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Micronutrient deficiencies (MNDs) remain widespread among people in sub-Saharan Africa 1 – 5 , where access to sufficient food from plant and animal sources that is rich in micronutrients (vitamins and minerals) is limited due to socioeconomic and geographical reasons 4 – 6 . Here we report the micronutrient composition (calcium, iron, selenium and zinc) of staple cereal grains for most of the cereal production areas in Ethiopia and Malawi. We show that there is geospatial variation in the composition of micronutrients that is nutritionally important at subnational scales. Soil and environmental covariates of grain micronutrient concentrations included soil pH, soil organic matter, temperature, rainfall and topography, which were specific to micronutrient and crop type. For rural households consuming locally sourced food—including many smallholder farming communities—the location of residence can be the largest influencing factor in determining the dietary intake of micronutrients from cereals. Positive relationships between the concentration of selenium in grain and biomarkers of selenium dietary status occur in both countries. Surveillance of MNDs on the basis of biomarkers of status and dietary intakes from national- and regional-scale food-composition data 1 – 7 could be improved using subnational data on the composition of grain micronutrients. Beyond dietary diversification, interventions to alleviate MNDs, such as food fortification 8 , 9 and biofortification to increase the micronutrient concentrations in crops 10 , 11 , should account for geographical effects that can be larger in magnitude than intervention outcomes. Geospatial variation in the micronutrient composition (calcium, iron, selenium and zinc) of staple cereal grains is nutritionally important at subnational scales in Ethiopia and Malawi; these data could be used to improve surveillance of micronutrient deficiencies in the region.

Background For evidence-based decision-making, there is a need for quality, timely, relevant and accessible information at each level of the health system. Limited use of local data at each level of the health system is reported to be a main challenge for evidence-based decision-making in low- and middle-income countries. Although evidence is available on the timeliness and quality of local data, we know little about how it is used for decision-making at different levels of the health system. Therefore, this study aimed to assess the level of data use and its effect on data quality and shared accountability at different levels of the health system. Methods An implementation science study was conducted using key informants and document reviews between January and September 2017. A total of 21 key informants were selected from community representatives, data producers, data users and decision-makers from the community to the regional level. Reviewed documents include facility reports, district reports, zonal reports and feedback in supervision from the district. Thematic content analysis was performed for the qualitative data. Results Respondents reported that routine data use for routine decision-making was low. All health facilities and health offices have a performance monitoring team, but these were not always functional. Awareness gaps, lack of motivating incentives, irregularity of supportive supervision, lack of community engagement in health report verification as well as poor technical capacity of health professionals were found to be the major barriers to data use. The study also revealed that there are no institutional or national-level regulations or policies on the accountability mechanisms related to health data. The community-level Health Development Army programme was found to be a strong community engagement approach that can be leveraged for data verification at the source of community data. Conclusion The culture of using routine data for decision-making at the local level was found to be low. Strengthening the capacity of health workers and performance monitoring teams, introducing incentive mechanisms for data use, engaging the community in data verification and introducing accountability mechanisms for health data are essential to improve data use and quality.

Dietary zinc (Zn) deficiency is widespread globally, and in particular among people in sub-Saharan Africa (SSA). In Malawi, dietary sources of Zn are dominated by maize and spatially dependent variation in grain Zn concentration, which will affect dietary Zn intake, has been reported at distances of up to ~ 100 km. The aim of this study was to identify potential soil properties and environmental covariates which might explain this longer-range spatial variation in maize grain Zn concentration. Data for maize grain Zn concentrations, soil properties, and environmental covariates were obtained from a spatially representative survey in Malawi (n = 1600 locations). Labile and non-labile soil Zn forms were determined using isotopic dilution methods, alongside conventional agronomic soil analyses. Soil properties and environmental covariates as potential predictors of the concentration of Zn in maize grain were tested using a priori expert rankings and false discovery rate (FDR) controls within the linear mixed model (LMM) framework that informed the original survey design. Mean and median grain Zn concentrations were 21.8 and 21.5 mg kg −1 , respectively (standard deviation 4.5; range 10.0–48.1). A LMM for grain Zn concentration was constructed for which the independent variables: soil pH (water) , isotopically exchangeable Zn (Zn E ), and diethylenetriaminepentaacetic acid (DTPA) extractable Zn (Zn DTPA ) had predictive value ( p  < 0.01 in all cases, with FDR controlled at < 0.05). Downscaled mean annual temperature also explained a proportion of the spatial variation in grain Zn concentration. Evidence for spatially dependent variation in maize grain Zn concentrations in Malawi is robust within the LMM framework used in this study, at distances of up to ~ 100 km. Spatial predictions from this LMM provide a basis for further investigation of variations in the contribution of staple foods to Zn nutrition, and where interventions to increase dietary Zn intake (e.g. biofortification) might be most effective. Other soil and landscape factors influencing spatially dependent variation in maize grain Zn concentration, along with factors operating over shorter distances such as choice of crop variety and agronomic practices, require further exploration beyond the scope of the design of this survey.

Selenium (Se) is an essential element for human health. However, our knowledge of the prevalence of Se deficiency is less than for other micronutrients of public health concern such as iodine, iron and zinc, especially in sub-Saharan Africa (SSA). Studies of food systems in SSA, in particular in Malawi, have revealed that human Se deficiency risks are widespread and influenced strongly by geography. Direct evidence of Se deficiency risks includes nationally representative data of Se concentrations in blood plasma and urine as population biomarkers of Se status. Long-range geospatial variation in Se deficiency risks has been linked to soil characteristics and their effects on the Se concentration of food crops. Selenium deficiency risks are also linked to socio-economic status including access to animal source foods. This review highlights the need for geospatially-resolved data on the movement of Se and other micronutrients in food systems which span agriculture–nutrition–health disciplinary domains (defined as a GeoNutrition approach). Given that similar drivers of deficiency risks for Se, and other micronutrients, are likely to occur in other countries in SSA and elsewhere, micronutrient surveillance programmes should be designed accordingly.

The dataset comprises primary data for the concentration of 29 mineral micronutrients in cereal grains and up to 84 soil chemistry properties from GeoNutrition project surveys in Ethiopia and Malawi. The work provided insights on geospatial variation in the micronutrient concentration in staple crops, and the potential influencing soil factors. In Ethiopia, sampling was conducted in Amhara, Oromia, and Tigray regions, during the late-2017 and late-2018 harvest seasons. In Malawi, national-scale sampling was conducted during the April–June 2018 harvest season. The concentrations of micronutrients in grain were measured using inductively coupled plasma mass spectrometry (ICP-MS). Soil chemistry properties reported include soil pH; total soil nitrogen; total soil carbon (C); soil organic C; effective cation exchange capacity and exchangeable cations; a three-step sequential extraction scheme for the fractionation of sulfur and selenium; available phosphate; diethylenetriaminepentaacetic acid (DTPA)-extractable trace elements; extractable trace elements using 0.01 M Ca(NO3)2 and 0.01 M CaCl2; and isotopically exchangeable Zn. These data are reported here according to FAIR data principles to enable users to further explore agriculture-nutrition linkages.Measurement(s)Trace Element • soil chemical propertiesTechnology Type(s)Inductively-Coupled Plasma Mass SpectrometryFactor Type(s)Geography • Staple cereal cropSample Characteristic - OrganismStaple cereal food cropsSample Characteristic - EnvironmentSmallholder farmingSample Characteristic - LocationEthiopia • Malawi

Background A strong health information system (HIS) is one of the essential building blocks for a resilient health system. The Ministry of Health (MOH) of Ethiopia is working on different initiatives to strengthen the national HIS. Among these is the Capacity-Building and Mentorship Partnership (CBMP) Programme in collaboration with public universities in Ethiopia since November 2017. This study aims to evaluate the outcomes and share experiences of the country in working with universities to strengthen the national HIS. Methods The study employed a mixed-methods approach that included 247 health organizations (health offices and facilities) of CBMP-implementing woredas (districts) and 23 key informant interviews. The programme focused on capacity-building and mentoring facilities and woreda health offices. The status of HIS was measured using a connected woreda checklist before and after the intervention. The checklist consists of items related to HIS infrastructure, data quality and administrative use. The organizations were classified as emerging, candidate or model based on the score. The findings were triangulated with qualitative data collected through key informant interviews. Results The results showed that the overall score of the HIS implementation was 46.3 before and 74.2 after implementation of the programme. The proportion of model organizations increased from 1.2% before to 31.8% after the programme implementation. The health system–university partnership has provided an opportunity for higher education institutions to understand the health system and tune their curricula to address real-world challenges. The partnership brought opportunities to conduct and produce local- and national-level evidence to improve the HIS. Weak ownership, poor responsiveness and poor perceptions of the programme were mentioned as major challenges in programme implementation. Conclusion The overall HIS has shown substantial progress in CBMP implementation woredas. A number of facilities became models in a short period of time after the implementation of the programme. The health system–university partnership was found to be a promising approach to improve the national HIS and to share the on-the-ground experiences with the university academicians. However, weak ownership and poor responsiveness to feedback were the major challenges identified as needing more attention in future programme implementation.

Background/Objectives: Selenium (Se) as part of glutathione peroxidase and iodothyronine deiodinase enzymes influences thyroid metabolism. This study investigated the association of serum Se levels with thyroid metabolism of severely iodine-deficient young children from the Amhara region of Ethiopia. Subjects/Methods: In a cross-sectional study, Se, thyroid-stimulating hormone, total thyroxin, total triiodothyronine and thyroglobulin in serum of children ( N =628) 54–60 months of age from the Amhara region, Ethiopia, were analyzed. In addition, iodine in urine and household salt was analyzed, and the presence of goiter was assessed. Results: The median serum Se concentration was 61.4 μg/l (10.7–290.9 μg/l). Selenium deficiency (serum Se <70 μg/l) was detected in 57.8% ( N =349) of the children. The median urinary iodine concentration (UIC) was 9.8 μg/l. The majority (86.6%, N =449) of children had UIC below the recommended value (100 μg/l). In addition, 59.8% ( N =310) of children were severely iodine deficient (UIC<20 μg/l). Only 12.7% of salt samples had iodine. Goiter was present in 44.6% ( N =280) of the children. Selenium-deficient children had higher serum thyroxin (T 4 ) than children with normal serum Se concentration ( P <0.001). Conclusions: Serum Se was negatively associated with T 4 level in young children from the Amhara region of Ethiopia and may endanger the effectiveness of the salt iodization program.

Strengthening the national health information system is one of Ethiopia's priority transformation agendas. A well-trained and competent workforce is the essential ingredient to a strong health information system. However, this workforce has neither been quantified nor characterized well, and there is no roadmap of required human resources to enhance the national health information system. We aimed to determine the current state of the health information system workforce and to forecast the human resources needed for the health information system by 2030. We conducted a survey to estimate the current number of individuals employed in the health information system unit and the turnover rate. Document review and key-informant interviews were used to collect current human resources and available health information system position data from 110 institutions, including the Ministry of Health, federal agencies, regional health bureaus, zonal health departments, district health offices, and health facilities. The Delphi technique was used to forecast human resources required for the health information system in the next ten years: 3 rounds of workshops with experts from the Ministry of Health, universities, agencies, and regional health bureaus were held. In the first expert meeting, we set criteria, which was followed by expert suggestions and feedback. As of April 2020, there were 10,344 health information system professionals working in the governmental health system. Nearly 95% (20/21) of district health offices and 86.7% (26/30) of health centers reported that the current number of health information system positions was inadequate. In the period from June 2015 to June 2019, health information technicians had high turnover (48/244, 19.7%) at all levels of the health system. In the next ten years, we estimate that 50,656 health information system professionals will be needed to effectively implement the Ethiopia's national health information system. Current health information system-related staffing levels were found to be inadequate. To meet the estimated need of 50,656 multidisciplinary health information system professionals by 2030, the Ministry of Health and regional health bureaus, in collaboration with partners and academic institutions, need to work on retaining existing and training additional health information system professionals.

Zinc (Zn) deficiency is a widespread nutritional problem in human populations, especially in sub-Saharan Africa (SSA). The Zn concentration of crops consumed depends in part on the Zn status of the soil. Improved understanding of factors controlling the phyto-availability of Zn in soils can contribute to potential agronomic interventions to tackle Zn deficiency, but many soil types in SSA are poorly studied. Soil samples (n=475) were collected from a large part of the Amhara Region of Ethiopia, where there is widespread Zn deficiency. Zinc status was quantified by measuring several fractions, including the pseudo-total (aqua regia digestion; ZnTot), available (DTPA (diethylenetriamine pentaacetate) extractable; ZnDTPA), soluble (dissolved in 0.01 M Ca(NO3); ZnSoln) and isotopically exchangeable Zn, using the enriched stable Zn isotope 70Zn (ZnE). Soil geochemical properties were assessed for their influence on Zn lability and solubility. A parameterized geochemical assemblage model (Windermere Humic Aqueous Model – WHAM) was also employed to predict the solid phase fractionation of Zn in tropical soils rather than using sequential chemical extractions. ZnTot ranged from 14.1 to 291 mg kg−1 (median = 100 mg kg−1), whereas ZnDTPA in the majority of soil samples was less than 0.5 mg kg−1, indicating widespread phyto-available Zn deficiency in these soils. The labile fraction of Zn in soil (ZnE as % ZnTot) was low, with median and mean values of 4.7 % and 8.0 %, respectively. Labile Zn partitioning between the solid and the solution phases of soil was highly pH dependent, where 94 % of the variation in the partitioning coefficient of 70Zn was explained by soil pH. Similarly, 86 % of the variation in ZnSoln was explained by soil pH. Zinc distribution between adsorbed ZnE and ZnSoln was controlled by pH. Notably, Zn isotopic exchangeability increased with soil pH. This contrasts with literature on contaminated and urban soils and may arise from covarying factors, such as contrasting soil clay mineralogy across the pH range of the soils used in the current study. These results could be used to improve agronomic interventions to tackle Zn deficiency in SSA.

SUBJECTS/METHODS: In a cross-sectional study, Se, thyroid-stimulating hormone, total thyroxin, total triiodothyronine and thyroglobulin in serum of children (N = 628) 54-60 months of age from the Amhara region, Ethiopia, were analyzed. In addition, iodine in urine and household salt was analyzed, and the presence of goiter was assessed. N = 449) of children had UIC below the recommended value (100 µg/l). In addition, 59.8% (N =310) of children were severely iodine deficient (UIC < 20 µg/l). Only 12.7% of salt samples had iodine. Goiter was present in 44.6% (N =280) of the children. Seleniumdeficient children had higher serum thyroxin ([T.sub.4]) than children with normal serum Se concentration (P < 0.001). European Journal of Clinical Nutrition (2016) 70, 929-934; doi:10.1038/ejcn.2016.27; published online 16 March 2016