The effect of UNIMMAP multiple micronutrient supplements versus iron-folic acid and placebo in anemia reduction among women of reproductive age in Kebribeyah Woreda, Somali Regional State, Ethiopia: a study protocol for a community-based individual RCT

BACKGROUND

Women of reproductive age (WRA) in developing countries are often at risk of micronutrient deficiencies due to inadequate intakes and excessive losses.

OBJECTIVE

The purpose of this trial is to assess the effectiveness of United Nations International Multiple Micronutrient Antenatal Preparation-Multiple Micronutrient Supplements (UNIMMAP-MMS) versus iron-folic acid (IFA) among WRA in reducing anemia.

METHODS

Three parallel groups of WRA will participate in a community-based, individually randomized, double-blinded, placebo-controlled superiority trial. After consent, the sample of 375 mildly or moderately anemic women based on hemoglobin by Hemocue will be randomly assigned across two interventions and one control arm. Trial participants in intervention arms will receive UNIMMAP-MMS or IFA while those in the control arm will receive placebos twice a week for 17 weeks. The primary outcome will be a change in mean hemoglobin (Hb) concentrations. Outcome assessors and study participants will be blinded to the type of supplements and study arm.

DISCUSSION

The World Health Organization (WHO) added UNIMMAP-MMS to its essential medicine lists in 2021 but recommended rigorous study. Several factors in addition to inadequate intakes of iron and folic acid contribute to the high prevalence of anemia among WRA in the Somali region. The findings of this study will provide evidence on the effect of UNIMMAP-MMS and IFA on Hb concentrations and anemia prevalence among anemic WRA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05682261. Registered on January 12, 2023.

Precision of Measurements Performed by a Cadre of Anthropometrists Trained for a Large Household Nutrition Survey in Ethiopia

BACKGROUND

Well-trained anthropometrists are essential for the delivery of high-quality anthropometric data used to evaluate public health nutrition interventions. Scant data are currently available on the precision of data collected by large teams of anthropometrists employed for nutrition surveys in low-income country settings.

OBJECTIVES

The purpose of this study was to assess the precision of child midupper arm circumference (MUAC) and length/height measurements taken by fieldworkers training for nutrition survey deployment.

METHODS

Following 3 d of training, an anthropometry standardization exercise was conducted in small teams of trainees at 7 sites in the Amhara region of Ethiopia. In groups of 2-4, trainee anthropometrists (n = 79) each measured 16 children aged 6-47 mo (n = 336) twice for MUAC and length/height. Both intraobserver and interobserver precision were analyzed using technical error of measurement (TEM), relative TEM, coefficient of reliability (R), and repeatability metrics. Bland-Altman limits of agreement were calculated for intraobserver measurements.

RESULTS

Intraobserver TEM was between 0.00 and 0.57 cm for MUAC (Bland-Altman 95% limits of agreement: -0.50 to 0.54 cm) and between 0.04 and 2.58 cm for length/height measurements (Bland-Altman 95% limits of agreement: -1.43 to 1.41 cm). Interobserver TEM was between 0.09 and 0.43 cm for MUAC and between 0.06 and 2.98 cm for length/height measurements. A high proportion of trainees achieved intraobserver R >0.95 (MUAC: 95%; length/height: 97%). Most teams also achieved interobserver R >0.95 (MUAC: 90%; length/height: 95%).

CONCLUSIONS

Large numbers of anthropometrists (>75) in low-income settings can attain satisfactory precision in anthropometry following training and standardization. These protocols permit researchers to assess trainees, identify individuals who have not achieved the desired level of precision, and retrain or adjust roles prior to survey deployment.

Evidence-Based Decision Making for Nutrition Policy and Programme Formulation in Ethiopia: A Qualitative Study Exploring Barriers and Facilitators

Objectives

Despite much nutrition research conducted in Ethiopia, none has described existing opportunities for synergy or possible missed opportunities to use research to inform policy and program decisions to foster accelerated progress. The study aimed to describe prevailing processes on evidence use in formulating nutrition policy and program decisions and identify potential barriers and opportunities for evidence-based decision-making for nutrition for Ethiopia's context.

Methods

In 2017, 29 purposively selected key informants (KIs) were interviewed. They were identified using a consultative stakeholder mapping workshop and represented National Nutrition Program coordinators, key actors in government sectors, program coordinators from selected local and international NGOs, local and international universities and research institutes involved in nutrition research and key actors in policy decision-making. A framework analysis including identifying themes, coding, indexing, charting, mapping and interpretation was used. A validation workshop discussed findings and added perspectives to interpretation.

Results

The KIs perceived that demand for evidence from the Ethiopian government had been increasing over time. Majority referred to poor research quality as a barrier for using research in decision-making processes. Other challenges identified included limited cross-linkage, coordination gaps between researchers and decision makers, and inadequate translation of research evidence into meaningful information for policy makers. Availability of different forums, research dissemination conferences and suitable institutional structures that enable research and evidence dissemination were considered to be opportunities that should be leveraged to inform policy making.

Conclusions

The quality of research, and of collaborative engagement between those who produce evidence and decision makers who formulate policies need to be strengthened. Regular evidence dissemination events and publication of action oriented easy to read briefs could increase use of evidence among nutrition policy makers.

Funding Sources

Ethiopian Public Health Institute and Evidence-informed Decision-making in Health and Nutrition Network.

Sustainable Undernutrition Reduction in Ethiopia (SURE): A Qualitative Study Assessing Feasibility of the Program Implementation in Basona Worana District, Ethiopia

Objectives

The Ethiopian government designed the SURE program which aims to reduce the prevalence of stunting by improving complementary feeding and dietary diversity as part of its national nutrition program. This study was conducted to test the feasibility of the SURE program before its implementation.

Methods

A qualitative research design with purposive sampling was employed for this study. A five-day overall SURE program training was provided for 6 health extension workers (HEWs) and 10 agriculture extension workers (AEWs). Trainees completed pre-post knowledge tests. Following their training, two pairs of health and agriculture extension workers jointly conducted household visits in each of three selected kebeles (sub-unit of district) to assess needs and counsel mother-father pairs. They also facilitated women's and men's group dialogues to reinforce messages in gender-specific peer groups. Research assistants and investigators observed 12 joint household visits. To further assess the program, 24 semi-structured interviews with extension workers and mother-father pairs and 6 focus group discussions with men's and women's groups were conducted. Data were analyzed using Nvivo version 11.

Results

Health and agriculture extension workers gained demonstrable knowledge about infant and young child feeding and nutrition-sensitive agricultural practices following their training, but they largely failed to apply the 3A's counselling process (assess, analyze and act) and delivered inconsistent messages during the counselling visits based on observation. However, they felt that they can realistically continue to work together. Pairs of mothers and fathers visited were supportive of the joint HEWs and AEWs visits. Focus group discussants from women's groups reported that segregating the group discussions by gender was helpful to ensure their participation and expression of ideas.

Conclusions

The SURE training provided to HEWs and AEWs resulted in knowledge retention. The integrated service delivery model of the SURE program is well-accepted by both extension workers and mother-father pairs. Further support to build counselling skills will be needed to improve program processes and the quality of services.

Funding Sources

Childrens' Investment Fund Foundation (UK) funded this research. No other involvement in carrying out the research activities.

Factors associated with dietary diversity and length-for-age z-score in rural Ethiopian children aged 6-23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation

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.

The fidelity and dose of message delivery on infant and young child feeding practice and nutrition sensitive agriculture in Ethiopia: a qualitative study from the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme

BACKGROUND

In Ethiopia, 38% of children under 5 years of age are stunted (low height for age). A novel government-led intervention called the Sustainable Undernutrition Reduction in Ethiopia (SURE) aims to tackle the burden of stunting by improving complementary feeding and dietary diversity among young children. The SURE programme design applies a transtheoretical model of behaviour change, whereby exposure to recommended infant and young child feeding (IYCF) and nutrition-sensitive agriculture messages is a first stage to adopting key behaviours. This qualitative study explored the fidelity and dose of the IYCF and nutrition-sensitive agriculture messages delivered by extension workers.

METHODS

A qualitative study was conducted across four regions in Ethiopia (Oromiya, Amhara, SNNP and Tigray) between April and October 2017. Across the four regions, 81 key informant interviews, 90 FGDs and 81 observations were conducted with 180 extension workers, 18 development agents and 54 mother-father pairs. Digitally recorded audio files were transcribed verbatim, and the data were analysed based on a framework analysis approach using NVivo (version 12) by coding and categorising texts into major themes and sub-themes.

RESULTS

SURE target households had the intended exposure to messages about exclusive breastfeeding, timing of initiation of complementary feeding, food groups, diversified food consumption, irrigation, rearing small animals and vegetables. Few households reported receiving messages on the content or frequency of complementary feeding of a child beyond 6 months of age. Frequency of household visits and hence exposure to SURE messages was also variable. Agricultural messages delivered during household visits focussed on improving standard agricultural practices and rarely covered the importance of nutrition-sensitive agriculture to improve household or child nutrition.

CONCLUSION

Despite variability observed in the breadth and depth of messages delivered, large-scale behaviour change communication programmes can achieve moderate to good message exposure among target groups. Qualitative data provide an in-depth insight into fidelity and may supplement our understanding of programme roll-out and implementation. Further research is required to understand longer-term message saturation including frequency and reach.

Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study: a protocol to evaluate impact, process and context of a large-scale integrated health and agriculture programme to improve complementary feeding in Ethiopia

INTRODUCTION

Improving 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 ANALYSIS

The 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 DISSEMINATION

The 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.

Linkages between health and agriculture sectors in Ethiopia: a formative research study exploring barriers, facilitators and opportunities for local level coordination to deliver nutritional programmes and services

Background

In Ethiopia, poor infant and young child feeding practices and low household dietary diversity remain widespread. The Government has adopted the National Nutrition Programme that emphasizes the need for multi-sectoral collaboration to effectively deliver nutrition-sensitive and nutrition-specific interventions. The Sustainable Undernutrition Reduction in Ethiopia (SURE) programme is one such Government-led initiative that will be implemented jointly by the health and agriculture sectors across 150 districts in Ethiopia. Prior to the design of the SURE programme, this formative research study was conducted to understand how the governance structure and linkages between health and agriculture sectors at local levels can support implementation of programme activities.

Methods

Data were collected from eight districts in Ethiopia using 16 key informant interviews and eight focus group discussions conducted with district and community-level focal persons for nutrition including health and agriculture extension workers. A framework analysis approach was used to analyze data.

Results

Few respondents were aware of the National Nutrition Programme or of their own roles within the multi-sectoral coordination mechanism outlined by the government to deliver nutritional programmes and services. Lack of knowledge or commitment to nutrition, lack of resources and presence of competing priorities within individual sectors were identified as barriers to effective coordination between health and agriculture sectors. Strong central commitment to nutrition, increased involvement of other partners in nutrition and the presence of community development workers such as health and agriculture extension workers were identified as facilitators of effective coordination.

Conclusions

Federal guidelines to implement the Ethiopian National Nutrition Programme have yet to be translated to district or community level administrative structures. Sustained political commitment and provision of resources will be necessary to achieve effective inter-sectoral collaboration to deliver nutritional services. The health and agriculture extension platforms may be used to link interventions for sustained nutrition impact.

Multisector Nutrition Program Governance and Implementation in Ethiopia

Governments globally are stressing both direct nutrition interventions combined with nutrition sensitive policies and programs to combat malnutrition. Governance at all levels has been identified as a critical element in ensuring success of national nutrition plans. For example, the most recent National Nutrition Program (NNP) in Ethiopia discusses the essentiality of governance and coordination at all levels. The research uses a qualitative study based on semi-structured interviews with key informant. The research discussed in this article focuses on governance structures from national to regional to district level in Ethiopia with an emphasis on translation of a strategy and implementation of the NNP. This article concentrates primarily on results from the national and regional levels. Data at both the national and regional levels indicate that there is general agreement on the nature of the nutrition problems in Ethiopia. At all levels of government, under nutrition, food insecurity, and micronutrient deficiencies were listed as the main nutrition problems. The challenges in governance and implementation identified at both the national and regional levels, however, varied. The implementation of the 2013 NNP was in its early stages at the time of this research. While there was palpable energy around the launch of the NNP, respondents indicated issues related to leadership, coordination, collaboration, advocacy, and budget would be challenges in sustaining momentum.