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Tool for Rapid Evaluation of Facility-Level Nutrition Assessment, Counseling, and Support: A User's Guide

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The Tool for Rapid Evaluation of Facility-Level Nutrition Assessment, Counseling, and Support (REF-NACS) is a generic tool that helps gather information on the capacity of health facilities to implement NACS for pregnant women, children, and people living with HIV (PLHIV). SPRING developed this tool, in collaboration with the other USAID-funded projects (FANTA, LIFT, and ASSIST), to assist countries in strengthening NACS services provided through the health system. This tool and user’s guide benefit from the collective experiences of these projects in strengthening NACS services in more than a dozen countries.

Malnutrition affects the health, social, and economic development of many countries (UNICEF 2012a). Poor nutrition contributes to a compromised immune response and a greater susceptibility to disease, while infections increase energy requirements and can cause poor absorption of nutrients, anorexia, and susceptibility to malnutrition (Victora et al. 2008; Black et al. 2008). Emerging evidence suggests that this relationship extends well beyond childhood—malnourished children appear to be more susceptible to diet-related chronic disease later in life (Black et al. 2013; Adair et al. 2013). A malnourished mother is more likely to deliver an under-nourished infant who is more likely to become an undernourished adult. There is growing evidence about the importance of both nutrition-specific and nutrition-sensitive interventions to break this cycle of malnutrition (Ruel et al. 2013).

For people living with diseases such as the human immunodeficiency virus (HIV) or tuberculosis (TB), the impact of malnutrition can be even more profound. These illnesses increase energy requirements while causing or aggravating malnutrition by reducing appetite and nutrient absorption and utilization, accelerating the cycle of poor health (de Pee et al. 2010). Malnutrition can hasten the progression of HIV and worsen its impact by weakening the immune system, increasing susceptibility to opportunistic infections, and reducing the effectiveness of treatment. Over the past decade, strengthening nutrition interventions as part of health service delivery has been increasingly recognized as imperative for the prevention and treatment of malnutrition for all, especially for pregnant and lactating women, infants and young children and people living with diseases such as HIV and TB (Bhutta et al. 2008; Bryce et al. 2008). Nutrition-specific interventions, such as nutrition assessment and counseling and treatment of moderate and severe acute malnutrition, are important components in managing the impact of these illnesses (Bhutta et al. 2008).

The REF-NACS tool is designed to stimulate discussions, facilitate an analytic process, and develop a prioritized plan for strengthening NACS services. The results from a REF-NACS will help government policy-makers, donors, program managers, service providers, and even clients:

  • Understand current services provided and human resource capacity to implement quality NACS services;
  • Identify gaps in services provided;
  • Identify weaknesses in the health system for implementing a continuum of comprehensive NACS services; and
  • Prioritize interventions and identify actions to strengthen NACS-related programming.

Assessment tools are often used to ensure that minimum standards of service provision are maintained. REF-NACS can determine whether the minimum elements required to implement the NACS approach are in place, help identify gaps in service delivery, and highlight priorities for integrating and improving NACS services. It is also designed to inform program planning for NACS, REF-NACS can be used to look across categories of health facilities and to establish an overview of how capabilities and services might vary within the country's health system.

REF-NACS can be used prior to implementation or during program implementation. It is designed to identify gaps, prioritize solutions, strengthen existing programs or services, design new programs or services, or take a program to scale. It can be implemented in a sample of health facilities or in all health facilities where a particular program is intending to work and is easy to administer with a modest budget. However, it can be easily modified to establish a more in depth baseline of service delivery within an individual health facility.

The present document, available for download (above), includes: i) a background section describing the NACS approach; ii) indicators measured by the tool; iii) steps for using the tool; and iv) the tool itself.

Related Resources

Tools for Assessing Nutrition Assessment, Counseling, and Support Services at the Facility and Community Levels

A Rapid Initial Assessment of the Distribution and Consumption of Iron-Folic Acid Tablets Through Antenatal Care in Haiti

Report on Findings from an Assessment of the Integration of Nutrition into HIV Programs in Selected Facilities and Communities in Haiti

Survey Report Results on Nutrition Indicators from Six Districts in Southwest and East Central Uganda

Facility-Level Nutrition Assessment, Counseling, and Support


Adair, Linda S, Caroline HD Fall, Clive Osmond, Aryeh D Stein, Reynaldo Martorell, Manuel Ramirez-Zea, Harshpal Singh Sachdev, et al. 2013. “Associations of Linear Growth and Relative Weight Gain During Early Life with Adult Health and Human Capital in Countries of Low and Middle Income: Findings from Five Birth Cohort Studies.” The Lancet 382 (9891) (August): 525–534. doi:10.1016/S0140-6736(13)60103-8.

Bhutta, Zulfiqar A, Tahmeed Ahmed, Robert E Black, Simon Cousens, Kathryn Dewey, Elsa Giugliani, Batool A Haider, et al. 2008. “What Works? Interventions for Maternal and Child Undernutrition and Survival.” The Lancet 371 (9610) (February): 417–440. doi:10.1016/S0140-6736(07)61693-6.

Black, Robert E, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, et al. 2013. “Maternal and Child Undernutrition and Overweight in Low-income and Middle-income Countries.” The Lancet 382 (9890) (August): 427–451. doi:10.1016/S0140-6736(13)60937-X.

Black, Robert E, Lindsay H Allen, Zulfiqar A Bhutta, Laura E Caulfield, Mercedes de Onis, Majid Ezzati, Colin Mathers, and Juan Rivera. 2008. “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences.” The Lancet 371 (9608) (January): 243–260. doi:10.1016/S0140-6736(07)61690-0.

Bryce, Jennifer, Denise Coitinho, Ian Darnton-Hill, David Pelletier, and Per Pinstrup-Andersen. 2008. “Maternal and Child Undernutrition: Effective Action at National Level.” The Lancet 371 (9611) (February): 510–526. doi:10.1016/S0140-6736(07)61694-8.

De Pee, Saskia; Semba, Richard D. 2010. “Role of nutrition in HIV infection: Review of evidence for more effective programming in resource-limited settings.” Food and Nutrition Bulletin31 (Supplement 4) (December): 313S-344S (32).

Ruel, Marie T, and Harold Alderman. 2013. “Nutrition-sensitive Interventions and Programmes: How Can They Help to Accelerate Progress in Improving Maternal and Child Nutrition?” The Lancet 382 (9891) (August): 536–551. doi:10.1016/S0140-6736(13)60843-0.

UNICEF. 2012a. The Community Infant and Young Child Feeding Counseling Package: Key Messages Booklet.

Victora, Cesar G, Linda Adair, Caroline Fall, Pedro C Hallal, Reynaldo Martorell, Linda Richter, and Harshpal Singh Sachdev. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371 (9609) (January): 340–357. doi:10.1016/S0140-6736(07)61692-4.