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 multisectoral 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.

IntroductionEthiopia has made significant progress in reducing malnutrition in the past two decades. Despite such improvements, a substantial segment of the country’s population remains chronically undernourished and suffers from micronutrient deficiencies and from increasing diet-related non-communicable diseases such as diabetes, hypertension and cancer. This survey aims to assess anthropometric status, dietary intake and micronutrient status of Ethiopian children, women and adolescent girls. The study will also assess coverage of direct and indirect nutrition-related interventions and map agricultural soil nutrients. The survey will serve as a baseline for the recently developed Ethiopian Food System Transformation Plan and will inform the implementation of the National Food and Nutrition Strategy.Methods and analysisAs a population-based, cross-sectional survey, the study will collect data from the 10 regions and 2 city administrations of Ethiopia. The study population will be women of reproductive age, children aged 0–59 months, school-aged children and adolescent girls. A total of 16 596 households will be surveyed, allowing the generation of national and regional estimates. A two-stage stratified cluster sampling procedure will be used to select households. In the first stage, 639 enumeration areas (EAs) will be selected using probability-proportional-to-size allocation. In the second stage, 26 eligible households will be selected within each EA using systematic random selection. Primary outcomes include coverage of direct and indirect nutrition interventions, infant and young child feeding (IYCF) practices, food insecurity, dietary intakes, mental health, anthropometric status, micronutrient status and soil nutrient status.Ethics and disseminationThe protocol was fully reviewed and approved by the Institutional Review Board of the Ethiopian Public Health Institute (protocol no: EPHI-IRB-317–2020). The study is based on voluntary participation and written informed consent is required from study participants. The findings will be disseminated via forums and conferences and will be submitted for publication in peer-reviewed journals.

Background Inconsistent reports have been made on the link of clothing style to vitamin D deficiency (VDD). However, there is no meta-analysis report on the link. Thus, we pooled the existing empirical evidence on the association of wearing concealing clothing with VDD and serum 25(OH)D level among healthy adult women.Method PubMed, Embase, Scopus, Web of Sciences, and Google Scholar were searched for studies published until December 15, 2020 on the relation of clothing type with vitamin D status. Odds ratio (OR) and standardized mean difference (SMD) were used to summarize the estimates on the association of concealing clothing with VDD status and 25(OH)D level, respectively. The summary estimates were calculated with random-effects meta-analyses, with heterogeneity assessed by I2–metrics and subgroup analyses done by types of clothing and regions of residence. Result In total, 14 studies with a total of 11,332 individual participants were included. Overall, women who wear concealing clothing were 2.28 times more likely to develop VDD compared with women who do not wear concealing clothing (pooled OR=2.28, 95%CI=1.67, 3.10, P<0.001). The summary odds of VDD was 1.36 times higher among women who wear veil hijab compared with women who do not wear veil hijab (95%CI=1.49, 3.59, P<0.001). The summary odds of VDD was 2.25 times higher among women who wear long sleeve clothes compared with those who wear short sleeve clothes (95%CI=1.63, 3.11, P<0.001). The mean serum 25(OH)D level of women who wear veil hijab was also significantly lower by 6.48 ng/ml (pooled SMD= -6.48, 95%CI= -8.24, -4.73, P<0.001). Conclusion Clothing type, particularly fully concealing clothes like hijab, might be contributing to the burden of VDD. Further studies are warranted to investigate the role and dose of additional VD supplement to compensate the effect of concealing clothing (hijab) on VD status of women.

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.