Checklist for Assessing Priority Nutrition Interventions in District Health Services

Abstract

• Name: Checklist for Assessing Priority Nutrition Interventions in District Health Services.
• Purpose: To assist district health managers in conducting program reviews to identify gaps in priority nutrition interventions.
• Type of Design: Descriptive, cross sectional. Can be repeated over time to track changes in policies and quality of services.
• Sample Size: Sample size varies with resources availability. Health facilities are purposively selected at each of three levels: district, intermediate and community. Those managed by NGOs and government services are also included. At least one community is also selected in the catchment area of each health facility.
• Where Used: The assessment tool was developed based on program reviews in Madagascar, Zambia, Ghana and Eritrea. It has also been used in Senegal and Benin.

To survey tool

Basic Information

Name:Checklist for Assessing Priority Nutrition Interventions in District Health Services

Origin: Nutrition and M&E Working Groups of the BASICS Project.

Source: BASICS Project

Basic Description: A checklist of items used by district health managers to determine the extent to which priority nutrition interventions are integrated with routine maternal/reproductive health and child health services in facilities and at the community level. The tool is used to assist program planning. Although the checklist was designed primarily for district health teams, it has been used at the national level to identify areas for donor support.

Country Applications: In the development phase, the checklist was used in the following countries:

Madagascar - To assess the status of nutrition activities and the partners involved in them, and to identify an appropriate role for USAID's nutrition assistance.

Zambia - To develop a plan for USAID nutrition assistance as part of its support of health reform in Zambia, and to design the nutrition components of USAID's bilateral health project.

Ghana - To develop an integrated plan of action for USAID assistance in the health sector.

Eritrea - To assist the government of Eritrea in drafting its first national nutrition policy and strategy, with a focus on identifying high priority interventions.

Senegal - To design a program for strengthening integrated, district health and nutrition services.

Benin - To identify nutrition components of USAID's bilateral family health program, and introduce them in one health region.

Languages Available: English. A French version is expected in 1998/1999.

Technical Scope: Improving policy and service quality related to six priority nutrition interventions:

• Promotion of exclusive breastfeeding for about six months;
• Promotion of adequate complementary feeding from about six to 24 months with continued breastfeeding;
• Adequate nutritional care of sick and malnourished children;
• Assuring adequate intake of vitamin A;
• Assuring adequate intake of iron;
• Promotion of iodized salt consumption.

The scope covers maternal/reproductive health and child health services.

Purpose: The purpose of the Checklist for Assessing Priority Nutrition Interventions in District Health Services is to assist district health managers in conducting program reviews and identify gaps in priority nutrition interventions.

Type of Methods: Qualitative. This tool can be combined with quantitative health facility and/or household survey methods.

Design: Descriptive, cross sectional. The tool is designed as a checklist to guide the collection of cross-sectional information on the nature and quality of a group of selected nutrition activities in routine maternal/reproductive health or child health services. The method includes collecting secondary data on the nature and magnitude of nutrition problems in the area, extracting information from records (e.g. status of supplies, record-keeping procedures, review of protocols, etc.), interviewing health managers and health providers, and observing health care being provided. The survey can be repeated over time to track changes in policies and quality of services.

Frequency of Administration: Possibly every two to three years. The tools can be used more frequently to document policy changes, improved health provider skills, training/orientation and supervision, or changes in recording/monitoring systems, etc.

Key Users of Information

The checklist primarily assists health managers from government and NGOs working at district level. However, it is also useful for national planning, and for assisting staff at health facilities. At all levels it helps identify program gaps in routine health services related to a high priority set of nutrition interventions, and highlights where additional support may lead to improved services.

The following are some examples of decisions made based on data from the checklist:

Madagascar - Decision to update national protocols for micronutrients, conduct qualitative research on infant feeding practices as a basis for community level IEC activities, and USAID's decision to develop a MOU with UNICEF to support priority nutrition interventions.

Zambia - Decision to include a minimum or essential package of nutrition components in the national health strategy, and to accelerate the fortification of sugar with vitamin A.

Senegal - Decision to include vitamin A supplementation in the Bamako Initiative, update protocols and policies for vitamin A, strengthen counseling components of iron/folate supplementation, focus more narrowly on the most cost-effective nutrition interventions and improve the integration of health and nutrition services in facilities.

Benin - Decision to conduct qualitative research for more effective IEC/behavior change strategies for priority nutrition behaviors. To orient staff to integrated delivery of health and nutrition services.

Global level - Decision at the global level to draft technical guidelines for neglected topics, e.g. iron supplementation protocols (developed by INACG/UNICEF/JHU/USAID), integration of vitamin A supplements with immunizations (BASICS/WHO). Also helped guide the development of nutrition components of household and health facility surveys.

Objectives and Scope of Tool

The objectives are two-fold:

• to provide a basis for decisions about nutrition program strengthening by determining the extent that priority nutrition interventions are integrated with health services, and
• to introduce, update and involve district health teams in priority nutrition interventions and to orient them to ways that district health systems can support these interventions in facilities and communities.

The assessment focuses on six interventions that have proven to be cost-effective, and have been considered the "Minimum Package" of nutrition services that all health workers must provide.

Most health programs already implement actions aimed at strengthening one or more of these interventions, but often they are not fully integrated with routine health services. Consequently their quality and coverage remain low. To fit in with existing health services, the following six categories of health contacts have been identified as primary targets for Nutrition Minimum Package strengthening. The assessment tool focuses on these contacts and a set of actions that should be implemented in each:

• Prenatal contacts;
• Assistance at delivery and immediate postpartum care;
• Postnatal contacts;
• Immunization contacts;
• Sick child visits;
• Well-child visits.

Key Monitoring Needs and Evaluation Questions Tool Seeks to Address

• Are nutrition activities focused on the most serious and preventable nutrition problems in the program area?

• What are the gaps in priority nutrition activities in health facilities? Specifically, what are the most common categories of health contacts (prenatal, delivery, postpartum and postnatal in maternal and reproductive health; and immunization contacts, sick- and well-child contacts in child health services)? What is the nutrition content of this care? What needs to be strengthened?
• What are the gaps in priority nutrition activities in community? Specifically, what are the community channels through which maternal and child health care is given? Through what channels in the community can feeding assessments and counseling, guidance and supplementation be provided? What is the nutrition content of these interactions at present? How can it be strengthened?
• How can district health systems provide adequate support for priority nutrition interventions in facilities and communities? Specifically, how adequate are current policies and protocols pertaining to priority nutrition problems, training and support given to front-line providers, supply systems, health education and IEC activities, planning/recording/monitoring, technical and financial resources? To fill gaps identified above in services at facilities and at community level, what support does the district team need to provide?

Key Indicators

The emphasis of the program review or assessment is on access and quality of nutrition components of health services. Examples of indicators are:

ACCESS

• Women and children are routinely assessed for priority nutrition problems at all contacts in facilities.
• Adequate supplies exist in facilities of vitamin A capsules, iron/folate tablets, iodized salt testing kits, counseling aids on maternal and child feeding, recording forms (e.g. vitamin A in immunizations/child health cards and child health registers, iron supplementation/breastfeeding/counseling/postpartum vitamin A with mother's cards and maternity registers).
• Regular community outreach is conducted by facilities' staff for supporting nutrition activities.
• Communities have trained child nutrition counselors.

QUALITY

Facilities Level

• Protocols for priority nutrition actions are consistent with international recommendations and national policies.
• Quality of counseling is given to pregnant women is adequate.
• Staff training is adequate.
• Supervision of nutrition components is adequate.
• Recording and tracking of coverage and quality is adequate.
• IEC materials and messages address priority themes and are based on qualitative research.

Community Level

• Community leaders and health workers know the extent of nutrition problems in their area and the importance of nutrition.
• There is a committee or group of community members that monitors nutrition indicators for each of the six priority nutrition interventions; they take action when a problem is detected.
• There is at least one person in each community trained to give priority nutrition services as part of maternal/reproductive, and child health care. This person is adequately supervised.
• There is community-based distribution of iron/folate tablets.
• Counseling is done on mothers' diets, breastfeeding and iron/folate.
• IEC materials and messages address priority themes and are based on qualitative research.
• Sick children are routinely screened for severe malnutrition, referred appropriately, and given follow-up care according to district guidelines.

SUSTAINABILITY/MANAGEMENT

• Supply system for iron/folate supplements, vitamin A supplements, iodized salt testing kits, and IEC and record keeping materials is integrated with routine procurement of other essential drugs and health supplies.
• Maternal and child recording forms are being appropriately used to record priority nutrition actions.
• Priority nutrition indicators are routinely analyzed and used for making decisions.
• Routine supervision in maternal/reproductive health and child health services include supervision of the priority nutrition actions.
• District targets for reducing nutrition problems are reasonable and widely known by health staff.
• Adequate staff and budget have been allocated to priority nutrition actions.
• Staff and resources are adequate for promoting priority nutrition behaviors at the community-level, specifically for:

• building awareness of priority nutrition actions and mobilizing community-based organizations;
• promotion of exclusive breastfeeding;
• assuring appropriate complementary feeding;
• improving vitamin A status of women and children;
• improving iron intake;
• improving iodized salt intake;
• appropriate nutritional management of sick and malnourished children.

Research Design

Standard protocol:
Type of Design: Cross-sectional, descriptive. Non-random, selective identification of facilities and communities.

Units of Observation and Analysis: District, health facilities, health providers and communities are the units of observation/data sources. Unit of analysis is the district as a whole; and type of health organization (e.g. NGO/government, health center/health post/rural maternity).

Sample Size: At least one of each type of health facility and type of health organization (NGO/government). At least one community per facility.

Target Population: Women and children.

Lessons from experience:
It is not easy to extrapolate to the entire program area with statistical confidence. However, application of the tool is a low-cost activity that allows the tool to be used widely. There is a possibility of selection bias. The design does not provide a quantitative baseline that may be required by some donors. The tool is more useful for exploratory assessments that can then lead to quantitative studies with representative samples of facilities and households. It is an efficient screening device to narrow the focus of more formal and expensive quantitative studies.

Training

Standard protocol:
District-level staff or staff from neighboring facilities are given a brief orientation and demonstration on how to use the tool. External consultants (public health nutrition) implement the district-level components of the checklist and orient/train district and health facilities staff (and field test or revise the tool). The training takes a few days.

Lessons from experience:
District staff should work with the tool as team, increasing the probability of producing viable recommendations for action. The orientation and 'field testing' of the tool is the key to building awareness of priority nutrition actions. Because the interventions are not completely new (though some aspects of quality and access are new), the period taken for training is not excessive.

Implementation

Standard protocol:
Interviewers: Experienced health service staff from maternal/reproductive health and child health services. Must include at least one team member from EPI and one from community outreach/social mobilization.

Administration Requirements: Two to three teams each with a vehicle, and frequent (daily) discussions among teams working in parallel.

Technical Resource Requirements: At least one team member should have experience with the assessment, and preferably have knowledge about the programs and policies related to infant feeding (e.g. BFHI) and micronutrients (e.g. vitamin A, Universal Salt Iodization initiative, etc.).

Lessons from experience:
Interviewers: It is important to wait until the appropriate level of staff are available for a one to three-week period for the assessment. There are no major administrative requirements. Supervision and data quality assurance requirements include: using a team approach to ensure checks and balances. The checklist is written in short-hand and requires experienced team members to orient other team members thoroughly. It is critical to have the instrument translated, and adapted to local languages and conditions.

Cost and Financing (budgeting guidance): Assuming a two-week assessment, one external consultant, and three local teams per district/region, a budget of about $20,000 to $30,000 per assessment is adequate.

Time Requirements: Two weeks of field work, one week for planning and drawing up recommendations.

Analysis

Analytical Requirements: Knowledge of nutrition indicators and how to interpret existing data.

Time and Labor Requirements: Two-three days are needed for synthesizing the findings in a group discussion format. An important objective is for future implementers of the plan of action to discuss the implications of the findings/observations, examine constraints, and develop the plans of action.

Reporting

Content: Reports contain documentation of the nature and magnitude of priority nutrition problems in the area, current status of priority activities in health services provided at facilities and at community level, main gaps, reasons/constraints, actions to improve access/quality/coverage/sustainability and management.

Flow of Information: The district team conducts the analysis and synthesis and draws up recommendations for the report.

Presentation: Tables, bullets on priority gaps, constraints, and lists of actions. Reports are shared with donors/funders of the assessment, national authorities and various partners involved in supporting maternal and child health in the area.

Lesson from Experience:
It is critical to hand over analysis, reporting and presentation to the district health team.

Summaries of findings and formal presentations at meetings at the national level and for various health partners/donors are useful.

Manuals and Guidelines

The guidelines exist in a draft checklist format available from BASICS.

Contact Person
Tina Sanghvi
BASICS Project
1600 Wilson Blvd.
Arlington, VA 22209
703-312-6800