Trials of Improved Practices (TIPS) for Evaluating Feeding Recommendations

Abstract

• Name: Trials of Improved Practices (TIPS) for Evaluating Feeding Recommendations

• Purpose: The purpose of TIPS is to test feeding recommendations before they are adopted in health education programs. Improved practices must be feasible and acceptable to families and caretakers. Testing should be done in homes before they are advocated, and TIPS is one method for doing so.

• Type of Design: Descriptive, cross sectional. Can be repeated over time to track changes in practices, perceptions, motivations and constraints to following recommendations on desirable child feeding practices.
• Sample Size: Trials are conducted in a sufficient number of sites so as to reflect differences in child feeding practices in the program area. A small number of children (e.g. two to four) are purposely selected in specific age groups in each site.
• Where Used: TIPS have been conducted in several countries in Africa, Asia and Latin America. WHO selected this method for adapting the feeding recommendations or "Food Box" in the Integrated Management of Childhood Illnesses'(IMCI) program.

To survey tool

Basic Information

Name: Trials of Improved Practices (Tips) for Evaluating Feeding Recommendations

Origin: The Manoff Group and SARA Project/AED

Source: BASICS

Basic Description: A guide for conducting qualitative research primarily on recommended child feeding practices. It provides the objectives, planning steps, worksheets, detailed field guidelines for implementation, analysis plans, forms and examples to assist a team of health/nutrition professionals and para-professionals to carry out the trials and develop feeding recommendations.

Country Applications: The tool has been used in several countries including Benin, Eritrea, the Gambia, Nigeria, Senegal, Swaziland, Tanzania, Zambia, Ecuador, Honduras, Bolivia, Indonesia, Pakistan, and others for the following main categories of applications:

• to develop health/nutrition education strategies and materials to improve child feeding practices;
• as part of the adaptation process for the IMCI program. It constitutes the "feeding recommendations component" of IMCI, or adaptation of the 'Food Box'.

Languages Available: English and French

Technical Scope: Feeding practices in infants and children in the age group of 0-59 months. The main themes are:

• initiation, exclusivity and frequency of breastfeeding;
• planned duration of breastfeeding and reasons for stopping;
• breastfeeding problems and solutions;
• ages and cues for introduction of complementary foods;
• frequency and amounts of complementary foods;
• water content/bulk and energy density, density of other nutrients in complementary foods;
• problems and solutions in complementary feeding;
• feeding and appetite during childhood illnesses;
• sources of information and advice on infant feeding.

TIPS identifies motivations and barriers related to the practice of improved behaviors including: perceived or attitudinal constraints, practical/physical/resource limitations and social/family norms.

Purpose: To test feeding recommendations before they are adopted in health education programs. Improved practices must be feasible and acceptable to families and caretakers. Testing should be done in homes before they are advocated, and TIPS is one method for doing so.

Type of Methods: Qualitative.

Design: Descriptive, cross sectional. The method includes developing an assessment and counseling guide on feeding practices based on existing information, conducting three home visits, analyzing the information, and drafting revised feeding recommendations and actions to support improved practices. The three home visits consist of an initial/assessment visit, a counseling visit where proposed practices are recommended and agreement reached with family members on trying out certain recommendations, and a follow-up visit to obtain feedback on the constraints and responses to the trial of recommended practices.

Frequency of Administration: Generally once, during the planning and development of health/nutrition education strategies/materials. However, TIPS can be repeated over time to track changes in practices, perceptions, motivations and constraints to following recommendations on desirable child feeding practices.

Key Users of Information

Program managers, and designers of training curricula for IMCI and/or nutrition intervention training. At present its most widespread use is in adapting IMCI "Food Box" or feeding recommendations.

Objectives and Scope of Tool

The main objective is to develop feeding recommendations that are acceptable and feasible for families in the program area. The TIPS method can also be used as practical training for health care providers to strengthen counseling skills. It gives implementers experience with systematic assessment and analysis of feeding problems, negotiating with families and caretakers on what modifications to bring about, and custom tailoring messages to fit the motivations and constraints of the family/caretakers. This method has been used to develop counseling guidelines for iron/folate supplementation of pregnant women where compliance can be a problem.

Key Monitoring Needs and Evaluation Questions Tool Seeks to Address

Are child feeding recommendations acceptable and practical for adoption by families in the program area?

Key Indicators

• Are the solutions being offered the most feasible and acceptable?
• What kind of motivation for improved feeding practices would be most convincing?
• What is the relative importance of feeding recommendations (are the problems being addressed among the most serious/common in the area?)
• Are concerns of influential individuals in the family and community being addressed?
• Have differences among population segments been taken into account?
• Are foods, names of conditions and items, terminology, language, and concepts used in the recommendations consistent with prevailing norms in the area?

Research Design

Standard Protocol:

Type of Design: Cross-sectional, descriptive.

Units of Observation and Analysis: Households and children are the units of observation. Recommendations are drawn for an area/population group by age-group.

Sample Size: Usually purposeful selection of children from age groups that represent differences in feeding practices and feeding problems. At least two children per site per age group, four children if feeding problems and differences within groups are common.

Target Population: Children.

Lessons from Experience:

• A minimum number of sites should be selected in a program area.
• Adequate time should be allocated to pre-planning for synthesizing all existing information about child feeding and nutrition in the program area.
• If enough information can be obtained to develop assessment and counseling guides, the home visits can be reduced to two (one for counseling and one for follow-up).
• The analysis should focus on information that is useful for program planning.
• Reasons for acceptance or rejection of recommendations should be highlighted along with how many cases accepted or rejected them; the most important motivating factors; and resistance points.

Training

Standard Protocol:

Topics include:

• review of existing information on child feeding in the area;

• data collection methods (e.g. open-ended questions and probing, observation, 24-hour diet recall, food frequency method, diet analysis and problem identification, etc.);
• importance of negotiating small/incremental vs. large/impractical changes while counseling mothers;
• negotiation with mothers to try changes;
• recording reasons and motivations for decisions by mothers;
• sampling and scheduling issues.

Lessons from Experience:

It usually takes three days of classroom work, at least one day of field testing and at least one day to discuss the field experience and make changes to instruments.

Implementation

Standard protocol:
A preliminary visit is made to each site to make arrangements. Local representatives are engaged to locate families with children in appropriate age categories. During the initial visit, a dietary assessment is conducted and child feeding practices that require improvement are identified. Occasional and daily foods are recorded. Open ended questions about child feeding and observations are made. In between visits the child's feeding is assessed with a supervisor using a guide, positive feeding practices are recorded, and problems identified. During the counseling visit, the mother's responses to feeding recommendations are recorded. In between visits, the analysis of information is started. In the final visits, mothers are asked about which advice she followed and why, how she felt about her experience, what others thought, benefits for the child/others, if she modified the recommendation and why, if she plans to continue and why.

Lessons from Experience:
The length of time in the field depends upon the number of sites, distances, logistics arrangements, and number of field workers. Interviewers can conduct two to three initial visits per day. Summarizing and discussing each day's information takes time in between visits. Follow-up visits need to be scheduled about three to five days after the counseling visit. Follow-up visits take less time and more households can be completed per day. An experienced nutritionist is required to develop guidelines for this analysis based on local food preparation practices, food composition tables and foods available. It is not necessary to quantify each child's intake exactly but rather to answer questions such as: is breastfeeding frequency adequate, are serving sizes of complementary foods large enough, do the foods contain enough energy or are they too dilute and bulky, etc. A surprising number of mothers agree to trying changes in child feeding practices. At most two to three changes should be negotiated with each mother. It is important to not leave out any recommendations from those being suggested to mothers. A second dietary assessment is important at the follow-up visit to determine overall changes in feeding practices, not only whether a specified practice was followed.

Analysis

Standard protocol:
Analytical Requirements: Experience with dietary assessments, use of food composition tables, and requirements.

Time and Labor Requirements: Much of the analysis occurs between home visits. The results of the final visits are summarized and recommendations added at the end.

Lessons from Experience:
The best approach to determining inadequacies in each child's diet and the most appropriate remedies is to ensure that clear guidelines are available, training is adequate and that researchers work closely with a trained and experienced supervisor. Comparing and contrasting different groups should be used to highlight important recommendations. In addition to tallying the number of cases where mothers succeeded in changing practices, it is important to identify the motivational messages and perceptions of successful recommendations, and the barriers to those not accepted.

Reporting

Standard Protocol:
Content: Reports give a brief description of methods, sample, summary tables of feeding recommendations offered, tried, accepted, rejected and motivations. Differences by area/site, population groups are summarized. Conclusions regarding program recommendations and additional research are also given.

Flow of Information: From the qualitative research team to program planners.

Presentation: Tables, bullets on priority findings, constraints, motivations and program actions. In the case of IMCI feeding recommendations, the "Food Box" is modified. In other programs, counseling cards may be drafted, radio messages developed, and training materials designed.

Dissemination of Results

Standard Protocol:
Communication strategies are used to disseminate the recommendations to various target audiences. In IMCI, health providers are trained in the use of assessment and counseling guides.

Lessons from Experience:
In IMCI, the training of health providers has not been as effective as had been hoped. More time and practice is needed in the use of the "Food Box".

Manuals and Guidelines

The guidelines exist in the form of Chapter 6 of a monograph "Designing by Dialogue: Consultative Research for Improving Child Feeding". Available from The Manoff Group, SARA/AED,and USAID/G/HN Washington D.C.

Contact Person
Marcia Griffiths
The Manoff Group
2001 S Street, NW Suite 400
Washington, DC 20009
202-265-7469