Authors: Lamstein S; Tharaney M; Kappos K; Nekatebeb H; Mokori A; D’Agostino A; Racine N; Exume R; Lyons C; Pomeroy, A; Lerebours, G
Background and objectives: Nutrition services are not systematically integrated into either international public health systems and services or routine health facility assessments. The nutrition assessment, counseling and support (NACS) approach is used to integrate nutrition into policies, programs and health services to ensure the prevention and treatment of malnutrition among all populations and across the continuum of care or health services. In Haiti and Uganda, one of SPRING’s goals is to strengthen NACS services at the health facility level through trainings and other quality improvement activities. As a first step in this process, SPRING conducted assessments to better understand the capacity of health facilities to integrate NACS services within pediatric, maternal, and HIV and AIDS units. Thereafter, SPRING set out to develop a refined and streamlined package of tools for facility-based NACS assessments.
Methods: The assessments were conducted in 14 health facilities in Haiti and 34 in Uganda. The assessments involved quantitative interviews (Haiti: n=157; Uganda: n=155) with facility staff on their knowledge, skills, and practices related to NACS services. In addition, observations of client-provider interactions were conducted with 37 Haitian and 34 Ugandan facility staff members.
Results: The results revealed differences between what facility managers and providers reported compared with what the facility was equipped to do and what was observed. In Haiti, there were no standardized methods for conducting nutrition assessments. According to facility managers, 86% of the facilities routinely provided nutrition counseling services. According to child health providers, 61% regularly provided nutrition counseling during well-child visits; however, only 51% reported having been trained in nutrition counseling in the last three years. When observed, only 35% of providers discussed complementary feeding, a key nutrition topic for mothers of children under the age of two.
In Uganda, a more comprehensive nutrition assessment (dietary, clinical, anthropometric, and biochemical) was reported by more than 80% of assessed hospitals compared to the 40% of health centers who reported a dietary and clinical assessment. Counseling was reported to be provided at all contact points in fairly similar rates by type of facilities; however, over two-thirds of the facilities did not have policy guidelines, protocols, or counseling charts and, when observed, only 1 out 6 providers mentioned the importance of initiating breastfeeding within one hour after delivery.
Conclusions: The study findings suggest that even though most health facilities report assessing nutrition status, they do not do so consistently. Likewise, although most providers reported providing nutrition counseling, they did not cover key topics under observation. Combining interviews of facility managers and providers with observations of client-provider interactions and client exit interviews is a necessity for assessing and strengthening capacity to integrate and implement quality nutrition services.
Building on existing tools and with experiences and findings from these assessments as well as input from local counterparts and global experts, SPRING developed the NACS Services Capacity Assessment package, which includes tools for interviews with facility managers and health workers, observations of client-provider interactions, site quality checklists of equipment and supplies, record review, and newly developed client exit interviews. SPRING expects that the NACS Services Capacity Assessment package will be useful for countries and programs interested in more fully integrating nutrition into their existing health services.