participants/intervention community Lived in same community; had 2-5 y old childSelected on internal wealth rankingNo IGA intervention/could have heard education

(iii) 287 controls Lived in similar, neighboring communities; had 2-5 y old childSelected on internal wealth rankingNo intervention (health education films)

Participant selection

Data Collection

Baseline

FUP1, 4 mo

FUP4, 16 mo

FUP2, 8 mo

FUP3, 12 mo

Longitudinal data

Longitudinal data collectedMicrocredit performance

Meeting attendanceRepaymentsSavingsCash flow for IGA (sub-sample)

Household Socio-demographicFood securityASF expenditures

Caregiver ExpendituresChild nutrition/health knowledge

Child Dietary intakes

FFQ Weighed food (subsample)

Anthropometry

Other data collectedCase studies (post intervention only)

Baseline household characteristics

Intervention communityControlsNon-

ParticipantsParticipants

3.13.8 6.8Not employed

36.936.363.163.756.1Low

44.2Medium/high

40.8

Head of household occupation,% *

72.972.463.6Agro-business8.415.417.3Trader

13.68.312.4Salary/artisan

Wealth rank,%52.947.2Extended families, %

* P<0.05

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Baseline caregiver characteristics

Intervention communityControls Non-participantsParticipants

4.13.844.439.751.456.4

Formal education,%50.3None46.0Primary3.7Secondary or above

33.2 ± 9.0

Main occupation,% *63.338.725.8Agro-business30.953.572.2Trader5.87.71.3Other/None

74.677.772.4Living with spouse,%32.4 ± 8.832.6 ± 8.9Age, y

* P<0.05

Baseline child characteristics

48.350.045.4Female,%3.12.81.2Wasted, %

28.533.828.6Stunted, %

-0.3 ± 0.9-0.3 ± 1.0-0.1 ± 0.9Weight-for-height Z *-1.4 ± 1.3-1.4 ± 1.2-1.3 ± 1.3Height-for-age Z-1.1 ± 1.0-1.0 ± 1.0-0.8 ± 0.9Weight-for-age Z

43.6 ± 12.3

16.415.58.1Underweight, % *

42.9 ± 11.638.9 ± 10.1Age, mo *

* P<0.05

Intervention community

Controls Non-participantsParticipants

Evidence that the intervention took place

0

25

50

75

100

Central Brong-Ahafo

UpperEast

% m

eetin

g at

tend

ance

cycle 1 cycle 2cycle 3 cycle 4

ENAM Project CSA members' weekly meeting attendance rates by loan cycle

Microcredit performance

16100%4

16-19100%3

16100%2

16-21 100%1WeeksRecovery Loan cycle

0

25

50

75

100

125

150

1 2 3 4

Loan Cycle

Mea

n s

aved

(G

hc)

Central Brong-Ahafo Upper East

0

25

50

75

100

125

150

1 2 3 4

Loan Cycle

Mea

n s

aved

(G

hc)

Central Brong-Ahafo Upper East

SavingsLoan increments

Caregivers’ perceptions of change in business earnings during the past 4 months, loan cycle 4

0

20

40

60

80

100

CSA member non-CSA member Control

Per

cent

of c

areg

iver

s (%

)

IncreasedUnchangedDecreased

Case studies: how do participants define success for ENAM?

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Independent researcherDr. Nana Akua Anyidoho (Inst. Statistical, Social and Economic

Research, University of Ghana)Gloria Y Kobati (Research Assistant, University of Ghana)

MethodsFocus groups

3; 1/region with 8 -10 CSA members eachCase studies

12 “successful”6 “less successful” (those that need a small push)

Life history interview with respondentInterviews with household members, SG, field officerObservations in householdENAM records

What would one expect to see in the life of a woman who is doing well in ENAM?

Indicators of ENAM success: (i) performance in CSA

Meeting attendancePunctualRegularCommitted to group activities / group

sacrifice

Repayments/savingsRegular and promptGood savings record

Hard working

Business has expanded

Good attitude towards:WorkCustomers

Able to sell & re-stock products quickly

Indicators of ENAM success: (i) business enterprises

Regular school attendance

Healthy & well dressed

Compound well kept

Indicators of ENAM success: (i) child welfare

Previous business

experiences

Higher loan amount

SUCCESS

Supportive family Healthy maternal status

Business commitment

and vision

What factors contribute to participants’ success …….

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Case study (Afia): ASF-related IGA

“Before the project, I would sell all the fish because I wanted the money. But now, I make sure there is always some fish left at home for them [the children]…I can tell you these practices have saved Dominic from a lot of illnesses… My other children did not benefit from what I now know and they were always falling ill…Dominic is very good in school, even the teachers say so. And I know this is because of what I feed him”.

Case study (Kapara): Increased income & educating peers

“I am able to buy any type of food I wish to give to my children. I am also able to pay their school fees without any difficulty. Generally, life is a lot easier for me today than before. Moreover, I have saved some money for my children’s future”.

She says that she teaches the ENAM nutritional education to her sister-in-law, who shares in the cooking for the household, so that no matter who cooks, the children enjoy good nutrition. A later conversation with the sister-in-law confirmed that, even though she is not in the ENAM project, she had significant knowledge of the nutritional lessons.

Case study (Assibi’s husband): family support

“This is the lean season when most households do not have food to eat…But we have enough money to buy food for the family and are not feeling the hunger like other people are. Since we are fishmongers, the children get to eat fish every day. And whenever my wife goes to town, she buys beef or goat meat, if she has money on her, and so the children eat food that ‘makes them strong’. … As you are aware, when a woman has money, the first thing on her mind is her children, and it is the same with my wife.”

Preliminary evidence that food insecurity decreased among intervention households

Described data have not been published yet.

Evidence that the promotion of ASF-related IGA may lead to increased ASF intakes among young children

Described data have not been published yet.

Preliminary evidence that ASF intakes increased among children in intervention households

Described data have not been published yet.

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Preliminary evidence that micronutrient intakes increased among children in intervention households

Described data have not been published yet.

Preliminary evidence that child growth improved among intervention households

Described data have not been published yet.

Phase 2

Community-based economic & educational intervention

Increased human & institutional capacity

Phase 3Transfer of activities to local agents

for sustainability

Partnerships to strengthen sustainability

ENAM interventions

Permanent Institutions

Enabling institutions& processes

Microfinance

Freedom from

Hunger

Entrepreneurial activities

Heifer

Nutrition education

Peer Education

Capacity building and systems strengthening

Rural Banks Communities

ParticipantsResearchersMinistriesNon-governmental organizationsCommunity residents

ObjectivesInitial research resultsPanel: ENAM participants voicesStudent presentations

Stakeholders’ workshop: Sustainability

OutcomesScaling upSustainability

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Enabling institutionsFreedom from Hunger, Ghana

Permanent institutionsRural banks (private)

Mechanism of sustainability“Credit with Education” via rural banks15% interest / 4 month cycle1st cycle in Central region = 320 women

Sustainability – (i) Access to credit Sustainability – (ii) IGA training

Enabling institutionsHeifer International, GhanaUC,Davis Avian Flu School

Permanent institutionsMOFAUniversity of Ghana

Mechanism of sustainabilityContinuing education courses

Sustainability – (iii) nutrition education

Enabling institutionsFreedom from Hunger, GhanaUniversity of Ghana

Permanent institutionsRural banksNGOGhana Health ServicesCommunities

Mechanism of sustainabilityPeer counseling“Credit with education”Continuing education courses

Sustainability – (iv) policies and directions

Enabling institutionsUniversity of Ghana (Vice-Chancellor’s Office)

Permanent institutionsBanking institutionsNGOMinistriesResearch/teaching universitiesCommunities

Mechanism of sustainabilityInter-institutional board

Phase 3

?

Key lessons learned

Enabling factors• Planning grant process• Identifying and applying ‘best

practices’ and lessons learned’ from stakeholder experiences

• Effective community participation processes

• Dynamic and committed field personnel

• Routine documentation/data collection and supervision enhanced accountability

• Integrating partners throughout process

Challenges• Fostering leadership

among women’s groups • Grappling with

sustainability issues• Linking research

institutions and implementation/policy institutions

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The ENAM Project is funded through the Global Livestock -CRSP funded in part by US-AID Grant No. PCE-G-00-98-00036-00; Women in Development, US-AID; and the Jim Ellis Graduate Mentorship Program.