1 Introduction

Despite a significant reduction over the years, malnutrition remains a major public health problem in Ethiopia that has a devastating impact on short-term survival, long-term well-being, and socioeconomic inequality [1, 2]. Because of increased nutrition requirements to promote children’s health and well-being [3], the first 1000 days from conception to 2 years of age are the most vulnerable segment of the population to irrepressible nutrition and related issues [4].

Increased consumption of an unhealthy diet, excessive consumption of cereals such as teff, maize, and sorghum, which have a relatively low micronutrient density, and insufficient consumption of food items from other food groups such as animal-source foods (ASFs), pulses, fruits, vegetables, nuts, and seeds, which are very rich in important micronutrients, are currently the most common causes of increased malnutrition in Ethiopia [5, 6]. As a result, the vast majority of the population (85%) had zero fruit or vegetable servings; less than 2% had three to four servings; and only 1.5% met the World Health Organization (WHO) target of five servings per day [7, 8].

According to the WHO 2021 report, 22% of all under-five children were stunted [9]. A recent Ethiopian Mini Demographic and Health Survey report found that 37%, 21%, and 7% of children under the age of five are stunted, underweight, or wasted, respectively [10]. As well, 57% of children ages 6–59 months suffered from some degree of anaemia [11]. As malnutrition in Ethiopia contributes to more than 50% of child deaths [12].

Children who are malnourished may never achieve their full height and weight potential; their brains may never grow to their full cognitive capacity; struggle in school; and encounter challenges to community involvement [9, 13, 14]. In addition, children who are malnourished or have a weaker immune system are more likely to face long-term developmental delays [15]. Furthermore, it has been linked to long-term negative functional outcomes such as overweight, obesity, insulin resistance, hypertension, dyslipidemia, a reduced capacity for manual labour, and other chronic non-communicable diseases during adolescence and adulthood [16,17,18], as well as a negative effect on future reproductive outcomes [19] and being responsible for slowing economic growth and perpetuating poverty [20].

Growth Monitoring and Promotion (GMP) is a preventive program aimed at reducing childhood malnutrition in its early phases [21]. It focuses on caregiver and family decisions for well-child growth outcomes and has a high potential to improve child growth and health. In addition, it facilitates communication and interaction, generates information and appropriate action, improves the nutritional status of the child, and reduces mortality and morbidity in children [22].

The government of Ethiopia and a number of non-governmental organizations are collaborating on malnutrition prevention and promotion activities that are being implemented at the community level, such as nutritional counselling and early disease detection [23]. However, performance indicators like GMP participation rate, frequency of supportive supervisors, community conversation, and quality of consultation indicators are underutilized and not evaluated on a regular basis. Furthermore, the outcome indicators, such as the proportion of children faltering, the proportion of children recovering after the next visit, and the proportion of children recovering after the third visit, are not determined on a regular basis at each level [24, 25]. Moreover, despite the establishment of nutrition steering and technical committees at all levels of government, there is a fragmented approach to responding to health and nutrition needs, resulting in insufficient coordination among multi-sectors, and the functionality of these committees is not well understood in this study area. As a result, the aim of this study was to assess the functionality of the nutrition steering and technical committees and the quality of the child growth monitoring program in northwest Ethiopia.

2 Methods and materials

2.1 Study period, area and design

A mixed-methods study was employed among the two districts (Gondar Zuria and East Dembia) in central Gondar Zone, Amhara Regional State, Ethiopia, from May to June 2021: Nine hospitals, 75 health centers, and 495 health extension workers are working in the central Gondar Zone. There were 12,422 and 10,825 estimated total numbers of children under 2 years’ old in Gondar Zuria and East Dembia districts, respectively.

2.2 Source and study population

All steering and technical committees as well as secondary GMP performance data in the central Gondar zone were the source population of the study, whereas both committees in selected districts and 8 months of GMP performance data were the study population.

2.3 Sample size and sampling procedure

The selected districts included 51 members from both the steering and technical committees. The lists of the two committees were found in each office, and the interview was conducted face-to-face. Data was collected at each district sector, such as health, agriculture, education, finance, and economic development; women, children, and youth affairs; and social protection offices. For the qualitative study, a purposive sampling method was used to select eleven participants who could provide enablers and barriers for the implementation of a growth monitoring program.

2.4 Variable measurements

Weight was measured using the Salter scale with heavy shoes and clothes removed, and growth faltering was considered when consecutive weights showed less than expected growth over time during the visits tracked on appropriate growth charts for children of the same age and sex [26]. Therefore, a weight for age (WAZ) value that is less than two standard deviations from the WHO Child Growth Standard is considered to be underweight [27].

The GMP participation rate is measured as the ratio of the sum of the actual individual monthly weightings to the sum of the total number of months the individual children were eligible and registered for the program. Finally, the GMP participation rate of 80% is classified as a good participation rate.

2.5 Data collection tools and procedures

For the quantitative (secondary) data, a data extraction sheet and a structured interview-administered questionnaire tool were prepared. The tool included data on the total number of children weighted, eligible children for weighing, socio-demographic characteristics, a tool for evaluating the functionality of the nutrition steering committee, the process and outcome of GMP indicators, and the quality of the data. Additionally, an in-depth interview guide was prepared by reviewing relevant literature. The interview guide explored the quality of the growth monitoring program in terms of criteria to define a good GMP programme, how GMP contributes to improved child health, a follow up system for faltering and malnourished children, and facilitators and barriers to implementing the GMP program. In the data collection process, four experienced public health officers and two Master of Public Health (MPH) nutritionists were hired and trained for data collection and supervision, respectively. In addition, research teams prepared the in-depth interview guideline and collected qualitative data.

An 8-month GMP record was considered to ascertain GMP participation rates and the percentage of infants and children who faltered in the GMP program. The dataset, which was extracted in Excel, contains the monthly weighted child as well as the total number of children who are moderately and severely undernourished.

Qualitative data was gathered from selected members. The interview lasted between 30 and 45 min and was held in a relaxed setting free from interruptions in their respective offices. During data collection, each question was probed for further exploration, and the responses were recorded in a notebook and digital electronic recorder for later transcription.

Before beginning fieldwork, data collectors and supervisors were recruited, and 2 days of training on the research objectives and the questionnaire’s contents and procedures were given to them. The interview was conducted on a day when the committee member had no demanding daily activities in order to obtain high-quality data. The principal investigator also requested the secondary data, which was then locked away until analysis. Members of the research team conducted the analysis.

2.6 Data analysis and interpretation

Microsoft Excel was used to analyze the secondary data. Using data from the 2007 population survey and a conversion factor of 5%, the total number of children under the age of two in each district was estimated. Then, we used the overall number of children in each month and the estimated number of children under the age of two in the study area to calculate the participation rate. Text and tables were used to present the results. For the analysis of qualitative data, thematic content analysis was used. Information obtained through in-depth interviews was transcribed and translated into English before being manually and thematically analyzed. Then, a sequence such as carefully reading, coding, displaying, reducing, and interpreting was done.

3 Results

3.1 Socio demographic characteristics of nutrition steering and technical committees

More than half (54.9%) of the respondents were in the age range of 28–35 years old. Less than two-thirds of the participants (58.8%) had a bachelor’s degree and above educational status. One third (33.3%) of the respondents had 4–10 years of work experience, and less than half (45.1%) of the study participants are steering committee members. Most (88.2%) of the members of the committee had no health-related professions. Most (80.4%) of the study participants were married (Table 1).

Table 1 Sociodemographic characteristics of nutrition steering and technical committee in central Gondar zone northwest Ethiopia, 2021
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3.2 Functionality steering and technical committees, GMP outcomes, and data quality indicators

Only one fifth (19.6%) of the committee knew that the district has a steering and technical committee for the implementation of the national nutrition program. Almost all (94.1%) of the committee members did not have an annual plan and a regular meeting schedule for the national nutrition program. Almost all committee members (98%) did not conduct monthly analyses and interpretations of community-based nutrition (CBN) data, nor did they have a working knowledge of the district’s CBN Plan. Less than one in five (17.6%) of the participants thought that a challenge was the lack of skill to analyze and interpret CBN data. All (100%) of the participants did not use the wall chart to analyze trends. About 98% of the participants did not have regular supportive supervisory schedules, and 96.1% of the participants didn’t use the GMP registration book on a monthly basis. All committee members (100%) didn’t know the proportion of flattering children in their area. Nearly all study participants (98%) were unaware of their annual GMP plan for children under the age of two. Nearly all (96.1%) of the participants did not evaluate their coverage with measures of normal, underweight, and severe underweight as per the report. More than three-fourths (78.1%) of the participants knew the role of the Health Development Army’s function in mobilizing mothers with children under the age of two (Table 2).

Table 2 Functionality, process and outcome indicators and data quality indicators among steering and technical committee in central Gondar zone northwest Ethiopia, 2021
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3.3 GMP participation rate and proportion of children faltering

The overall GMP participation rate was 49.89% and 50.06% in Gondar Zuria and East Demiba districts, respectively. The result showed that every visit’s participation rate was very far from the GMP standards (Fig. 1). The average GMP participation in both districts’ was also lower than the 80% global recommendation (Fig. 2).

Fig. 1
figure 1

Participation rate of GMP services among East Demiba District, Gondar Zuria District and central Gondar zone, 2020/2021

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Fig. 2
figure 2

Average participation rate of GMP services among East Demiba District, Gondar Zuria District and central Gondar zone, 2020/2021

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Similarly, the proportion of faltering children in Gondar Zuria district was much higher than that in East Dembia district, and the proportion was high in July in both districts. However, the proportion of faltering children who recovered by the next visit and by the third visit can’t be determined from the dataset (Fig. 3).

Fig. 3
figure 3

Proportion of children faltering during GMP services in Gondar Zuria and East Dembia District in 2020/2021

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3.4 In depth interviews findings

On barriers and challenges to GMP benefits, processes, outcomes, and quality of indicators.

3.5 GMP benefits

Because physical and mental development is so rapid in the first 2 years, all children under the age of two receive growth monitoring and promotion. Some team members highlight the benefits of GMP in terms of appropriate child growth and mental development, as well as its long-term effects, such as future academic performance and skills, by providing counselling, community conversation, and sample porridge preparation for complementary feeding.

A 40 year old committee member underscored the importance of GMP services as follows: “…. practicing GMP based on GMP protocol contributes to good child health and nutritional status through nutritional counselling and a live demonstration of complementary feeding preparation.”

3.6 GMP process

The GMP program is integrated into a multi-sectoral collaboration with all concerned sectors, providing a framework for coordinated nutrition intervention to end malnutrition among the most vulnerable segments of the population, such as infants and children. But most of the study participants didn’t know the existence and importance of both committees and didn’t have annual and regular meetings to follow up on the GMP program. In addition, a lack of skills in interpreting and analyzing for action. The GMP program is given for health professional only.

A 29 year old secretary of the committee said, “….the committees were not functional in their establishment role because of several reasons, such as lack of accountability/enforcement, lack of skill in GMP data analysis and utilization, and shortage of materials, among the common ones.”

52 years old committee member said… “lack of generating reports for decision making, lack of integrative supporting supervision, little attention to the program, no capacity building and refreshment training, and looking at it as the main and only duty of the district health office and health extension workers were the factors for poor functionality of the nutrition technical and steering committee”.

3.7 GMP outcome and quality of indicators

Monitoring GMP outcomes and the quality of GMP indicators is an important action for reducing the impact of malnutrition, but various challenges were identified by both committee members, like the types of material useful for the GMP programme, including the lack of a wall chart for analyzing GMP trend analysis, an integrative regular supportive supervisor on GMP performance, and the monthly recording of the GMP registration book. There were committee members who said that there was no wall chart in the health facilities, including district health offices. Both committees pointed out that the lack of an integrated, supportive supervisor was the most challenging aspect of improving our weaknesses and increasing the GMP participation rate based on the annual plan of the district as well as the catchment area. In addition, many members of the committee had no idea how many of the total measured children were normal, underweight, mild, moderate, severe, and faltering. Furthermore, there was a lack of written and oral feedback from the monthly, quartet, and yearly performance reports.

A 36 year old committee member had also stressed “…. The common problem of GMP practice was a lack of refreshment training, no written and oral feedback, and less program attention after partner handover to the government’s regular activities.”

A 38 steering committee said….’’currently, health facilities do not have all necessary materials like growth charts, wall charts, registration books, and guidelines used as references if there is uncertainty, especially in the health facilities.”

4 Discussion

To effectively prevent malnutrition in a community, a GMP programme should allow at least 80% of all children under the age of two to participate on a monthly basis, and high programme participation rates are connected to improved child health and growth trends. However, the overall average participation in the GMP central Gondar zone was 50.4%. This finding is lower than those from Senegal [28] (72%), and South Africa [29] (90%). The possible reason might be due to the fact that the current evidence shows that poor collaboration with the health development army, inadequate reporting and analysis at the health post, district, and zonal health department levels, and supportive supervision were the possible reasons for the low GMP participation rate in the study area. In addition, inadequate support from the nutrition programme steering and technical committees, as substantiated by qualitative data, may be a contributing factor to the low GMP participation rate.

The qualitative findings confirmed that a lack of refreshment training, feedback, relevant materials, and attention given to the program were major factors affecting the low participation rate. Furthermore, all NNP signatories, from the federal to the local level, made a poorly coordinated effort to implement GMP services in accordance with its principles and use GMP information for decision-making. Because GMP is a component of health extension packages [30, 31], the health extension workers and the nutrition steering and technical committee should work together to improve the participation rate of children in the GMP service [32].

GMP participation was low in both the district and the zonal health departments, with a high proportion of participants faltering rate out in July, August, and January. The possible reason might be due to the fact that the seasonal drop will be due to heavy workloads for the mother’s planting and harvesting periods and weather conditions, especially during the rainy season [33]. Furthermore, there is a period of tight scheduling for weddings and other special events in January, which may cause mothers’ to miss the GMP schedule.

All necessary materials for GMP and the skills of health professionals are the key strategies to achieve the intended goals of GMP [34]. Since GMP is a practical program, it needs at least weight measurement, a data recording logbook, child health care, and a growth reference chart [35]. Thus, the health care system should have all these necessary materials for its routine tasks. In addition, the health care professionals should have the required skills for measuring, recording, interpreting, and taking actions based on the findings. As a result, refreshment training is crucial to renew any outdated information picked up from previous training [36].

Overall, when GMP is conducted according to its core principles, it is one of the quality indicators of child growth. Equal attention to all health extension packages and integrative supportive supervision are the key roles among the concerned bodies. However, there are some limitations to this study. The study used a secondary report and didn’t include observation of the GMP practically in the study area. Second, the proportion of faltering children is very low compared to the regional prevalence of undernutrition, and the reasons for this were not well described.

5 Conclusion

The overall GMP participation rate is very low in the study area. GMP materials were also unavailable, and the technical and steering committees are not fully functional. As a result, it is critical to prepare working documents, assign a specific duty to reinforce the current steering and technical committees, provide refresher training for employees involved in GMP, and ensure the availability of critical GMP resources.