LESSONS LEARNED Food and Nutrition Technical Assistance III Project June 2017

Integrating Nutrition Assessment Counselling and Support (NACS) into ’s Health Service System: Lessons Learned from Demonstration Sites

The Need Nutrition plays an important role in preventing illness and reducing morbidity and mortality, especially for people living with infectious diseases such as HIV, tuberculosis, or malaria. A healthy diet can help people manage symptoms, maximize the benefits of medications, and enhance their quality of life. Integrating nutrition services into care systems can be instrumental in preventing malnutrition and improving the nutritional status of people affected by infectious diseases, especially HIV and tuberculosis. Nigeria has committed to investing in improved nutrition during the first 1,000 days, providing Gana Catherine credit: Photo nutrition services to infants and young children, as well as to pregnant and lactating women. Despite integrated into existing services. In consultation this, rates of malnutrition for children under 5 with the Rivers State Ministry of Health (SMOH) remain high, with 34.8 percent stunted, 24.2 authorities, two local government areas (LGAs) percent underweight, and 10.2 percent wasted; only were selected to reflect the urban ( 15.1 percent of mothers breastfeed exclusively for LGA) and semi-rural/peri-urban (Obio-Akpor LGA) six months.1 While the health system focuses on experiences. The four health facilities from the the critical needs of these most vulnerable groups, LGAs provided a mix of levels of care, and included Nigeria has not yet systematically addressed the public and private approaches. Two were primary nutrition needs of adolescents and adults who care service facilities—Eneka and Churchill, the face a broad range of health problems related to third was public—Braithwaite Memorial Specialist undernutrition, as well as to overweight and obesity, Hospital (BMSH), and the fourth was private— which are associated with increasing risk of type 2 Meridian Hospital. diabetes, hypertension, and heart problems. FANTA collaborated with the Federal Ministry of Health (FMOH), Rivers State Ministry of Health The Response (SMOH, and FHI 360’s Strengthening Integrated USAID/Nigeria asked FANTA to provide technical Delivery of HIV/AIDS Services (SIDHAS), to establish assistance (TA) to integrate nutrition assessment, three goals for integrating NACS into the health counseling, and support (NACS) into the health service system: service delivery system in four target health 1. Strengthen the capacity of facility staff to facilities in Rivers State, which would serve as consistently and effectively conduct nutrition demonstration sites to show how NACS can be assessment and classification for all clients

1 2011 Nigeria Multiple Indicator Cluster Survey (MICS), published in 2013.

FANTA III FOOD AND NUTRITION TECHNICAL A SSISTANCE INTEGRATING NUTRITION ASSESSMENT COUNSELLING AND SUPPORT (NACS) INTO NIGERIA’S HEALTH SERVICE SYSTEM: LESSONS LEARNED

entering a health facility, and inform clients of TIMELINE OF NACS their status. IMPLEMENTATION IN NIGERIA 2. Improve the coverage and quality of group nutrition education and one-to-one counselling. October– February 2016: 3. Improve documentation of nutrition services November 2015: Stakeholders’ provided, particularly at the ART Clinic. FANTA scoping visit meeting at federal FANTA’s TA, in collaboration with the Applying and state levels Science to Strengthen and Improve Systems identifies priority (ASSIST) project, included use of a Quality LGAs and health Improvement (QI) approach that involved hands- March 2016: facilities on coaching for trained health providers, ongoing Rapid NACS analysis of data collected, regular monitoring of readiness NACS services delivery, and supportive supervision assessment of staff. Results from initial needs and readiness April 2016: assessments informed FANTA’s plans for training, Sensitization of supervision and mentoring, provision of equipment, FMOH on NACS. and design of communication materials. Routine Customization monitoring-data reported by SIDHAS staff June 2016: of NACS training documented coverage and quality of service NACS QI training of modules. Selection provision. An end-line assessment captured opinions trainers of 4 NACS sites. of health workers and stakeholders on the extent to which NACS services have been integrated in target facilities and the value attributed to those services.

The Activities June–July 2016: Capacity strengthening. FANTA’s approach Step-down training to capacity strengthening began with a rapid in the 4 facilities Aug 2016: assessment that found health facility staff and Launch of systems capable of implementing NACS, but lacking implementation equipment, tools, and NACS-specific skills, such as knowing how to use a body mass index (BMI) wheel and how to classify nutrition status. FANTA then October 2016: provided FMOH with a basic NACS curriculum that NACS refresher was adapted to fit the Nigerian context. FANTA and training for the ASSIST facilitated a week of planning with local February 2017: master trainers partners from FMOH, SMOH, the Primary Health End-line Care Management Board, and SIDHAS, which assessment included designing a NACS training of trainers (TOT) to meet Nigerian needs and mobilize local talent. FANTA used participatory training methods including the micro-teaching method where participants learn FANTA NACS implementers trained: by facilitating sessions themselves, which fostered 68 master trainers in NACS sustainable development of skills and knowledge for NACS implementation. The same approach was 558 health care providers in NACS step-down replicated in step-down trainings. Based on a gap training analysis of performances after the first TOT, these 25 nutrition champions to promote nutrition in gains were reinforced by a refresher TOT three the community months later that covered all 12 NACS modules.

2 INTEGRATING NUTRITION ASSESSMENT COUNSELLING AND SUPPORT (NACS) INTO NIGERIA’S HEALTH SERVICE SYSTEM: LESSONS LEARNED

Monitoring, reporting, and assessment. FANTA • Document changes in the scope and quality of worked with FMOH to develop and integrate NACS services that were provided and identify factors indicators into the National Health Management that affect capacity and service quality. Information System (HMIS) for Nutrition, then • Inform the required deliverable to USAID/ developed monitoring tools. In collaboration with Nigeria and USAID/OHA: a report on lessons SIDHAS, FANTA also coached staff in how to use learned and recommendations for further NACS those tools to record height, weight, BMI, nutritional improvement and integration. status and nutrition counseling, and technical support provided to monitor provision of services and record • Establish the best performing of the four sites keeping. Monitoring data were collected over the as a NACS learning site to facilitate future 10 months of implementation in the four sites (see replication. Figure 3). An end-line assessment was conducted to Quality improvement. Quality Improvement complement these quantitative data with qualitative (QI) teams were established in each of the perspectives. Ten semi-structured interviews facilities to define improvement objectives and were conducted, five each with stakeholders2 and work on solutions to challenges encountered in implementing health facility staff, as well as 10 client implementation. QI teams met regularly to review QI exit polls and one focus group discussion with SIDHAS data, discuss progress, and implement changes as team members in Rivers State. needed. QI team work was tracked and supported by the FANTA technical team and Rivers State Primary The objectives of the routine monitoring and final Health Care Management Board as part of their assessment were to: monthly support visits, during which they reviewed • Document changes in target facilities’ capacity to records to reinforce the need for quality data and deliver quality NACS services. provide mentoring and coaching on any aspect of implementation as needed.

2 5 key stakeholders represented the FMOH, the Rivers State Ministry of Health (SMOH), the Primary Health Care Management Board, and the SIDHAS project.

Figure 1: NACS process

NACS STEPS ENTRY • ATTEND to COMPLETE emergency PLAN NEXT STEPS ASSESS CLASSIFY & INFORM COUNSEL & EDUCATE RECORDS cases first 1 2 3 4 5 • Assess ALL Measure and record: • Classify nutritional status • In an area as private as possible, explain • Record all information in the • If the client’s HIV status Is clients weight and height by using the BMI wheel or nutritional status individual client card unknown, refer for provider- chart, or MUAC for pregnant initiated testing and • If pregnant or • Based on information collected from clients, • Document the next and postpartum women counselling (PITC) postpartum woman provide specific recommendations and discuss appointment and referrals use MUAC • Inform the client of his/her how the client can make changes • Put the client card • If child use length nutrition status in folder board and baby • Use printed materials to engage clients weighing scale • Complete the Daily Register Review: Severe acute malnutrition (SAM)/ If patient has Counseling: • Client records severely underweight medical complications • Do not share • Complete Daily Activity tally and/or no appetite, specialized food card sheet • Medical history • BMI <16.0 refer to clinician for products with • If outpatient SAM or • Lab test results • Or: bilateral pitting edema inpatient treatment. others—they are • Submit NACS monthly If patient has report MAM schedule follow up • Or: MUAC < 18.5 cm treatment for appointment in 1 or 2 weeks. Check for bilateral appetite and no • If pregnant/postpartum: MUAC <21.0 cm malnutrition. pitting edema complications, treat as • Eat more from all • Arrange for community • If age 6-59 months, WHZ < -3 or outpatient with RUTF/ the food groups, worker to make home visit Ask about: MUAC < 11.5 cm Soya Plus especially body- • Refer to community-based food security as available programs • Food and drink building and energy consumed in last 24-hours Moderate-mild acute malnutrition (MAM)/ Address symptoms products with others—they are • Schedule follow up • Food allergies moderately underweight Prescribe treatment for appointment in 2 months. • BMI 16.00 – 18.4 supplementary food/ • HIV status malnutrition. • Refer to community support • Or: MUAC 18.5 – 20.9 cm RUSF/Soya Plus as available. • Eat more from all activities. Do appetite test, if SAM • If pregnant/postpartum: MUAC 21.1-23.0 cm the food groups, • Arrange for community worker Record information • If age 6-59 months, WHZ ≥ -3 to < -2 or Counseling: especially body- to make home visit MUAC ≥ 11.5 cm to < 12.5 cm Do not share building and specialized food energy foods. FOR ALL CLIENTS: Provide health and nutrition Normal Counseling: education in the triage/ • BMI 18.5 - 24.9 • Praise good • Eat foods from all waiting area. • Or: MUAC ≥ 21.0 cm behaviors. food groups daily. Advise to: • If pregnant/postpartum: MUAC ≥ 23.0 cm • Maintain healthy • Stay active. dietary practices. EXIT • Avoid smoking and • If age 6-59 months, WHZ ≥ -2 to < +2 or MUAC ≥ 12.5 cm drinking alcohol. • Maintain weight. • ASK: Do you have any questions? What are you • Follow optimal food and Overweight Address symptoms • Avoid fatty foods and going to do after today, to water safety, hygiene and packaged snacks. improve your nutrition? sanitation practices. • BMI 25.0 – 29.9 Counseling: • Exercise more • Agree on a small, • Eat more vegetables. each day. Eat less starch doable action step to Obesity and sweets. improve nutrition. • BMI ≥ 30 • Avoid sweet drinks.

3 INTEGRATING NUTRITION ASSESSMENT COUNSELLING AND SUPPORT (NACS) INTO NIGERIA’S HEALTH SERVICE SYSTEM: LESSONS LEARNED

Provision of assessment equipment. FANTA anthropometric measurements to diagnosing provided the four sites with stadiometers, BMI and addressing nutrition problems; a poster for wheels, length boards, and MUAC tapes for taking counseling on how to improve diet based on anthropometric measurements. This enabled making nutrition status (see Figure 2); and a poster to raise evidence-based diagnoses of nutritional status and awareness and stimulate action on overweight and providing individualized advice, rather than basing obesity. assessments “only on appearance,” which, according Health workers shared clients’ enthusiasm for to many health workers interviewed for the end-line the counseling materials, with one health worker assessment, often was done in the past. noting how easy the dietary guidance was to Materials for counseling and education. Printed understand: “Even without being able to read, all job aids were created for NACS. These included a could understand the red and green up and down poster to guide health workers on the key steps arrows.” in the NACS process (see Figure 1), from taking

Figure 2: NACS counseling and education aid

IMPROVE YOUR HEALTH YOU SHOULD EAT: WITH NUTRITIOUS FOODS

PROTECTIVE FOODS BODY BUILDING FOODS ENERGY FOODS NUTRITIONAL Fruits & vegetables: Plant protein: Animal protein: Maize, wheat, rice, Vegetable oil, A HEALTHY PERSON OF NORMAL WEIGHT STATUS: dark green leaves, beans, lentils, meat, chicken, fish, cassava, potatoes, margarine, butter, SHOULD EAT FOODS IN THIS PROPORTION: mango, pumpkin, etc. groundnuts, peas. liver, eggs, milk. bread, coconut. honey

SEVERELY ENE RG MALNOURISHED Y FO O Your body is not getting D S enough nutrients for basic S bodily functions. You need • Eat more foods from each of the food groups every • Take supplements and therapeutic foods as prescribed. D O medical and nutrition support. day, especially extra protein and energy foods. • Get adequate rest. O F

G

N I MODERATELY D

L I or MILDLY U MALNOURISHED B

Y

D You are under weight and

O lack nutrients for good health.

B • Eat more foods from each of the food groups every • Take supplements and therapeutic foods as prescribed. You need nutrition support. day, especially extra protein and energy foods. • Get adequate rest.

NORMAL WEIGHT Your weight is in the normal range and you are getting adequate nutrients to sustain basic • Eat a varity of healthy foods from each of the • Maintain regular exercise and adequate rest. S P OD groups, daily. ROTECTIVE FO bodily functions. Water

EVERYONE SHOULD: OVERWEIGHT Eat a colorful variety of foods Avoid food and drinks that can Your weight is unhealthy. every day. harm you: You are at risk for many • Eat more vegetables and fruits. • Avoid sugars, sweet drinks, and excessive salt. Choose fresh, locally available • packaged “junk” foods health problems. options from each group. • sugary drinks • Eat low-fat protein foods such as fish and legumes. • Increase level of activity with regular exercise and walking. Drink lots of boiled or • alcohol • Eat less energy foods, including fats and oil. treated water. • foods heavy in fat and salt

OBESE Your weight is very FANTA III unhealthy. You are at high FOOD AND NUTRITION risk for diseases such as TECHNICAL A SSISTANCE • Eat more vegetables and fruits. • Avoid sugars, sweet drinks, and excessive salt. diabetes, heart disease, and high blood pressure. • Eat low-fat protein foods such as fish and legumes. • Increase level of activity with regular exercise and walking. • Eat less energy foods, including fats and oil.

4 INTEGRATING NUTRITION ASSESSMENT COUNSELLING AND SUPPORT (NACS) INTO NIGERIA’S HEALTH SERVICE SYSTEM: LESSONS LEARNED

The Results Improved coverage and integration of NACS of transfers of trained staff to other facilities. In services. Progress on NACS integration was addition to resupplying data collection forms, FANTA positive overall, despite some uneven results. The worked with data entry clerks to improve the quality four target health facilities’ records show that of data collection and supported the QI teams to the total number of clients nutritionally assessed improve systems for replenishing the supply of forms increased by more than 80 percent; the number of as well as overseeing data quality. clients that received nutrition counseling also saw a System strengthening. The introduction of NACS large increase. All interview participants rated NACS strengthened the health system beyond the four as either “partly” (7) or “almost completely” (5) targeted facilities in several ways. The training integrated into the service system. Figure 3 presents curriculum was formally customized to the Nigerian the number of NACS services delivered over the 10 context by FMOH, and is being used in new sites to months at the four facilities. expand nutrition services. Pre- and post-assessment The drop in number clients assessed between results showed 15.5 percent improvement in learning October and November 2016 was mainly due to outcomes from training (from 69.1% to 84.5% an insufficient number of data collection forms for respectively). In addition, 25 representatives from recording data, which led to a smaller number of community-based organizations were trained to clients whose nutritional data were recorded. The promote nutrition in their communities as nutrition drop in number assessed and number counseled champions. between March and April 2017 was the result

Figure 3: NACS services provided: Total for 4 sites in Rivers State, August 2016–May 2017 7,000 7,0007,000 7,000 7,0006,000 6,0006,000 6,000 6,0005,000 5,0005,000 5,000 5,0004,000 4,0004,000 4,000 4,0003,000 3,0003,000 3,000 3,0002,000 2,0002,000 2,000 2,0001,000 1,0001,000 1,000 1,0000 0 0 Aug-16 Sep -1 6 Oct-16 Nov-16 Dec-16 Jan-17 Feb -1 7 Mar-17 Apr-17 May-17 Aug-16Aug-16 Sep-16Sep -1 6 Oct-16Oct-16 Nov-16 Dec-16Dec-16 Jan-17Jan-17 Feb-17Feb -1 7 Mar-17Mar-17 Apr-17Apr-17 May-17May-17 0 Aug-16Aug-16 Sep-16Sep -1 6 Oct-16Oct-16 Nov-16Nov-16 Dec-16Dec-16 Jan-17Jan-17 Feb-17Feb -1 7 Mar-17Mar-17 Apr-17Apr-17 May-17May-17 Aug-16Aug-16SepSep-16 -1 6 Oct-16Oct-16Nov-16Nov-16Dec-16Dec-16Jan-17Jan-17Feb -1Feb-17 7 Mar-17Mar-17Apr-17Apr-17May-17May-17 ## assessed assessed Aug-161,9551,955Sep-161,3631,363Oct-162,9952,995Nov-162,0092,009Dec-162,7342,734Jan-174,0524,052Feb-176,2636,263Mar-175,5295,529Apr-173,6023,602May-173,813 3,813 # assessed 1,955 1,363 2,995 2,009 2,734 4,052 6,263 5,529 3,602 3,813 # assessedcounseled Aug-161,955 Sep-161,3541,363 Oct-161,8162,995 Nov-161,9302,009 Dec-162,6872,734 Jan-173,4804,052 Feb-175,3086,263 Mar-175,0255,529 Apr-173,1873,602 May-173,4413,813 # counseled 1,955 1,354 1,816 1,930 2,687 3,480 5,308 5,025 3,187 3,441 ## assessedcounseledgiven counseled food support 1,95511,955 1,3541,363331,354 1,8162,995451,8161,9302,0093 1,9302,6872,73414 2,6873,4804,052333,4805,3086,263945,3085,0255,529905,0253,1873,6021053,1873,4413,81397 3,441 # given food support 1 33 45 3 14 33 94 90 105 97 # counseledgiven food support 1,9551 1,35433 1,81645 1,9303 2,68714 3,48033 5,30894 5,02590 3,187105 3,44197 ## given given food food support support 1 1 33 33 45 45 3 3 14 14 33 33 94 94 90 90 105 105 97 97

5 INTEGRATING NUTRITION ASSESSMENT COUNSELLING AND SUPPORT (NACS) INTO NIGERIA’S HEALTH SERVICE SYSTEM: LESSONS LEARNED

Sixty-eight master trainers were trained in NACS, Impact. Both the quantitative and qualitative data and they trained 558 health care providers to attest to improved knowledge and technical capacity implement NACS in other health facilities. One of trained health facility staff to deliver NACS training of the master trainers from the BMSH convinced and direct services, as exemplified by this health the head of Rivers State hospitals management worker who was interviewed: board to organize a NACS training for 40 health care workers (doctors and nurses), comprising 22 “I have gained increased knowledge and males and 18 females from all 22 general hospitals skills, and the satisfaction of providing in the Rivers State. The training was a success. The average pre-test score was 36.7 and average valuable services to satisfied clients.” the post-test score was 71.8. As a result, the board management has undertaken efforts to ensure that According to health staff interviewed, NACS NACS is incorporated into clinical services at the dramatically increased the level of knowledge and general hospitals. awareness about nutrition among their clients. They also observed their clients making dietary changes Integration of NACS into relevant national resulting in improved nutritional status. policies and guidelines. NACS guidelines have been integrated into Nigeria’s national guidelines “You know what your nutritional status on nutrition for PLHIV and NACS indicators have been integrated into the National HMIS for is, you know the possible consequences, Nutrition. NACS training materials have been after being assessed. You are now adopted by the Federal Ministry of Health as national technical resources for cascading NACS empowered.” training at national level. Perhaps the greatest impact was heightened provider and client awareness of overweight and obesity as a health and nutrition problem, which was mentioned by most health workers interviewed: “My clients are now conscious of their nutrition; there is reduction in their weight gain. You know the hazards of overweight, they are conscious; they eat right now.”

6 INTEGRATING NUTRITION ASSESSMENT COUNSELLING AND SUPPORT (NACS) INTO NIGERIA’S HEALTH SERVICE SYSTEM: LESSONS LEARNED

The Lessons Learned and Recommendations

Two keys to successfully integrate NACS into Recommendations to consider for future NACS health service systems are: implementation in Nigeria include: 1. Cultivating buy-in from government and • Define clearly NACS ownership and roles and local partners is essential for building local responsibilities with relevant stakeholders. ownership and enhancing the prospects for • Expand sensitization and engagement of sustainability. Strong buy-in by River State was stakeholders to build awareness of the value accomplished by: of NACS and shared commitment. • Investing considerable time up front to • Provide regular capacity-building build relationships with key stakeholders at opportunities through training and supportive federal and state levels supervision for as many health care workers • Advocating for NACS with sensitivity to as possible at as many and various service Nigeria’s unique nutrition situation, and delivery points as possible. making a compelling case for how NACS fills • Budget for the provision of NACS equipment key gaps the government wants to fill and tools, including anthropometric • Including government partners as leaders equipment, job aids, nutrition education of the planning process and working and counseling materials, monitoring and together to adapt training materials, plan reporting materials, etc. trainings, design a QI process, and develop • Expand provision of therapeutic food (this is communication materials. currently provided through SIDHAS support 2. Implementing NACS in collaboration with but it would benefit many beyond PLHIV). the existing clinical partner on the ground (SIDHAS project), and leveraging resources, enhanced efficiencies and facilitated the expansion of NACS tools and approaches beyond the FANTA demonstration sites to over 200 health facilities across ten states.

7 www.fantaproject.org @FANTAproject

Contact Information: Recommended Citation: Food and Nutrition Technical Assistance Food and Nutrition Technical Assistance III Project (FANTA) III Project (FANTA). 2017. Integrating Nutrition Assessment FHI 360 Counselling and Support (NACS) into Nigeria’s Health Service System: Lessons Learned from Rivers State Demonstration Sites. 1825 Connecticut Avenue, NW Washington, DC: FHI 360/FANTA. Washington, DC 20009-5721 Tel: 202-884-8000 This brief is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, Fax: 202-884-8432 and Nutrition, Bureau for Global Health, U.S. Agency for International Email: [email protected] Development (USAID), and USAID/Nigeria, under terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360.

The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.