Cogent Food & Agriculture

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Impact of agricultural interventions on food

and nutrition security in Ethiopia: Uncovering
pathways linking agriculture to improved nutrition

Muluken G. Wordofa & Maria Sassi |

To cite this article: Muluken G. Wordofa & Maria Sassi | (2020) Impact of agricultural
interventions on food and nutrition security in Ethiopia: Uncovering pathways linking
agriculture to improved nutrition, Cogent Food & Agriculture, 6:1, 1724386, DOI:
10.1080/23311932.2020.1724386

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Wordofa & Sassi, Cogent Food & Agriculture (2020), 6: 1724386
https://doi.org/10.1080/23311932.2020.1724386

FOOD SCIENCE & TECHNOLOGY | REVIEW ARTICLE

Impact of agricultural interventions on food and
nutrition security in Ethiopia: Uncovering
pathways linking agriculture to improved
Received: 25 January 2020 nutrition
Accepted: 27 January 2020
Muluken G. Wordofa1* and Maria Sassi2
*Corresponding author: Muluken
G. Wordofa, Department of Rural
Development and Agricultural
Abstract: Achieving sustainable food and nutrition security calls for multi-sectoral
Extension, Haramaya University, P.O. coordination mechanisms in implementing, among others, nutrition-sensitive agri-
Box 138, Dire Dawa, Ethiopia
E-mail: [email protected] cultural interventions. Despite progresses made in evaluating the effectiveness/
Reviewing editor:
impact of these interventions in some countries, very little is known about the
Fatih Yildiz, Middle East Technical nature and causal effect of these interventions in Ethiopia. Therefore, this sys-
University, Turkey
tematic review aims to provide evidence on the impact of nutrition-sensitive agri-
Additional information is available at cultural interventions and pathways linking agriculture to improved nutrition. Based
the end of the article
on a comprehensive advanced literature search using keywords in various data-
bases and setting inclusion/screening criteria, we identify 25 relevant studies con-
ducted between 2008 and 2018. Overall, we find positive effects on knowledge,
attitude, and practice of complementary feeding and economic indicators (income,
poverty and asset accumulation). We also find an overwhelming positive effect on
food consumption, dietary diversity, and food security indicators. However, we also
note mixed effectiveness in relation to child anthropometry. The most important
pathways linking agriculture to improved nutrition center on its role as a source of
food and income, and its effect on food prices/market. Hence, enhancing commu-
nity-based nutrition education, accelerating adoption of improved technologies,
improving access to farm inputs and technical information, integrating farmers to

ABOUT THE AUTHORS PUBLIC INTEREST STATEMENT

Muluken G. Wordofa (PhD) is an Assistant Agriculture continues to be the life support
Professor in the Department of Rural mechanism for millions of smallholders across
Development and Agricultural Extension, the globe. In addition to enabling food security,
Haramaya University. He also leads a Research the sector is expected to positively impact nutri-
Thematic Area (Institutions, Innovation Systems, tional security. Hence, there is a lot of attention
and Economic Development). He obtained his given to uncover the link between agricultural
PhD degree in Local Development and Global investments and changes on food security status,
Dynamics, MSc degree in Agricultural household dietary diversity, and overall economic
Development, and BSc degree in Agricultural development. In developing countries like
Extension from various European universities. Ethiopia, however, there is a scanty systematic
Maria Sassi (PhD) is a Professor of Agricultural and empirical literature available to shed light on
Economics serving at the Department of this role of agriculture. This contribution is, there-
Economics and Management, University of fore, an attempt made to illuminate the role
Pavia, Italy. In addition to her extensive research nutrition-sensitive agricultural interventions play
in food security, impact and other economic in the context of Ethiopian livelihoods.
issues, she taches Food Economics and
Agricultural Development and Quantitative
Policy Analysis for Development.

© 2020 The Author(s). This open access article is distributed under a Creative Commons
Attribution (CC-BY) 4.0 license.

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markets, and boosting enabling environments and capacities should be

emboldened.

Subjects: Environment & Agriculture; Development Studies; Economics & Development;

Rural Development

Keywords: nutrition-sensitive agriculture; effectiveness; impact; pathways; malnutrition;

food security
JEL CLASSIFICATION: D13; I31; O13; O33; Q12; Q16

1. Introduction
There have been growing global consensus that multi-sectoral approaches and coordination
mechanisms should be followed to address the debilitating impacts of malnutrition (FAO, 2017;
Sassi, 2017; World Bank, 2015). In particular, nutrition-sensitive interventions in the food and
agricultural sector are believed to play a pivotal role (Beyero, Judith, & Amanda, 2015; FAO,
2017; Herforth & Terri, 2016; Ruel & Harold, 2013) alongside the nutrition-specific interventions.
According to FAO (2017), nutrition-sensitive agriculture entails the sustainable production of
diverse, economically affordable, culturally acceptable, and safe animal-/plant-based foods in
adequate quantity and quality in order to satisfy the dietary needs of populations. Such interven-
tions can be a game-changer contingent upon favourable/enabling environments (Beyero et al.,
2015; Ruel & Harold, 2013), appropriate policy and governance structures (Turner et al., 2013), and
enhanced local implementation capacities (Warren and Edward, 2017).

In this regard, there have been progresses made in evaluating the effectiveness/impact of such
interventions (see, for instance, Rahman & Islam, 2014; Yosef, Andrew, Barnali, & Stuart, 2015;
Fiorella, Rona, Erin, & Lia, 2016). These studies provide evidence on how agriculture can potentially
influence nutrition, entry points into nutrition-sensitive agriculture, specific interventions with
a greater effect on nutritional outcomes, and challenges in targeting vulnerable segments of the
society. Nevertheless, gaps still remain to draw definitive conclusions. For example, there are
studies that show weak or little effect on nutritional outcomes (Haddad, 2013; McDermott,
Myriam, Julien, & Nancy, 2013; Ruel & Harold, 2013; Webb & Eileen, 2014) or mixed efficacy of
such interventions in some developing countries (Dorward, 2013).

A recent analysis shows weaknesses in study design, survey tools and measurements as the
major contributing factors (Webb & Eileen, 2014). Realizing these gaps and variations in the design
and implementation of nutrition-sensitive agricultural interventions across countries and regions,
there is a need to generate additional knowledge to build a strong evidence base. In particular,
methodologically rigorous and high-quality evaluations are required (Beyero et al., 2015; Girard,
Julie, Corey, & Olafunke, 2012; Ruel & Harold, 2013). Furthermore, location-specific research is
needed on many of the agriculture-nutrition pathways and processes (Yosef et al., 2015) and
diverse outcome indicators (Herforth & Terri, 2016).

Therefore, the present study is one that addresses these gaps in order to provide specific and
policy-relevant recommendations. In this regard, Ethiopia provides a special case because despite the
high commitment from the government and other stakeholders—reflected through the National
Nutrition Programme (NNP), increased budget, and promotion of nutrition-sensitive interventions—
undernutrition remains to be a serious challenge (see Section 2 for details). In addition, there is little
recent empirical evidence that evaluates the impact pathways especially after the introduction of the
NNP in 2008. Hence, this study is aimed at identifying nutrition-sensitive agricultural interventions in
the country, evaluating their impact primarily on food and nutrition security, and identifying key
pathways linking agriculture to enhanced food and nutrition outcomes.

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1.1. A brief review of agriculture-nutrition linkages in Ethiopia: progresses and gaps1

According to the Global Nutrition Report (2017), worldwide 23% of children under five years of age
were stunted and 8% were wasted in 2016. The data for Eastern Africa imply worsened conditions
especially for stunting (37%). In Ethiopia, both stunting (38%) and wasting (10%) were higher.
Huge gaps also remain in adolescent and adult nutritional status. Several interventions have been
initiated to address the underlying and immediate causes, and thereby curb the effect, of under-
nutrition in the country. The National Nutrition Strategy (NNS) was launched in 2008 and oper-
ationalized through the National Nutrition Programme (NNP). The NNP aims at mainstreaming
nutrition into the programming of various sectors. The NNP has five strategic objectives (Federal
Ministry of Health (FMOH) Government of Ethiopia, 2013): (1) improve nutritional status of women
(15–49) and adolescents (10–19), (2) improve nutritional status of infants, young children and
children under-five, (3) improve delivery of nutrition services for communicable and non-
communicable/lifestyle-related diseases, (4) strengthen implementation of nutrition-sensitive
interventions across sectors, and (5) improve multisectoral coordination and capacity. In the
2015–2020 revised NNP-II, the government is committed to reduce stunting to 26% by 2020
and to allocate additional domestic funding of US$15 million (FMOH, 2013).

The Ministry of Agriculture and Natural Resources (MOANR) also included nutrition-sensitive
provisions in the Productive Safety Net Program (PSNP) and Agricultural Growth Program II (AGP-
II). In addition to ensuring food security and better livelihoods, the current phase (2015–2020, i.e.,
PSNP4) focuses on addressing undernutrition through multisectoral programming (World Bank,
2015). The MOANR also drafted a strategic plan for nutrition-sensitive agriculture in October 2016
(The FDRE MONR, 2016). This strategy aims at: (1) increasing production of diverse nutrient-dense
foods, (2) increasing dietary diversity, (3) developing agricultural markets, and (4) enhancing
enabling environment for nutrition-sensitive agriculture (Ethiopian Agricultural Transformation
Agency [ATA], 2017). Other notable actions by the government include joining the global Scaling
Up Nutrition (SUN) movement in 2010 and the 2015 Seqota Declaration to end the stunting of
children under two years of age by 2030.

Despite these progresses, there are still widespread challenges associated with malnutrition in
the country. The country has the seventh highest number of stunted children in the world
(European Commission, 2017), and according to the Global Burden of Disease Study, childhood
stunting, wasting and underweight are the major reasons for deaths of children under five years of
age due to diarrhoea and other common infections (Deribew et al., 2010). Moreover, according to
Save the Children (2014), the cost of malnutrition to the national economy in 2013 was US$
4.7 billion (i.e., 16.5% of GDP). So, what is the contribution of nutrition-sensitive agricultural
interventions in the fight against malnutrition? This is one of the central questions that we
investigate in this review.

2. Data and methods

2.1. Conceptual framework

A careful consideration is made in the development of a conceptual framework that illustrates the
linkages between agriculture and nutrition and serves as a guide in the review process. In this
regard, the conceptual frameworks in previous reviews, such as in Masset, Lawrence, Alex, and
Jairo (2011), Gillespie, Harris, and Kadiyala (2012), Hawkes, Turner, and Waage (2012), Ruel and
Harold (2013), and Kadiyala, Jody, Derek, Sivan, and Stuart (2014) are critically evaluated. In
addition, conceptual frameworks in studies, such as Girard et al. (2012), Turner et al. (2013),
Webb (2013), and Herforth and Terri (2016) are assessed. Consequently, the framework by
Masset et al. (2011), with the addition of seven impact pathways (Webb, 2013), is adapted in
our investigation.

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2.2. Comprehensive literature search

As a second stage in the review process, past and current publications are searched to locate and
list all the relevant interventions, pathways and processes. A similar approach was followed in
previous studies (e.g., Girard et al., 2012; Masset et al., 2011; Turner et al., 2013; Webb & Eileen,
2014). The search is done in February 2018 on the following databases/search engines: PubMed,
Web of Science (All Databases), EconLit, Popline, Scopus, The Lancet, Proquest, AGRIS, ELDIS,
Ideas/repec, World Bank (Jolis), DFID, IFPRI, FAO (fapda) and Food Security Portal. The keywords
used in the search relate to: agriculture, nutrition, food production, rural development, homestead
garden, livestock, dairy, poultry, crop, food security, anthropometry, child growth, diet, health, and
sustainable development.

The studies obtained through the search procedure are scrutinized for relevance through setting
inclusion criteria. Such criteria were set and employed by previous studies, such as by Masset et al.
(2011), Girard et al. (2012), Turner et al. (2013), and Kadiyala et al. (2014). The present study
considers the following inclusion criteria: (1) time period: 2008–2018 (the year 2008 was chosen in
order to coincide with the onset of the Ethiopian National Nutrition Programme); (2) studies that
exclusively state improvements in nutritional outcomes as an objective; (3) studies that evaluate
the impact/effect of agricultural interventions; (4) availability and accessibility of full-length peer-
reviewed articles; and, (5) study design considerations. As a result, a total of 630 publications are
obtained using the advanced search in the title field. After checking for duplicates and irrelevant
contents, 284 papers are saved to Mendeley. From these, 163 relevant papers are found after
reading the title, abstract, and keywords. A full-length quick scan resulted in 75 potentially suitable
papers. Finally, after reading throughout these papers, 25 studies are selected for the review.2

3. Result and discussion

3.1. Description of the studies included in the review

The types of development interventions included in this review are given in Table 1. Geographically,
we note a high concentration of studies in few regions of the country, i.e., Southern Nations,
Nationalities and Peoples (SNNP), Amhara, Oromia, and Tigray. No studies are found for four
regions (Afar, Benishangul Gumuz, Gambela, and Harari), Dire Dawa Administrative Council, and
Addis Ababa City Administration. The main units of analysis in the reviewed studies are households
(20%), children 6–24 months old (20%), children under five years of age (16%), and mother/
caregiver and children (16%).

Table 1. Distribution of studies by intervention category

Intervention category Number of studiesa
Crop production 6
b
Livestock production and management (exclusive) 6
Livestock (general)c 5
Productive safety net program (PSNP) 3
Nutrition education and complementary feeding 4
Agricultural water use 3
Agricultural production (general)d 4
a
The numbers do not add up to 25 because some studies fell into more than one intervention category.
b
These refer to interventions that focused entirely on livestock production and management.
c
These are studies that have many components but treated livestock production as one aspect.
d
These refer to general agricultural activities as reflected by crop-livestock mixed farming, access to farmland or farm
input use.
Source: Based on the authors’ elaboration of reviewed papers.

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Concerning study design, 15 out of the 25 studies were based on cross-sectional survey design;
seven studies used quasi-experimental design; and, the rest employed longitudinal design. All the
studies used questionnaires to gather data; 12 of them applied measurements (to obtain anthro-
pometric data). Other methods, such as focused group discussions (FGDs), key-informant inter-
views (KIIs), and observations were rarely used. Data analysis was predominantly carried out
through regression techniques (60%) and mean comparisons (20%). Other analytical procedures
include propensity score matching (PSM) combined with regression (8%), PSM only (8%), and
qualitative analysis (4%). We identified a total of 21 outcome/impact indicators, which we grouped
into six broader categories following Herforth and Terri (2016).3

3.2. Effectiveness/impact of agricultural development interventions

3.2.1. The effect of crop production on dietary diversity, consumption practices, and child
anthropometry
The list of studies in the crop production category is presented in Table 2. We find that half of the
studies measured dietary diversity in children in Amhara (Beyero et al., 2015; Gebremedhin et al.,
2017) and SNNP (Dangura & Gebremedhin, 2017) regions. Overall, all the studies document
a significant positive association between ownership of home/backyard garden and children’s
dietary diversity. In particular, possessing home gardens doubled the likelihood of children having
minimum dietary diversity (Beyero et al., 2015). Dangura and Gebremedhin (2017) found that the
dietary diversity score of such children is 0.32 higher than their counterparts in households without
home gardens. Nonetheless, the relationship between home gardening and minimum meal fre-
quency is found to be insignificant (Beyero et al., 2015).

Three out of the six studies assessed changes in consumption practices. The assessment of the
orange-fleshed sweet potato (OFSP) intervention in the SNNP region revealed that although 63% of
the sampled households grew potato, only 7% of them produced OFSP. Moreover, it was found that
only 1% of the 63% of mothers consumed OFSP (Busse et al., 2017). Another study by Negash and
Swinnen (2013) showed that castor bean contract farming in the SNNP region increased food
consumption and reduced the length of food gap months.

Concerning child anthropometry, Zeng et al. (2017) showed that adoption of improved maize
varieties (IMV) positively and significantly affected children’s height-for-age Z-score (HAZ) and
weight-for-age Z-score (WAZ) but not weight-for-height Z-score (WHZ) in four regional states of
the country (i.e., Oromia, Amhara, SNNP, and Tigray). The empirical findings show that allocating
0.25 hectare of land for IMV cultivation resulted in a HAZ and WAZ increase of 0.257 and 0.176
standard deviations, respectively.

3.2.2. Livestock production and management

(a) Exclusive interventions in livestock production and management

Table 2. Characteristics of studies in crop production

Study Study unit Sample size
Busse et al. (2017) Mothers 150
Zeng et al. (2017) Children 1216
Negash and Swinnen (2013) Households 476
Beyero et al. (2015) Children 925
Gebremedhin et al. (2017) Children 2080
Dangura and Gebremedhin (2017) Children 417
Source: Based on the author’s elaboration of reviewed papers.

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Table 3. Characteristics of studies in the livestock sub-sector

Study Study unit Sample size
Kebebe (2017) Households 669
Geday et al. (2016) Households 333
Lenjiso et al. (2016) Households & children 0–59 164
months old
Headey et al. (2017) Mother & child (6–24 months old) 2104
dyads
Headey and Hirvonen (2016) Households & children 0–59 2704 households; 3494 children
months old
Hoddinott et al. (2015) Households & children 0–59 7930
months old
Source: Based on the author’s elaboration of reviewed papers.

Table 3 presents the six studies in this sub-category. It should be noted here that 50% of the
studies (Geday et al., 2016; Kebebe, 2017; Lenjiso et al., 2016) were based on quasi-experimental
designs of impact evaluation, with “intervention” and “control” groups specifically identified.
Moreover, these studies employed the propensity score matching (PSM) technique in their
analysis.

Four out of the six studies evaluated the impact on anthropometric indices. Starting with stunting
(HAZ), we find that all the studies provide evidence of a positive and significant reduction in stunting
levels. For instance, Hoddinott et al. (2015) showed that owning a single cow has the potential to
increase HAZ (between 0.25 and 0.47 standard deviations) and reduce stunting levels (between 6%
and 13%). Positive associations between livestock ownership and HAZ were also documented by
Headey et al. (2017) and Headey and Hirvonen (2016). Lenjiso et al. (2016) also found a significant
mean difference between non-participants and participants of the formal milk market. Concerning
wasting (WHZ), three out of the four studies measured it but found mixed results. Whereas Lenjiso
et al. (2016) and Hoddinott et al. (2015) found no significant impact, Headey et al. (2017) documented
a positive association between livestock ownership and WHZ. Lenjiso et al. (2016) also found
improvements in underweight (weight-for-age Z-score—WAZ) for children in market participant
households, although the estimated mean difference between participants and non-participants is
significant only with Kernel matching (and not with Nearest Neighbour matching).

Although the above studies provide empirical evidence that livestock ownership has the poten-
tial to improve nutrition, such a generalization is not always warranted. For instance, exposure to
livestock excreta was shown to negatively affect HAZ and WHZ in Ethiopia (Headey et al. 2017).
Likewise, keeping poultry in the same house with people is found to be negatively associated with
HAZ (Headey and Hirvonen, 2016).

Two of the six studies analyzed the causal effect on household income. Kebebe (2017) found that
adopters of dairy development interventions (i.e., cross-bred dairy cows and improved forage) earned
a significantly higher income than non-adopters. The milk value-chain participation study by Geday
et al. (2016) also found a positive and significant gain in household income, although the Kernel
matching result was not significant, casting doubts on the robustness of the impact estimates.

A positive and significant effect was also found for dietary diversity in three out of six studies.
A unique feature of the study by Lenjiso et al. (2016) is that it provides, in addition to the
household dietary diversity, an analysis result of intra-household dietary diversity. In addition to
dietary diversity, Geday et al. (2016) also showed that per-capita calorie intake was higher for
participants. Nevertheless, similar to our earlier reservation, the average treatment effect (ATT)
should also be treated with caution for the same reason.

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Some of the studies investigated the impact on production, consumption, and marketing of
animal source foods (ASFs). The evaluation by Lenjiso et al. (2016) showed that milk production
was higher for market participant households. Concerning consumption, however, there are mixed
findings. Whereas Hoddinott et al. (2015) found that cow ownership increases the probability and
frequency of milk consumption, Geday et al. (2016) showed that participants of the milk value
chain consumed less milk. On the contrary, Lenjiso et al. (2016) documented no significant
difference between milk market participants and non-participants. There are also mixed findings
on the consumption of other ASFs. Despite the findings that egg consumption by children
increased, no evidence was found for increased consumption of meat and other dairy products
due to poultry production (Headey and Hirvonen 2016). Hoddinott et al. (2015) demonstrated that
cow ownership significantly increases dairy product consumption. In relation to marketing, Lenjiso
et al. (2016) found that milk market participants sold higher quantities of milk, which may be the
reason why such households had a lower level of milk consumption.

Only one of the six studies assessed the effect of livestock production on child illness and
maternal/child cleanliness (Headey et al., 2017). The results indicate a strongly negative associa-
tion between the presence of animal excreta around the homestead and maternal/child cleanli-
ness. However, the presence of animal faeces or ownership of livestock was found to be not
associated with illness (e.g., diarrhoea, fever, and cough/cold).

(b) Other studies with a livestock component

The list of studies that have a livestock component is depicted in Table 4. The major focus of
these studies is dietary diversity. It has to be noted, however, that none of these studies are strictly
impact evaluations. In general, all the studies found a positive association between livestock
ownership and dietary diversity. Specifically, it is noteworthy that although a huge rural-urban
gap in children’s dietary diversity was revealed, the higher probability of owning livestock in rural
areas contributed to narrowing down this difference (Hirvonen, 2016). Concerning diet quantity,
Goshu et al. (2013) found no effect on daily calorie availability.

3.2.3. The Productive Safety Net Program (PSNP) and its impact on food security, asset holding,
and child nutrition
Three studies investigated the impact of Ethiopia’s Productive Safety Net Program (PSNP) on food
and nutrition security (Table 5). In a relatively large study based on longitudinal data obtained
from four regions of the country (i.e., Oromia, Amhara, SNNP, and Tigray), Berhane et al. (2014)
estimated impact of the PSNP, and that of other food security programs (OFSP) and household
asset building programs (HABP) operating in the study regions. In doing so, the study not only
accounted for some potential confounders but also quantified the combined impact of the PSNP
and these programs. A key finding of the study is that participation in the PSNP improved food
security and raised livestock holdings. The combined impact of the PSNP and OFSP/HABP is shown
to be greater than the impact of each intervention separately.

Table 4. Characteristics of other studies in livestock production and management

Study Study unit Sample size
Goshu et al. (2013) Households 260
Hirvonen (2016) Children 2898
Hirvonen et al. (2017) Households & children 775
Gebremedhin et al. (2017) Children 2080
Dangura and Gebremedhin (2017) Children 417
Source: Based on the author’s elaboration of reviewed papers.

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Table 5. Characteristics of studies in the Productive Safety Net Program (PSNP)

Study Study unit Sample size
Berhane et al. (2014) Households 3140
Debela et al. (2015) Children <5 years 383
Baye et al. (2014) Households & children 195
Source: Based on the author’s elaboration of reviewed papers.

The findings of Debela et al. (2015) in Tigray region revealed that children in PSNP member
households have WHZ that were higher than those of children in non-member households. In
another PSNP evaluation, Baye et al. (2014) documented that the dietary diversity of households
receiving food was significantly lower than that of households receiving cash. Households receiving
cash had significantly higher levels of consumption of oils and fats, and somewhat higher con-
sumption of legumes and dairy products. Although statistically insignificant, the average HAZ and
the prevalence of stunting were also lower in households receiving cash.

3.2.4. Nutrition education/complementary feeding interventions

The first three studies in Table 6 assessed the mediating role of nutrition education interventions in
promoting pulse-based complementary feeding practices in the SNNP region.

One of the major findings of Yetnayet et al. (2017) relates to knowledge, attitude, and practice
(KAP) of food-based approaches to nutrient deficiency. In this regard, the study found significant
changes in the KAP scores of the participants due to exposure to the intervention. Concerning
consumption, the study showed substantial improvements in the proportion and consumption
frequency of pulse-based diets in the intervention group. Similar changes in knowledge and
practice of complementary feeding were documented by Negash et al. (2014). However, unlike
Yetnayet et al. (2017), they did not measure changes in attitude. Analogous to the findings in
Yetnayet et al. (2017), there is clear evidence on the enhanced consumption of legumes as a result
of the intervention. An added dimension in this study, unlike Yetnayet et al. (2017), is the analysis
pertaining to anthropometric indices, although no significant changes in height and weight of
children were detected.

The findings reported in Mulualem et al. (2016) are also the same as those found in Yetnayet
et al. (2017) for KAP scores and consumption practices. They are also related to Negash et al.
(2014) in terms of knowledge and practice scores. However, contrary to Negash et al. (2014),
Mulualem et al. (2016) found a positive and significant effect of the intervention on WAZ and WHZ.
However, the effect of the intervention on HAZ was found to be negative. The study by Hirvonen
et al. (2017) investigated the role of caregiver’s nutrition knowledge on dietary diversity of children
in north-west Ethiopia and found a positive and considerable effect. However, the study also
illustrated that the impact of nutrition knowledge decreases as one moves far away from the

Table 6. Characteristics of studies in nutrition education and complementary feeding

Study Study unit Sample size
Yetnayet et al. (2017) Women 15–49 years old 200
Negash et al. (2014) Caregivers (mothers) & children 197
6–23 months old
Mulualem et al. (2016) Mother-child pairs 160
Hirvonen et al. (2017) Households & children under five 775
Source: Based on the author’s elaboration of reviewed papers.

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main market, suggesting that the caregiver’s nutrition knowledge translates to improved dietary
diversity conditional on well-functioning markets.

3.2.5. Agricultural water use (irrigation) interventions

There are three studies on agricultural water use (Table 7). Surprisingly, the observational study in
Central and Hararghe highlands found that irrigation water use adversely affects the household’s
daily calorie availability, diet diversity, and food security status (Goshu et al., 2013). In a stark
contrast, however, Cafer et al. (2015) showed a positive effect of small-scale irrigation on food
security in Amhara region. This study also found higher crop diversity and better nutritional status
in villages where irrigation is practiced. Moreover, crop loss was minimal and drought-tolerance
capacity was better in these villages.

The study by Hagos et al. (2017) also provides evidence for a positive effect of irrigation on the
depth and severity of poverty. The study found a statistically significant difference between spate
irrigation users and non-users in terms of absolute poverty, poverty gap, and severity of absolute
poverty. The comparison between traditional and modern spate irrigation schemes indicated that
the use of modern spate irrigation resulted in a significant reduction of household poverty levels.

3.2.6. Effect of general agriculture interventions on dietary diversity, food security, and
nutritional status
The studies investigating the effect of food production and access to farm resources (i.e., general
agriculture) are given in Table 8. We note that all the studies are not strictly impacted evaluations. Two
of the studies found that dietary diversity is enhanced through improved access to farm resources (i.e.,
fertilizer in Goshu et al., 2013) that could result in production diversity. Hirvonen and Hoddinott (2017)
showed that a one food group increase in household’s production diversity leads to a 0.49 (Poisson
regression) to 0.62 (OLS regression) food group improvement in child’s dietary diversity score.

The two studies that assessed food security found that access to farmland (Cafer et al., 2015)
and the use of fertilizer (Goshu et al., 2013) had a positive effect on food security status. In
addition, Goshu et al. (2013) found that fertilizer use enhanced daily calorie availability and intake.
However, the studies investigating nutritional status reported conflicting results. Whereas Cafer
et al. (2015) documented that access to farmland plays a significant role in household nutritional
status, Derso et al. (2017) found higher odds of stunting among children whose parents use their
own production as a source of food.

Table 7. Characteristics of studies in irrigation water use

Study Study unit Sample size
Goshu et al. (2013) Households 260
Cafer et al. (2015) Individuals 433
Hagos et al. (2017) Households & children under five 122
Source: Based on the author’s elaboration of reviewed papers.

Table 8. Characteristics of studies in general agriculture

Study Study unit Sample size
Goshu et al. (2013) Households 260
Cafer et al. (2015) Individuals 433
Hirvonen and Hoddinott (2017) Households and children 6–59 7011 households; 3448 children
months
Derso et al. (2017) Mother–child (6–24 month) pairs 587
Source: Based on the author’s elaboration of reviewed papers.

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3.3. Impact pathways from agriculture to improved nutrition

In the 25 studies reviewed, we find varying levels of evidence for 6 impact pathways. No evidence
is found for agricultural interventions affecting nutrition through women’s enhanced control over
resources. Overall, the most dominant mechanism linking agriculture to improved nutrition out-
comes is through the production of crops to increase household consumption. This is followed by
the income effect of agriculture. We find a very meagre support for the role of agriculture in
enhancing non-food expenditures, and the nutrition and health of the household (Figure 1).

In Table 9, we present the proportion of the key pathways by intervention category. Although
some pathways are common across the interventions, there are also a few of them uniquely
important in only some intervention categories (see, for instance, “women’s time and caring
practices” in the PSNP and nutrition education interventions). In general, in six out of seven
categories, we find more than three mechanisms from agriculture to nutrition. In what follows,
we present discussions by intervention category.

3.3.1. Impact pathways in crop production

Overall, in all the studies in crop production, we find overwhelming evidence that crop production
contributed to household’s own consumption by serving as a source of food. For instance, Zeng
et al. (2017) showed that improved maize cultivation raises household own-produced maize
consumption that translates to increments in HAZ, WAZ, and WHZ. Likewise, Gebremedhin et al.
(2017) indicated that households with home gardens are twice as likely to provide diversified food
to their children. Beyero et al. (2015) found that most farmers possessing home gardens used the
produce for home consumption. Likewise, Dangura and Gebremedhin (2017) documented that
many children in household’s producing fruits and vegetables consumed vitamin A-rich foods.
Finally, Negash and Swinnen (2013) illustrated that the production of cash crop (castor bean)
helped farmers store their food crops to be consumed during the lean season.

Regarding the income effect of crop production, we find evidence only in one study (Negash and
Swinnen 2013). In that study, it was shown that households earn income by selling castor beans.
Such contract farming schemes also safeguarded farmers against low food crop prices during
harvest because the farmers sell their castor beans to generate income, but store their food crops
to be consumed or sold later. Hence, the households involved in the contract farming did not have
to pay higher prices for food during the lean season. The OFSP study by Busse et al. (2017) suggests
that women’s own health and nutrition could be improved through enhanced production and
consumption of OFSP.

Figure 1. Proportion of identi-

fied key pathways (y-axis) from Nutrition and health 12.90%
agriculture to nutrition

Source: Authors’ calculations. Time and caring practices 19.35%

Non-food spending 6.45%

Food prices/market 35.48%

Source of income 45.16%

Source of food 90.32%

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 Table 9. Agriculture to nutrition pathways by intervention category
Pathways Intervention category (per cent)
https://doi.org/10.1080/23311932.2020.1724386

Crops Livestock Livestock Nutrition The PSNP Irrigation General

(exclusive) (general) education/ agriculture
complementary
Wordofa & Sassi, Cogent Food & Agriculture (2020), 6: 1724386

feeding
Source of food 100.00 100.00 60.00 75.00 100.00 100.00 100.00
Source of income 16.67 66.67 40.00 0.00 100.00 100.00 25.00
Food prices/market 16.67 33.33 40.00 25.00 100.00 33.33 25.00
Non-food spending 0.00 16.67 0.00 0.00 0.00 33.33 0.00
Time and caring 0.00 0.00 20.00 75.00 66.67 0.00 0.00
practices
Nutrition and health 16.67 33.33 0.00 25.00 0.00 0.00 0.00
Source: Authors’ calculations.

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3.3.2. Impact pathways in livestock production and management

As can be seen in Table 9, the most prominent mechanisms in this category are through increased
consumption and income. Concerning the consumption of animal source foods (ASFs), Hoddinott
et al. (2015) found that cow ownership increases the likelihood and frequency of consuming milk,
cheese, and yoghurt. Similarly, Headey and Hirvonen (2016) showed that poultry ownership
increases the probability of egg consumption, but not the consumption of other ASFs. Contrary
to Hoddinott et al. (2015) regarding milk consumption, Geday et al. (2016) found a negative
relationship between production and household consumption due to the fact that most of the
milk produced was sold. Lenjiso et al. (2016) found no significant difference in terms of milk
consumption for the same reason. Similar to Headey and Hirvonen (2016), however, Lenjiso
et al. (2016) also found no significant difference in terms of consumption of other ASFs.
Suggestive evidence about enhanced consumption is also found in Kebebe (2017) and Headey
et al. (2017).

Concerning the income effect of livestock interventions, we find evidence in four out of six
studies. For instance, Kebebe (2017) found that adoption of cross-bred dairy cows and improved
forages resulted in increased income; Lenjiso et al. (2016) showed that milk market participants
have higher income that helped them boost their dietary diversity; and, Geday et al. (2016)
indicated that higher incomes resulting from dairy value-chain participation may lead to consump-
tion of better or diversified foods.

In relation to food prices/market, we find evidence only in two studies. Whereas Geday et al.
(2016) indicated that higher income from milk value-chain participation can improve the ability of
households to buy nutritious foods from the market (i.e., food expenditure), Hoddinott et al. (2015)
argued that cow ownership is less relevant in situations where households have better access to
markets. The study by Geday et al. (2016) also provided indicative evidence that higher income due
to milk market participation can improve non-food expenditures.

Two studies indicated that exposure to livestock excreta can have adverse effects on nutrition
and health. In particular, Headey and Hirvonen (2016) showed that indoor keeping of poultry is
negatively associated with children’s HAZ. Likewise, Headey et al. (2017) found that livestock
ownership and poor personal cleanliness are strongly associated with the presence of animal
excreta. Finally, among the five general livestock-related studies, we find evidence for consump-
tion in three studies (Goshu et al., 2013; Hirvonen, 2016; Gebremedhin et al., 2017). Goshu et al.
(2013) and Gebremedhin et al. (2017) also contain some proof for income effect. Gebremedhin
et al. (2017) and Hirvonen et al. (2017) provide support for food price/market effect. Lastly,
Hirvonen et al. (2017) showed that nutrition knowledge of caregivers positively affects children’s
dietary diversity through enhanced caring practices.

3.3.3. Impact pathways in nutrition education and complementary feeding interventions

As can be seen in Table 9, the two dominant pathways in this category are improved consumption
and caring practices. Three out of four interventions provide evidence that nutrition education
sessions enhanced consumption of locally available pulse-based diets by women and children
(Negash et al., 2014; Mulualem et al., 2016; Yetnayet et al., 2017). Additionally, we find evidence on
enhanced caregivers’ knowledge and practices regarding complementary feeding (Negash et al.,
2014; Mulualem et al., 2016; Hirvonen et al., 2017). Nevertheless, as Hirvonen et al. (2017) caution,
better nutrition knowledge translates to substantial improvements in children’s dietary diversity
only in areas with relatively good market access, or better own production of nutritious foods. The
market-related result complements the findings of Hoddinott et al. (2015) regarding the impor-
tance of integrating smallholders to well-functioning markets. Finally, it can be deduced from
Yetnayet et al. (2017) that increased consumption of pulse-based foods can stimulate women’s
own nutrition and health.

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3.3.4. Impact pathways in the Productive Safety Net Program (PSNP)

In all the PSNP interventions, we find strong evidence for enhanced consumption, income, and
food price/market effects. The food-for-work component of the PSNP is one pathway to enhance
household consumption. The cash transfer component of the PSNP works to improve household
income that translates to, for instance, higher consumption of ASFs and vitamin A-rich plant foods
(Baye et al., 2014). The PSNP also generally improved the household’s purchasing power despite
the rising food prices (Berhane et al., 2014) that adversely affect beneficiaries of the cash transfer
component of the PSNP (Baye et al., 2014). Finally, since most Public Works activities of the PSNP
occur in the months between January and June (Berhane et al., 2014), extra female labour can be
mobilized for such activities (Debela et al., 2015) without affecting their time for farming and
caring practices.

3.3.5. Impact pathways in agricultural water use (irrigation) interventions

In all the studies in agricultural water use, we find evidence for consumption and income effects.
Generally, irrigation helped households produce diversified crops. However, Goshu et al. (2013)
argue that the focus of crop production in irrigated agriculture may shift from staple food crop to
cash crop production. This, in turn, may result in increased household income (Cafer et al., 2015;
Hagos et al., 2017). Hagos et al. (2017) also showed that food and non-food expenditures were
significantly higher for irrigation users, although the items purchased did not appear to have
contributed to improved nutrition.

3.3.6. Impact pathways in general agriculture

All the studies in this category provide evidence for the consumption effect. For instance, access to
farmland enhances crop diversity (Cafer et al., 2015), and increased crop diversity leads to
improved children’s dietary diversity (Hirvonen and Hoddinott, 2017). Contrary to these, own
production as a source of food is found to be significantly associated with higher odds of stunting
probably due to low productivity and poor complementary feeding practices (Derso et al., 2017).
Regarding income effect, Goshu et al. (2013) showed that an increase in crop income reduced total
income inequality. Finally, Hirvonen and Hoddinott (2017) illustrated that market access plays
a greater role than production diversity in children’s dietary diversity.

4. Conclusions and policy implications

In the present study, we investigate the impact of agricultural interventions and discuss the
pathways linking agriculture to improved food and nutrition outcomes. Overall, we find
positive effects on knowledge, attitude, and practice (KAP) and economic indicators (income,
poverty and asset accumulation). We also find an overwhelming positive effect on food
consumption, dietary diversity, and other food security indicators. However, we also note
mixed effectiveness pertaining to anthropometric indices.4 In addition, the most important
pathways linking agriculture to improved nutrition center on its role as source of food, source
of income, and food prices/market. Consequently, the following are lessons and recommen-
dations for practitioners, planners and implementers of nutrition-sensitive interventions, and
policy makers.

To start with, sustained community-based nutrition education interventions in diverse agro-

ecological settings are important to accelerate the adoption of improved technologies and best
practices, and promote household’s consumption of nutrient-dense foods. Such efforts should be
complemented by strategies to improve access to farm inputs, physical and financial resources,
technical information, and input/output markets. Social protection schemes, such as the PSNP,
should be integrated with other rural development interventions for maximum effectiveness and
sustainability of impact.

The design, implementation, and evaluation of such interventions should take into account
several issues. First, increased coordination among multisectoral actors (especially agricul-
tural education, research and extension; health and nutrition) is required to build capacities

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at various levels. Second, the interventions should be designed and implemented in such
a way that they contribute to improvements in nutrition and health outcomes of individuals,
households and communities. In this regard, there should be a concerted effort to improve
methodological approaches: include diverse agricultural, health and nutrition indicators; col-
lect pre-intervention/baseline data; implement (quasi-) experimental designs in treatment
allocation; gather time-series/panel data that can capture seasonality of production and
consumption; and, employ rigorous impact evaluation techniques that account for unob-
served heterogeneity, spillover effects, and sensitivity of parameter estimates to different
specifications. Moreover, there should be a special attention on more qualitative studies and
mixed research designs in order to capture evolutionary dynamics in food habits and con-
sumption patterns and preferences. Finally, future research should also investigate, in addi-
tion to the abovementioned issues, the impact of policies and governance structures and
research and development expenditures in relation to nutrition-sensitive agricultural inter-
ventions by employing meta-analysis techniques.

Notes References
1. See Appendix A for more on trends and patterns. Baye, K., Negussie, R., & Cherinet, A. (2014). Comparison of
2. See Appendix B for a complete bibliography of the the effects of conditional food and cash transfers of the
studies included in the review. ethiopian productive safety net program on household
3. See Appendix C for details. food security and dietary diversity in the face of rising
4. See Appendix D for a pictorial summary of the overall food prices: Ways forward for a more nutrition-sensitive
impact of the interventions. program. Food and Nutrition Bulletin, 35(3), 289–295.
Berhane, G., Daniel, O. G., John, H., Neha, K., &
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Appendix A
Brief Review of Agriculture-Nutrition Linkages in Ethiopia

As a result of the actions taken by the government and other stakeholders, some progresses
have been made. For instance, in 2016, undernourishment decreased to 28.8%; depth of food
deficit decreased to 201 kcal/capita/day; and, GDP per capita (PPP, constant 2011 international
$) increased to 1,608.3 (FAOSTAT, 2018). As can be seen in Table 1, the country reduced
children underweight to 23.3%; infant mortality rate (number of deaths per 1,000 live births)
to 48; and, under-five mortality rate (number of deaths per 1,000 live births) to 67. Available
evidence also indicates that exclusive breastfeeding of infants under six months increased to
58% and the prevalence of anaemia decreased to 24% among women of reproductive age.
Likewise, the median duration of exclusive breastfeeding increased from 2.5 to 3.1 months; the
percentage of mothers receiving antenatal care (ANC) increased from 27% to 62%; and,
institutional delivery by women increased from 5% to 26% during the period 2000 to 2016
(CSA and ICF, 2016).

Appendix B
Complete List of the 25 Studies Included in the Review

(1) Baye K, Negussie R, and Cherinet A. (2014). Comparison of the Effects of Conditional Food and Cash
Transfers of the Ethiopian Productive Safety Net Program on Household Food Security and Dietary
Diversity in the Face of Rising Food Prices: Ways Forward for a More Nutrition-Sensitive Program. Food
and Nutrition Bulletin 35(3): 289–95.

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Table A1. Trends in Undernutrition, Health and Mortality in Ethiopia, 2000–2016

2016 2011 2005 2000
Stunting of children 38.4 44.4 50.8 57.7
U5 years of age (%)
a,b,c

Wasting of children 9.9 9.7 12.2 12.2

U5 years of age (%)
a,b

Children 23.3 28.7 32.9 41.2

b
underweight (%)
Overweight of 1 - - -
children U5 years of
age (%) b
Exclusive 58.0 52 49 -
breastfeeding of
infants U6 months
(%)b
Median duration of 3.1 2.3 - 2.5
exclusive
breastfeeding
(months)b
Maternal health 62 34 - 27
care (antenatal
a
care – ANC in %)
Institutional 26 10 - 5
delivery (%)a
Total fertility rate 4.6 4.8 5.4 5.5
(15–49) – number
per woman b
Infant mortality 48 59 77 97
rate – number per
1,000 live birthsb
U5 mortality rate – 67 88 123 166
number per 1,000
live births b
Prevalence of 24.0 17 27 -
anaemia (%)b
Women of
reproductive age
Children (6–59 57 44 54 -
months)
Iodized salt use 89 15 - -
(%)b
a
Ethiopia Demographic and Health Survey 2016, key indicators (as reported in European Commission. Country Profile
on Nutrition (Ethiopia). July 2017).
b
The DHS Program Country QuickStats – https://www.dhsprogram.com – 19 October 2017. Central Statistical Agency
(CSA) [Ethiopia] and ICF, 2016. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville,
Maryland, USA: CSA and ICF.
c
National target by 2020: 26% (4 million); WHA target by 2025: 3.68 million; Expected by 2025 (according to current
trend): 5.05 million.
Note: WHA – World Health Assembly; DHS – Demographic and Health Survey (Ethiopia); U5 – under five; SDG –
Sustainable Development Goal.

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(2) Berhane G, Daniel OG, John H, Neha K, and Alemayehu ST. (2014). Can social protection work in
Africa? The impact of Ethiopia’s productive safety net programme. Economic Development and
Cultural Change 63(1): 1–26.
(3) Beyene M, Abebaw GW, and Molla MW. (2015). Dietary Diversity, Meal Frequency and Associated
Factors among Infant and Young Children in Northwest Ethiopia: A Cross- Sectional Study. BMC
Public Health 15(1): 1007.
(4) Busse H, Henok K, Ptak M, and Fofanah M. (2017). A Food-Based Approach to Reduce Vitamin
A Deficiency in Southern Ethiopia: A Cross-Sectional Study of Maternal Nutrition and Health
Indicators. African Journal of Food, Agriculture, Nutrition and Development 17(3): 12226–42.
(5) Cafer AM, Mary SW, Shimelis B, and Martha M. (2015). Growing Healthy Families: Household
Production, Food Security, and Well-Being in South Wollo, Ethiopia. Culture, Agriculture, Food and
Environment 37(2): 63–73.
(6) Dangura D, Samson G. (2017). Dietary Diversity and Associated Factors among Children 6–23
Months of Age in Gorche District, Southern Ethiopia: Cross-Sectional Study. BMC Pediatrics 17(1): 6.
(7) Debela BL, Gerald S, and Stein TH. (2015). Does Ethiopia’s Productive Safety Net Program Improve
Child Nutrition? Food Security 7(6): 1273–89.
(8) Derso T, Amare T, Gashaw AB, and Molla MW. (2017). Stunting, Wasting and Associated Factors
among Children Aged 6–24 Months in Dabat Health and Demographic Surveillance System Site:
A Community Based Cross-Sectional Study in Ethiopia. BMC Pediatrics 17(1), 96.
(9) Elias AG, Tolossa D, Padilla M, Montaigne E. (2016). Food Security and Nutrition Impacts of
Smallholder Farmers’ Participation in Dairy Value Chain in Ethiopia. Journal of International
Business and Economics. 16.
(10) Gebremedhin S, Kaleab B, Tilahun B, Manisha T, Yonas A, Yewelsew A, and Nigusse R. (2017).
Predictors of Dietary Diversity in Children Ages 6 to 23 Mo in Largely Food-Insecure Area of South
Wollo, Ethiopia. Nutrition 33(January): 163–68.
(11) Goshu D. (2013). Measuring Diet Quantity and Quality Dimensions of Food Security in Rural Ethiopia.
Journal of Development and Agricultural Economics 5 (5): 174–85.
(12) Headey D, Kalle H. (2016). Is Exposure to Poultry Harmful to Child Nutrition? An Observational Analysis for
Rural Ethiopia. Edited by Jacobus van Wouwe. PLOS ONE 11(8). Public Library of Science: e0160590.
(13) HeadeyD, Phuong N, Sunny K, Rahul R, Marie R, and Purnima M. (2017). Is Exposure to Animal Feces
Harmful to Child Nutrition and Health Outcomes? A Multicountry Observational Analysis. American
Journal of Tropical Medicine and Hygiene 96(4): 961–69.
(14) Herforth A, Terri JB. (2016). Nutrition indicators in agriculture projects: Current measurement,
priorities, and gaps. Global Food Security 10(2016): 1–10.
(15) Hirvonen K. (2016). Rural–urban Differences in Children’s Dietary Diversity in Ethiopia: A Poisson
Decomposition Analysis. Economics Letters 147: 12–15.
(16) Hirvonen K, and John H. (2017). Agricultural Production and Children’s Diets: Evidence from Rural
Ethiopia. Agricultural Economics 48(4): 469–80.
(17) Hirvonen K, John H, Bart M, and David S. (2017). Children’s diets, nutrition knowledge, and access to
markets. World Development 95(2017): 303–315.
(18) Hoddinott J, Derek H, and Mekdim D. (2015). Cows, Missing Milk Markets, and Nutrition in Rural
Ethiopia. Journal of Development Studies 51(8). Routledge: 958–75.
(19) Kebebe EG. (2017). Household Nutrition and Income Impacts of Using Dairy Technologies in Mixed Crop–
livestock Production Systems. Australian Journal of Agricultural and Resource Economics 61(4): 626–44.
(20) Lenjiso BM, Jeroen S, and Ruerd R. (2016). Smallholder Milk Market Participation, Dietary Diversity
and Nutritional Status among Young Children in Ethiopia. Journal of Gender, Agriculture and Food
Security 1(2): 129–47.
(21) Mulualem D, Carol JH, Getenesh B, and Susan JW. (2016). The Effectiveness of Nutrition Education:
Applying the Health Belief Model in Child-Feeding Practices to Use Pulses for Complementary
Feeding in Southern Ethiopia. Ecology of Food and Nutrition 55(3): 308–23.
(22) Negash C, Tefera B, Carol JH, Afework K, Kebede A, and Susan JW. (2014). Nutrition Education and
Introduction of Broad Bean-Based Complementary Food Improves Knowledge and Dietary Practices of
Caregivers and Nutritional Status of Their Young Children in Hula, Ethiopia. Food and Nutrition Bulletin 35
(4): 480–86.
(23) Negash M, Johan FMS. (2013). “Biofuels and Food Security: Micro-Evidence from Ethiopia.” Energy
Policy 61: 963–76.
(24) Yetnayet M, Carol H, Berhanu G, Whiting SJ, and Regassa N. (2017). Nutrition Education Promoted
Consumption of Pulse Based Foods among Rural Women of Reproductive Age in Sidama Zone,
Southern Ethiopia. African Journal of Food, Agriculture, Nutrition and Development 17(3): 12377–94.

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(25) Zeng D, Jeffrey A, George WN, Bekele S, Moti J, and Chilot Y. (2017). Agricultural technology
adoption and child nutrition enhancement: improved maize varieties in rural Ethiopia. Agricultural
Economics 48(5): 573–586.

Appendix C

Table C1. Outcome and impact indicators categorized according to Herforth and Terri (2016)
Category Indicators
Knowledge, attitude, practice Knowledge
Attitude
Practice

Health and caring Illness (diarrhoea, fever, cough/cold)

Maternal/child cleanliness

Economic indicators Household income

Livestock holdings
Poverty
Amount of milk sold

Food consumption Dietary diversity

Consumption of animal source foods (ASFs)
Food consumption

Food security Number of food gap months

Food security
Meal frequency
Milk production
Crop diversity and seasonality

Nutritional status Stunting (HAZ)

Wasting (WHZ)
Underweight (WAZ)
Nutritional status of adults (BMI)
Source: Author’s analysis.

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Appendix D

Overall Impact of all the Interventions

Figure D1. Overall effect of all Practice
the interventions on outcome/ Attitude
impact indicators (y-axis). Knowledge
Number of studies displayed on
x-axis Maternal/child cleanliness
Illness (diarrhoea, fever, cough/cold)
Source: Author’s analysis and
illustration. Milk sold
Poverty
Livestock holdings
Household income

Crop diversity & seasonality Positive

Milk production Negative
Meal frequency Not significant
No. of food gap months
Food security

Nutritional status (BMI)

Underweight (WAZ)
Wasting (WHZ)
Stunting (HAZ)

Food consumption
Consumption of ASFs
Dietary diversity
0 2 4 6 8 10 12 14 16 18

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