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 focus groups for a response rate of 72%. Seventeen of 18 of all intended participants in the semi structured interviews attended personally for a response rate of 94%. Thirty-three out of 99 participants of workshops, focus groups and interviewees answered the questionnaire regarding their 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 %.
Demands for ISA.
Participants of workshops indicated that ISA for stunting must incorporate sectors other than health such as the executive branch of the government, social assistance, education, economic development, environment, the community, and the private sector. Two representatives from the education sector, when asked about their potential role in the prevention of stunting, responded that the district education sector could aid towards reducing teenage pregnancy incidence and improving food security for those already pregnant. They also confirmed that they were aware of “the consequences or sequelae of inadequate treatment [for stunting], and saw it reflected in some indicators in subsequent years, especially in school dropout”.
Parents and caregivers highlighted the importance of the health and social assistance sectors for infant nutrition. Notably, some caregivers were less concerned about the stunted child, and more about the child who failed to be ‘chubby’, which was interpreted as a healthy nutritional state.
In one of the interviews the question arose as to why only health and social assistance sectors were the focus of ISA for the intervention. In this regard, a committee member responded: “we thought about stunting from the conceptual framework of the project as a problem that surpassed just the health sector and we needed to add the social component. For this reason the District Secretariat for Social Integration sent a representative, and, when we were recruiting participants, we approached the Colombian Family Welfare Institute who also sent a representative”. Another member of the committee explained: “we started this project with a view on intersectoral actions, since we had to [coordinate between] two Secretariats – social integration and health – and the third actor that was the private sector”. Although the health, social assistance, and private sectors were invited to participate, some members of the committee felt that additional sectors could have been invited, such as the education sector, economic development, and perhaps the District Secretary for Women. The sectors for the intervention were selected based on their institutional mission statements regarding infant nutrition, those that complied with this requirement were the health and social assistance sectors, and two private institutions.
Conditions for ISA.
As an example of “political will”, a member of the committee highlighted that the Mayor of Bogota authorized the implementation of the stunting intervention through the collaboration of the health and social assistance secretariats. The main role of the health secretariat was to identify infants at risk or with low Height-for-Age Z score (HAZ) registered in their database. The main role of the social assistance sector was to cross-check this information to identify infants affiliated to their programs and include them in the intervention. Helpfully, a member of the committee from the social assistance sector was already working on public-private partnerships, especially on technical support and supervision of legal agreements between the two, which facilitated ISA in the intervention. The private sector assumed a notable advocacy role by promoting the intervention within national and local government entities.
Lack of the following factors limited the ISA, legislative support, full engagement of the health sector, decentralization of local health services, and lack of social participation. In regard to the lack of legislative support for prevention of 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.” The same barrier was highlighted in the workshops, and participants mentioned the lack of legislative support for surveillance of stunting in the city. 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 to address wasting [intervention, since] children can die, so it sets alarm bells ringing ”. An interviewee of a health insurance company also stated that they focus their attention on low WAZ.
The lack of full engagement on the part of the health sector was criticized as it did not include key actors, the health insurance companies. 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 actors, 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 by other sectors. In her words: “without them I think we are incomplete because early identification [of stunting] is not going to happen […], or if we give one message and they give a different one, we will be in conflict, and also I think that the societal profile of doctors is higher in our culture than that of any other educational agent.” This interviewee was referring to trained social assistance personnel who give advice in IYCF to parents and caregivers.
Local health service decentralization presented barriers to harmonize knowledge in IYCF. For example, healthcare workers from insurance companies had given IYCF advice to the parents and caregivers which was outdated in view of recent national guidelines, so harmonization was not feasible as these healthcare workers were not trained. Additionally, although indications were given during the intervention, these healthcare workers could not join the intervention due to time constraints.
There was a barrier to “social participation” by some community leaders who were lost to follow up due high migration in and out of the city for personal reasons.
Triggers for ISA.
Regular meetings of the committee were important for coordination efforts. According to a committee member, “these meetings help us to ask ourselves about how to end or mitigate barriers and work together”.
Core institutional objectives of the private sector included qualification of the public sector to improve health and social assistance services for infants. A representative from the private institution that funded the intervention 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 party […] in charge of channeling resources.” Thus, another private sector institution was designated for this role.
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 participate in the intervention, and measure the change, and to present information and policy recommendations that are 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 the triggering of ISA were related to “management approach”. Members of the committee highlighted bureaucratic barriers to establish a contractual partnership with health insurance companies. For example, during implementation there were administrative barriers for nurses and medical doctors to receive training during working hours. A health insurance company representative indicated that “professionals were not allowed to spend eight hours of training on [identification of] stunting”. Also, “the project’s expectations could not be accomplished because training [for identification of stunting] was planned during a time of the year when upper respiratory problems are increased and were a priority”. 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. Each sector had its own database and these were incompatible for data sharing and moreover hindered by data protection laws. According to a committee member, “intersectoral actions were presented to find infants [at risk or with stunting], but databases were useless to find them”.
Figure 2 summarizes factors that facilitated and limited ISA grouped by demands, conditions, and triggers for ISA.
[Figure 2 goes here].
General opinions on the demands, conditions, and triggers for ISA to address stunting.
Factors related to the failure to achieve the potential height-for-age were most frequently ascribed to family income (76%), food quality (76%), and health services (64%). The most frequent conditions for ISA addressing stunting in the three localities were the need for local government coordination between the involved sectors (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, triggers for ISA were ascribed to the perceived importance of health outcomes 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 1.
[Table 1 goes here].
Strengths and weaknesses of partnership functioning
The responses to the adapted “Checklist for Intersectoral Partnerships for Health Promotion” (22) (Annex 5) showed higher agreement between members of the intervention committee in the categories: Need for the partnership, Mission, Context, Resources, Leadership, Roles and structures, and Partners’ profile (Figure 3). Members of the committee agreed that strengths were:
- they comprehended the need for collaboration between sectors because of common interests and capacity complementarities
- the intervention made use of intersectoral committees already existing in the city
- they considered the possibility that some sectors did not understand the relevance of their own participation
- in the planning and implementation of the intervention, the sectors provided time, human talent and other materials for intersectoral collaboration
- the intervention showed the level of importance that each sector ascribes to health outcomes
- the mutual respect shown by the member sectors.
Categories that showed lower agreement were Communication and Partnership functioning. Members of the committee agreed that weaknesses were:
- the intervention allowed for strategic partnerships to surpass institutional limits
- the roles of each member depended on tasks of other members or sectors
- the partnership allowed for the participation of the community as a sector
- plans to monitor and evaluate the partnership were considered
- 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 Figure 3.
[Figure 3 goes here].