A Monitoring Report
The 2014 monitoring of the integration of Nutrition Assessment Counselling and Support (NACS) into routine health care in South West (SW) Uganda and Namutumba district in East Central (EC) Uganda was designed as a follow-up to the 2012 and 2013 NACS assessments. The main objective of this study was to better understand the context for NACS programming in the SW and EC regions and to determine the availability of the required essential elements of nutrition services (assessment tools, counseling skills, and anthropometric tools). In addition, the study sought to determine the availability of supplies, such as micronutrient supplements, drugs, and therapeutic and supplementary foods, for adults and children in supported health facilities and at the community level.
The findings of the 2014 monitoring assessment are critical to measuring the achievements of NACS integration into routine health care in SPRING/Uganda health facilities since 2011. The findings of the supported assessment will support the refocusing of interventions that are relevant and essential for enhancing the capacity of health facilities to implement NACS to achieve better health outcomes.
Study Methodology
The study used a descriptive cross-sectional design with both qualitative and quantitative data collection methods. The study covered all the 46 health facilities, 42 from Ntungamo and Kisoro, and four of the seven facilities in Namutumba as well as the five former NuLife supported hospitals from Kanugu, Rukungiri, Sheema, and Bushenyi; one regional referral hospital in Kabale district. A randomly selected 457 health workers across all health facilities were interviewed. Of these, 344 were in Kisoro and Ntungamo districts, 105 in former NuLife districts, and eight in Namutumba district.
Data Analysis
Before the analysis, quantitative data analysts captured data in Epidata software and analyzed them using SPSS 19 and Microsoft Excel to obtain descriptive statistics, frequencies, and percentages. Analysts performed data verifications, cleaning, and consistency checks before the analysis. Bivariate analysis was the main mode of analysis used. To tease out the differences in performance, the analysis was disaggregated by type of facility and service delivery points.
Limitations
Even though the 2014 monitoring assessment planned to reach all 51 supported health facilities, one hospital refused to participate in the assessment. Data from two hospitals (Ibanda and Mbarara) were not included in the analysis as they failed to respond to the survey. In Namutumba district, the team did not reach three health facilities. Despite these difficulties, the findings presented in this report cover 90 percent of the SPRING/Uganda-supported facilities and provide a good description of the context for programming. The 2014 monitoring of NACS covered all 10 SPRING/Uganda-supported districts in SW and EC Uganda, and results were compared to the 2012 survey (which covered only SW Uganda).
Key Findings
Health Work Force
Study findings showed that lower-level staff, including nurses, midwives, and nursing assistants, continue to predominate the health work force. These health workers have attained midlevel training, and most of them provide maternal and child health services. For effective integration of NACS in routine health care, NACS trainings, coaching, and mentorship should continue targeting nurses, midwives, and nursing assistants since they account for the greatest part of the health work force.
Nutrition Capacity
More health workers in health center (HC) IIIs have received training on nutrition focus areas than those in hospitals and HC IVs. Health workers in HC IVs missed out on Integrated Management of Acute Malnutrition (IMAM), infant and young child feeding (IYCF), and Baby-Friendly Hospital Initiative (BFHI) trainings. In general, capacity gaps are present in the offering of BFHI and Integrated Management of Adolescent Illnesses (IMAI) training for health workers. Capacity building is still needed for IMAM contact points in the offering of IYCF, Integrated Management of Childhood Illness, and elimination of Mother to Child Transmission (eMTCT) services.
Nutrition Assessment
The 2014 assessment found that all 46 health facilities visited have integrated nutrition assessment into routine health care, compared with findings of the 2012 assessment, when this was true for only 80 percent of hospitals, 60 percent of HC IVs, and 40 percent of the HC IIIs. Health workers at 46 facilities were conducting one or more nutrition assessment of patients, including anthropometric, biochemical, clinical, and dietary assessments. Documentation of nutrition data was not standard across all facilities, and anthropometric equipment was not receiving the routine calibration needed to ensure accuracy of nutrition assessments. Taking mid–upper arm circumference (MUAC)/weight, or both, checking for edema/pallor or both, and noting dietary history were the common assessments performed. The least performed, though greatly improved compared to the 2012 assessment, were taking length/height and estimating hemoglobin. Though the use of MUAC cutoffs increased among HC IIIs and HC IVs from 18 percent and 25 percent, respectively, in 2012 to 100 percent in 2014, the use of weigh-for-height Z (WHZ) scores, body mass index (BMI) for age Z scores, and BMI cutoff across all types of facilities increased only very slightly. These findings show that a significant gap persists in the use of nutrition assessment for classification of nutrition status.
Nutrition Counseling
Health workers practice nutrition counseling in all health facilities, though it varies by type of facility and contact point. The provision of counseling services increased to 100 percent among all health facilities from 66 percent among hospitals and HC IIIs, and 33 percent among HC IVs in 2012. Individual counseling at the antiretroviral therapy (ART) service delivery point increased from an average of 50 percent in the 2012 survey to 100 percent among hospitals, 80 percent among HC IVs, and 90 percent among HC IIIs in the 2014 survey.
Nutrition Support
Nutrition assessment equipment were widely available at all health facilities, but only a few counseling tools, infant scales, and height boards were available. All health facilities reported having MUAC tapes for both adults and children. Adult weighing scales were also available in all health facilities, while infant weighing scales were lacking at some service delivery points where they are most appropriate. None of the HC IVs had a length board, and its availability was limited to only 38 percent of the hospitals and 22 percent of the HC IIIs. In addition, counseling tools, job aids, guidelines, and protocols were not widely available. Most of the health facilities managed nutrition-related supplies and drugs but continued to experience stock outs of supplies in the three months before the survey. None of the health facilities managed combined minerals or combined minerals and vitamins.
Documentation of Nutrition Data/Information
The proportion of health facilities documenting MUAC assessment increased from 80 percent among hospitals, 19 percent among HC IVs, and seven percent among HC IIIs in the 2012 NACS assessment to 100 percent across all facility types. Similarly, documentation of weight assessment increased to 100 percent in all health facilities from 10 percent among hospitals, 69 percent among HC IVs, and 44 percent among HC IIIs in the 2012 survey. Irrespective of the nutrition assessment service, health workers documented nutrition services mainly in patient registers and on clinic cards in all health facilities and service delivery points. The exception was pediatric outpatient departments, where health worker routinely documented on client cards.
Quality Improvement (QI) and Supportive Supervision
Survey results showed that QI teams existed in 88 percent of the hospitals, 77 percent of HC IIIs, and in all HC IVs, though the number of regular meetings and functionality of the teams were still low. On the other hand, all HC IIIs, HC IVs, and 88 percent of the hospitals reported health workers receiving technical supportive supervision. Health workers received feedback on supportive supervision mostly through verbal and written means for HC IIIs and HC IVs. In hospitals, 88 percent and 83 percent of health workers reported verbal and written feedback, respectively.
Community-based Health Services
The provision of community-based nutrition services, including nutrition counseling on proper feeding practices for the entire population, is a key strategy in the prevention of malnutrition. Seventy-five percent of the hospitals, 50 percent of HC IVs, and 57 percent of the HC IIIs reported that Community-based Health Workers (CHWs) attached to their health facilities provided community-based nutrition screening. All hospitals and HC IVs, and 93 percent of HC IIIs identified CBHWs as key actors in the prevention of undernutrition at the community level through community-based nutrition counseling. CHWs are also key players in facilitating community-facility and facility-community referral mechanisms. Among the facilities with a referral mechanism, 87 percent of the HC IIIs and all hospitals and HC IVs received referrals from the communities. Health facilities linked clients to community-based services, including client treatment and support, home care, HIV counseling and testing, food security support, social support for people living with HIV (PLHIV), economic and livelihood development, community-based nutrition screening, and social support for mothers.
Conclusion
This survey focused on assessing the status of the integration of nutrition services into routine health care and identifying ways to improve nutrition interventions. The ultimate goal of the survey is to improve nutritional services in all supported health facilities. Findings indicated that the delivery of nutrition services continued to improve and facilities have built capacity to manage acute malnutrition. For sustainable integration of NACS services into routine health care, program interventions should ensure continued capacity building of health workers through refresher trainings, coaching and continuous nutrition education. Nutrition program interventions should build the capacity of district quality improvement teams to continue conducting technical support supervision for health workers that includes their role in providing nutrition-related services.
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