Towards re-positioning nutrition as a multi-sectoral priority program for improved nutritional outcomes of children under five (0-59 months) in Tigray, Ethiopia
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There is unequivocal evidence of workable solutions to the malnutrition problem in developing countries; however, nutrition remains one of the lowest investment priorities for countries that need it the most. Lack of political commitment, weak implementation and coordination mechanisms have been identified as important factors leading to this problem. With this, the current study was designed to assess the factors that affect World Vision Ethiopia's nutrition mainstreaming as a multi-sectoral priority and to identify the strengths, weaknesses, opportunities and threats of mainstreaming nutrition in the agriculture, health and education sectors of the country. In addition, the outcome of the phasing out of World Vision long-term development program on child malnutrition and mortality were evaluated. Comparative cross-sectional surveys were conducted in the Tigray National Regional state in Northern Ethiopia. The Eastern zone in Atsbi district was selected as World Vision phasing out program while Enderta district in the southern zone was selected as non-program area. A combination of purposive, random and cluster sampling were employed to select 600 and 596 households in Atsbi and Enderta districts, respectively. Pre-tested and structured questionnaire were used to collect information on the weight, height/length and Mid Upper Arm Circumference. Appropriate software packages were used for data management, entry, cleaning, dependent variable normality test, and statistical analysis. The levels of malnutrition were established using World Health organization 2006 standards. Assessment of nutrition mainstreaming in World Vision Ethiopia was done using six key qualitative indicators, while strength, weakness, opportunity and threats analysis was used for the agriculture, health and education sectors that are primarily responsible for current nutrition interventions at the moment. The economic loss owing to malnutrition was calculated using the PROFILE software. The prevalence of stunting was 57.2% in Atsbi and 63.4% in Enderta districts, while underweight was 23% and 31% in Atsbi and Enderta, respectively. Wasting rates were 4% in Atsbi and 3.5 % in Enderta with no severe cases in both districts. Wasting assessed through Mid Upper Arm circumference measurements was 16.8% with 2.5% severe cases in Atsbi while Enderta had 9.6% and 1.2% severe cases. Bivariate analysis based on stunting showed significant association with dietary caring practices, health caring practices and environmental risk factors. The multivariate result also showed sponsored family, mothers' age, mothers' education, colostrums feeding, pre-lacteal feeding, and frequency of breast feeding and dietary diversity as important risk factors for stunting. The first two hypotheses i.e, "the mean prevalence of stunting is the same in two areas" and "the crude and under five children mortality rates are the same in two areas" were rejected. The third hypothesis "associated factors of stunting are the same in two areas" is accepted by considering factors associated with stunting in two areas are the same. There was significant mean difference in height for age (stunting) Z-score (t=2.214, P<0.027) in Atsbi compared to Enderta. The average mean of stunting in Enderta was higher than Atsbi which implied Atsbi was better than Enderta. However, within Atsbi the mean stunting was higher in sponsored than non-sponsored families (-11.150, p=0.000). Owing to the lack of a nutrition champion, nutrition skills and knowledge and nutrition ownership status among staff, the level of nutrition mainstreaming in World Vision Ethiopia was rated as level 2. At this level, nutrition mainstreaming is not at full scale of awareness stage at all levels even if it brought a significant reduction of underweight in Atsbi from 59.1% in year 2000 to 30.1% in year 2010 which is still very high. Contrary to underweight reduction, the stunting in Atsbi did not show significant decline from 68.3% in year 2000 to 51.8% in year 2010. Such critical level of stunting in both areas and the economic loss USD 3,025.197 million per annum owing to malnutrition at national level were indicating slow malnutrition risk reduction at all levels. Health related caring practices, dietary related caring practices and environmental factors were important risk factors for stunting among under five years of age in these two areas. The critical levels of stunting in both areas, low level of nutrition mainstreaming and huge economic loss at national level confirmed that nutrition has been trapped within low priority cycle. Level four nutrition mainstreaming is the solution for breaking this cycle and repositioning nutrition from one sector issue to a multi-sectoral priority program. This study therefore, recommends that there should be political commitment and partners' involvement towards repositioning nutrition as a multi-sectoral priority program under the semi-standalone coordination mechanism.