Blog: Increasing municipal governance to tackle the drivers of child malnutrition

This blog from Professor Pat Pridmore at the Department of Humanities and Social Sciences at University College London, summarises key learnings from the study called NICK (Nutritional Improvement for children in urban Chile and Kenya) which focused on the issues of child obesity in Chile and child under nutrition in Kenya.

The study facilitated participatory action research (PAR) to find the most effective ways to change social determinants. This was done by establishing and supporting a multi-sectoral urban nutrition working group (UNWG) in Mombasa and another in Valparaiso.

Greatest challenges and opportunities presented to the research team

Challenges in Kenya

• National and local budgetary constraints and lack of political will to invest in multi-sectoral initiatives to tackle social determinants have challenged long-term sustainability of the UNWG.
• During the study, ongoing devolution led to UNGW and advisory group members being moved away from the study areas and difficulties in knowing at which level key decision makers sat. These challenges increased after the study when the constitution laid down a new country structure, which has yet to be fully implemented. These changes have led to confusion, delays in funding flows, and key decision makers involved with the study being moved to other counties. Adequate support has not yet been given to sustain the UNWG.
• Despite support at central and local institutional level for establishing the UNWG municipal line managers sometimes required members to prioritise other activities.
• Closure of an Export Processing Zone providing vital employment to local families in the study area led to negative change in employment, food security and income. The intervention area was more affected by this than the control area which explains the unfavourable results of the impact survey on child nutrition.

Challenges in Chile

• Devolution and a change of government during the study led to funding cuts and reduced political commitment to initiatives to tackle social determinants.
• Drug cartels operating in the low income study areas posed a security risk to researchers collecting base-line survey data and reduced community participation. This delayed establishment of the UNWG. Communication participation was also low because many parents did not view child obesity as a problem.
• Two years into the study the senior in-country researcher resigned due to personal difficulties in working with the junior in-country researcher and the junior researcher then resigned due to ill-health. The University of Valparaíso, a partner in the research, subsequently withdrew from the study but continued to work with the UNWG making it impossible for the research team to partner with the University of Santiago to complete the study. The senior researcher re-joined the research team at the writing up stage.

Opportunities

At the outset, the NICK researchers built on acknowledgement from all major actors in both study countries that child malnutrition was a public health problem which demanded greater collaboration between sectors; a long established tradition of community participation; and a tried-and-tested model of engagement (PAR with multi-sectoral working groups) used by the Principal Investigator (PI) and Chilean Co-Investigator (Co-I) in a previous World Health Organisation (WHO) project on primary health care. This model was adapted and used to provide a structure and supportive environment for collaboration.

Shortly after the study started, the Kenyan government specifically called for the establishment of multi-sectoral UNWGs thereby providing a mandate for the NICK UNWG to be formed in Mombasa. This helped sustain interest and commitment of group members and their line managers throughout the 18 month PAR phase of the study.

The researchers used findings from their situational analyses (literature reviews, interviews and base-line anthropometric and household data collection) to help break down the silo mentality and shift the mind-set of UNWG members towards collaborative planning to tackle social determinants.

Two UNWG members were invited to discussions in Nairobi to feed into the National Nutrition Action Plan 2012-2017. Evidence from the NICK study was included in the justification for the need for such a policy and for the formation of county level UNWGs. UNWG members were later instrumental in informing the Mombasa County Integrated Development Plan 2013 -201. Data generated by the NICK anthropometric surveys have been used by the Mombasa county government for planning.

Approaches, activities and outside influences that had the most significant effect on the impact of research and why

Selecting a team of international and national researchers who had a proven track record of successful, high quality research and consultancy in the study countries; the research skills, professional networks and experience needed to conduct PAR; and the communication skills needed to disseminate findings at all levels. The in-country researchers also needed expert facilitation skills informed by detailed knowledge of the local context, culture and language, experience of working in local low-income communities, strong local networks and to be linked to robust institutions.

Strategically selecting advisory group members at central, municipal and community levels to build and maintain support for the study, provide guidance, open doors and enable the findings to inform practice and policy development; and adding new members as the local, political environment changed.

Using the tried-and-tested model of engagement strategy mentioned above to broaden stakeholder participation, strengthen governance and build capacity for collaboration.

Holding regular dissemination events throughout the study to maintain support and share emerging study findings so they could inform policy and practice when opportunities arose.

Ensuring that ownership on the UNWG was located with group members and that the in-country researchers understood their role as one of facilitation and capacity building. This was aided by group members appointing their own co-ordinator and allocating individual roles and responsibilities to individual members. Monthly group meetings were crucial for creating an environment of progress and accountability and shifting the silo mentality towards one of sharing and cross-sectoral collaboration.

What might the research team have done differently next time?

The initial approach to partner with the University of Valparaiso was made by the senior in-country researcher, in whom I (as the PI) had confidence, and the junior researcher whom she had chosen to work with. Both researchers were employed by this University. I then followed up the initial approach through e-mail and telephone communication from London. If I had been able to initiate the partnership face-to-face I might have been able foresee the issues of prestige and status and commitment that challenged the study later.

In Mombasa, the team could have collected more data to ensure the intervention and control groups were well-matched, conducted more informal interviews with beneficiaries telling their own story in their own words and recorded all unexpected outcomes such as the vegetable gardening in the psychiatric hospital garden started by an UNWG member. Taking more time (as the researchers did in Chile) to prepare the ground for establishing the UNWG could have led to a smaller group being formed initially with all members having strong commitment to stay throughout the study. The research team could have guided the UNWG to carry out more ‘upstream’ activities rather than initially focusing more ‘downstream’ to engage the community. Policy impact might have increased if dissemination activities had been more closely followed up and discussions informed by deeper understanding of how to influence policy in fast changing political environments.