Forty out of 124 representatives participated in the workshops for a response rate of 32%. Sixty-five out of 90 parents and caregivers participated in the focal groups for a response rate of 72%. Thirteen out of 14 representatives were interviewed for a response rate of 93%. Thirty-three out of 99 participants of workshops, focal groups and interviewees answered the questionnaire about general opinion of stunting for a response rate of 33%. Nine out of 10 members of the intervention committee answered the questionnaire of ISA for stunting for a response rate of 90%.
Factors that facilitated and limited demands, conditions, and triggers for ISA in the intervention
Demands for ISA.
Members of the committee commented on why health and social assistance sectors were the focus of ISA for the intervention. In this regard, the principal investigator commented: “we thought about stunting from the conceptual frame of the project as a problem that surpassed the health sector and we needed to add up the social component. That is why the District Secretary for Social Integration joined, and, when we were recruiting participants, the Colombian Family Welfare Institute joined.” A representative from Fundación Éxito commented: “I think that we started this project with a view on intersectoral actions, since we had to articulate two Secretaries – social integration and health – and the third actor that was the private sector – Fundación Santa Fe and us”. Although the health, social assistance, and private sectors were summoned to fulfill the task, some members of the committee felt that additional sectors could have been gathered, like the education sector, economic development, and even a District Secretary of women policies. In the juncture of establishing the partnership for the intervention, the sectors that were associated from their institutional mission with infant nutrition were the health, social assistance, and two private institutions which shared that institutional core.
Two representatives from the education sector, when asked about their potential role in the prevention of stunting that the intervention was proposing, answered that the education sector of the city could aid towards reducing teenage pregnancy incidence and improving food security for those already pregnant. Besides, those representatives highlighted that they were aware of “the consequences or sequels of inadequate treatment [for stunting], and saw it reflected in some indicators in subsequent years” especially on school dropout.
Conditions for ISA.
Regarding “political will”, the government summoned sectors that were linked to infant nutrition like health and social assistance sectors. The main role of the health sector was to identify infants at risk or with low Height-for-Age Z score (HAZ) registered in the system of nutritional vigilance, and the main role of the social assistance sector was to cross-check this information to identify infants affiliated to their programs to join the intervention. A member of the committee highlighted that “the authority [of the local Mayor] endorsed the participation of [the District Health Secretary and the District Social Integration Secretary] to continue the process.” The private sector (Fundación Éxito) did the advocacy for positioning stunting in the stakeholder agendas. A member of the committee from the social assistance sector was already working on public-private partnerships, especially on technical support and supervision of the agreements, which facilitated ISA in the intervention.
“Legislative support”, “engagement of the health sector”, “local health services decentralization”, and “social participation” were identified as factors that limited the ISA. In regard to the lack of legislative support for stunting, a member of the committee from the health sector mentioned that “unfortunately, in the current plans [of the District Health Secretary] stunting is not an explicit goal. When we talk about prevention of stunting, we talk about breastfeeding, about which we do have a goal.” Wasting or low weight for age (WAZ), is a priority for many sectors. For stunting, as mentioned by the principal investigator, “there is a normative barrier, [because] we do have an obligation on wasting [intervention, since] children can die, so it is an absolute alarm”. An interviewee of a health insurance company also mentioned that they focus their attentions on low WAZ.
“Engagement of the health sector” was a concept with multiple comments regarding the lack of participation of the whole health sector in the intervention. The principal investigator commented that “although we were already represented in the health sector by the District Health Secretary, this sector was not fully represented because we did not have the main actor that is the health insurance companies.” A member of the social assistance sector in the intervention committee highlighted the importance of participation by health insurance companies, and ISA that could not be accomplished for other sectors. In her words: “without them I think we are not complete because an early identification [of stunting] is not going to happen […], or if we give a message and they give a different one, we will be against each other, and I think that the role of doctors is higher in our culture than that of any other educational agent.” The intervention had an important objective of IYCF knowledge harmonization between the health and social assistance sectors.
Regarding “local health service decentralization,” there were barriers for coordination. An operative member who checked that each participating child had adequate health services said that she “was shocked about how impotent the public [health] sector was in facing the private groups, the health insurance companies”. Thus, in local caregiver dwellings, in spite of getting indications from operative members, harmonization could not be done since health professionals were not qualified. Concerning “social participation”, there was a barrier to identify community leaders due to high migration in and out of the city.
Triggers for ISA.
Regular meetings of the committee were important for coordination (“management skills”). The presence of a committee with regular face-to-face communication, according to a member from the Colombian Institute of Family Welfare, “aided to visualize institutional fragmentation: [that sectors are working separately] and these scenarios help to ask ourselves about how to end or mitigate barriers and work together”.
Premises of the private sector included qualification of the public sector to improve health and social assistance services for infants. A representative from Fundación Éxito highlighted that in the meetings to arrange the partnership both private and public sectors agreed on the need for a third party to drive the intervention, since “we are not allowed to give resources to them [public institutions], nor they are allowed to receive these resources […]. We qualify those institutions through a third ally […] in charge of channeling resources.” The institution that acquired this role was FSFB.
A further trigger for ISA was “recognition of health as a collaborative outcome”. The principal investigator said that “we accomplished the project in order to study the problem [of stunting], to gather the base line [of participants], to participate in the intervention, and measure the change, and to present information and policy recommendations that are, at last, the final result of this exercise.” The implementation of the intervention and the elaboration of a guideline for prevention and management of stunting gathered sectors towards a common goal.
The main factors that limited ISA triggering were related to “management approach”. Members of the committee highlighted bureaucratic barriers to establish a contractual partnership with health insurance companies. During implementation there were administrative barriers for nurses and medical doctors to receive continued education during worktime. A health insurance company representative indicated that “professionals were not allowed to spend their eight hours of training on [identification of]stunting”, and that “the project’s expectations could not be accomplished because training [for identification of stunting] was planned during a time of the year when higher respiratory problems are increased”. Virtual training was proposed but the approach was not within the context of the ISA and difficult to implement.
Barriers to information sharing were identified during implementation. Recruitment of infants was hampered by inconsistent updating of data shared between sectors. “Intersectoral actions were presented to find infants, but data bases were useless to find them. Infants were found in a totally different way. Then we had more problems [with] sharing information” because of data protection laws.
Figure 2 summarizes factors that facilitated and limited ISA grouped by demands, conditions, and triggers for ISA.
General opinions on the demands, conditions, and triggers for ISA in the intervention
Workshops, focal groups, and interviews showed that failure to achieve the potential height-for-age in the three localities was most frequently ascribed to family income (76%), food quality (76%), and health services (64%). Other factors that demanded ISA to address stunting in Bogotá related to the need of community participation and social network support, food safety and nutrition, and feeding practices. The caregivers valued recommendations made by family members like introducing vegetable and meat broth before the sixth month of life. Some caregivers were less concerned about the stunted child, and more about the child who failed to be chubby, which was interpreted as healthy feeding.
The most frequent conditions for ISA addressing stunting in the three localities were the importance that local governments summon all sectors involved (66.6%), the capacity and authority to guarantee infant nutrition services by the health sector (57.1%), and sufficient resources for the intervention (54.8%). Other factors conditioning ISA for stunting were the need for motivated and IYCF qualified human talent across sectors and an alignment of IYCF guidelines between sectors.
Finally, participants of workshops, focal groups and interviewees identified triggers for ISA like the importance of health results by each of the participating sectors (69%), that coordinated and participatory ISA are explicitly promoted (64.3%), and that ISA guarantee interactions between sectors by work group dynamics and/or community participation (59.5%). Results are shown in Table 2.
Table 2
Factors that demand, condition, and trigger ISA intervention against stunting in Bogotá.
| n | %* |
| 42 | |
Factors that demand ISA for prevention and management of stunting | | |
Family income. | 32 | 76,2 |
Health services. | 27 | 64,3 |
Educational level of caregivers. | 23 | 54,8 |
Vulnerable condition of mothers. | 19 | 45,2 |
Quality of food. | 32 | 76,2 |
Water and sanitation. | 16 | 38,1 |
No answer | 0 | 0,0 |
Others | 8 | 19,0 |
Factors that condition ISA for prevention and management of stunting | | |
That local governments comprehend the importance of summoning different sectors to solve the problem (Political will). | 28 | 66,7 |
Support from the current legislation (Legislative support). | 18 | 42,9 |
That the local health institutions are in charge of managing the problem and are capable of being the health authority (Engagement of the health sector) | 24 | 57,1 |
Enough local resources to pose the problem and commitment of each sector (Local health decentralization). | 23 | 54,8 |
That people working in the locality are committed to teamwork within representatives of other sectors (Motivated human resources). | 23 | 54,8 |
That the community as a sector is considered the most important for healthy growth of infants (Social participation). | 19 | 45,2 |
No answer | 0 | 0,0 |
Others | 4 | 9,5 |
Factors that trigger ISA for prevention and management of stunting | | |
That interventions that tackle the problem can promote collaborative and participatory interactions between sectors (Management approach). | 27 | 64,3 |
That a leading sector to tackle the problem could be identified (Management skills). | 18 | 42,9 |
That interventions that tackle the problem guarantee dynamic sector interactions working with the community (Teamwork skills). | 25 | 59,5 |
That interventions that tackle the problem use technologies and other knowledge management skills (Management techniques). | 17 | 40,5 |
That interventions that tackle the problem guarantee that each of the participating sectors is concerned about contributing to health results (Recognition of health as a collaborative outcome). | 29 | 69,0 |
No answer | 0 | 0,0 |
Other | 2 | 4,8 |
*Total adds up to more than 100% due to multiple choice answers |
Strengths and weaknesses of partnership functioning
The adapted “Checklist for Intersectoral Partnerships for Health Promotion” (22) showed higher agreement between members of the intervention committee in Need for the partnership, Mission, Context, Resources, Leadership, Roles and structures, and Partners’ profile (Fig. 3). Specifically, members of the committee agreed that: (1) they perceived the need for collaboration between sectors because of common interests and capacity complementarities; (2) the intervention made use of intersectoral committees already existing in the city; (3) they considered the possibility that other sectors did not understand the relevance of their participation; (4) in the planning and implementation of the intervention, the sectors provided time, human talent and other materials for intersectoral collaboration; (5) the intervention showed the importance that each sector considers health results as a social product and; (6) the member sectors showed respect towards each other.
Checklist items that showed lower agreement were Communication and Partnership functioning. More specifically, members of the committee agreed less that: (1) the intervention allowed for strategic partnerships to overcome institutional limits; (2) the roles of each member depended on tasks of other members or sectors; (3) this partnership allowed for the participation of the community as a sector; (4) plans to monitor and evaluate the partnership were considered and; (5) plans for problem solving regarding communication and leadership were considered in the partnership. A summary of strengths and weaknesses of the partnership functioning are described in Fig. 3.