Food and Nutrition Technical Assistance III Project (FANTA)FHI 360 1825 Connecticut Ave., NW Washington, DC 20009Tel: 202-884-8000 Fax: 202-884-8432 Email: fantamail@fhi360.org Website: www.fantaproject.org

THE “C” IN NACS:Counseling as part of Nutrition, Assessment, Counseling and SupportSub-title

Serigne Diene, PhD, MPH Technical Advisor – Nutrition & Infectious Diseases - Country programs

Rebecca Egan Technical Advisor, Nutrition & Infectious Diseases

CORE Group

May 6, 2014

Objectives

Introduction to NACS

Counseling approaches in NACS

Effectiveness of counseling and areas for improvement

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Objectives

Introduction to NACS

Counseling approaches in NACS

Effectiveness of counseling and areas for improvement

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NACS: A platform for integrating nutritioninto the continuum of care

Nutrition care and support

Economic strengthening, livelihoods, and

food security

Health system strengthening

HIV-free survival

OBJECTIVES:

• Improve nutritional status• Improve infant survival• Reduce food insecurity• Strengthen health systems

GOAL:

Improved health and quality of life

The three components within the NACS continuum of care:

1. Nutrition assessment2. Counseling

3. Support

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NACS Hinges on Nutrition Assessment1. Routine comprehensive assessment.

• Anthropometric• Biochemical• Clinical• Dietary• Household food security

2. Analyze/interpret data using evidence-based standards.

3. Identify nutrition problems.

4. Determine causes/contributing risk factors.

5. Cluster signs/symptoms and defining characteristics.

6. Determine an appropriate Nutrition Care Plan.

NACS Counseling Focus Areas

1. Understanding of client preferences, constraints, and options

2. Discuss the “Nutrition Care Plan” assigned3. Optimal diet4. Dietary management of symptoms and drug side-effects5. Adherence to medications and clinical visit schedule6. Chronic disease management7. Exercise8. Water, sanitation, and hygiene (WASH)9. Referrals to additional services

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Treatment of malnutrition

Prevention of malnutrition

Food security and livelihood support

Water, sanitation, and hygiene (WASH)

• Medical care and treatment

• Prescription of specialized food products

• Provision of MN supplements

• Routine medical care and treatment

• Provision of MN supplements

• Food fortification

• Provision of complementary foods and dietary supplements

• Savings• Microcredit• Income-

generating activities

• Household food production

• Food assistance

• Distribution of POU water treatment products or vouchers

• Latrine construction

Nutrition Support

CommunityClinic

NUTRITION ASSESSMENT

NUTRITION SUPPORT

NUTRITION COUNSELING

WASH

IYCF / GMP

Nutrition Care Plan

Adherence to medications

Dietary management of symptoms, drug side-effects and drug-food

interactions

Maternal nutrition

Exercise

Treatment of infections

Household food

rations

Referrals

Referrals

Food by prescription: therapeutic, supplementary, complementaryfoods

Micronutrient supplementsPoint-of-use water treatment

AnthropometricBiochemical

ClinicalDietary

Food security

Referrals

Referrals

Support groups

Community Health workers Economic

strengthening, livelihoods, and food security

Targeting NACS Services

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Nutrition Assessment

All clients receive nutrition assessment

Nutrition Counseling

All clients receive counseling based on

assessment

Nutrition Support

Support is targeted based on client

needs

Objectives

Introduction to NACS

Counseling approach in NACS

Effectiveness of counseling and areas for improvement

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FANTA’s counseling products

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Brochures Clinic Cards

Flipcharts

Training

Research

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Skills to facilitate NACS counseling

Using helpful non-verbal communication Showing interest Showing empathy Asking open-ended questions Reflecting back what the client says Avoiding judgement Praising what a client does correctly Giving a little relevant information at a time Using simple language Giving practical suggestions, not commands

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The NACS “Critical Nutrition Actions” messages

Objectives

Introduction to NACS

Counseling approaches in NACS

Effectiveness of counseling and areas for improvement

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Measuring impact: some of the key constraints

• Counseling is rarely a standalone intervention, making it difficult to measure the degree of impact of the counseling itself

• Counseling impact pathway: behavior may change but not result in improvements in health or nutrition status

• Counseling environments vary across programs – community vs facility; clinician vs community volunteer

• Monitoring the quality of counseling in programs – we often measure whether or not a client was counseled, not what counseling the client received or the duration

• The intensity of the intervention - how frequently is the client counseled, for how long, etc

Making NACS counseling (more) effective

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• Has the intervention assessed the local context?

• What cultural factors in the community affect nutrition-related behaviors?

• How many clients do clinicians see per day?

• How many different populations being counseled (e.g. adults, adolescents, PLW)?

• Has the clinician been trained (in-service or pre-service) in nutrition and/or counseling?

• Is the clinician incentivized to counsel?

• Is the message easy for the client to understand?

• Does the counseling address the client’s specific needs?

Community

Health facility

Clinician

Client

New approaches undertaken to enhance NACS counseling

• Quality improvement activities• Leveraging alternative counseling points of contact

(beyond the clinician)• Introducing nutrition and counseling curriculum

into pre-service clinical training• Implementing stronger monitoring of counseling

to identify what is effective• Systematic approaches to facilitate contextualizing

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FANTA’s ongoing activities on counseling

• Developing a literature review focusing on the “clinician and client” counseling paradigm and its impact on nutrition outcomes & behavior change

• Looking at performing an RCT comparing HIV+ clients receiving:– ART– ART + NACS assessment and counseling – ART + NACS assessment, counseling, and food support

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FANTA’s ongoing activities on counseling (Continued)

• Counseling materials that are under development or being revised

• Training materials that cover counseling that are being developed (Uganda)

• NACS Guidance module on counseling• New countries (Lesotho, Malawi, Nigeria) where we

will be providing TA on counseling

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Discussion… and questions• Are there existing M&E systems already to monitor

the quality of counseling?• Are there more effective in-service training methods

that foster stronger counseling skills?• Can clinicians effectively provide nutrition counseling

to clients with limited time?• Should we advocate more for counseling in the

community instead of the clinic setting?• Are there simple formative research methods to

facilitate contextualizing messages?

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Discussion… and questions• Are there existing M&E systems already to monitor

the quality of counseling?• Are there more effective in-service training methods

that foster stronger counseling skills?• Can clinicians effectively provide nutrition counseling

to clients with limited time?• Should we advocate more for counseling in the

community instead of the clinic setting?• Are there simple formative research methods to

facilitate contextualizing messages?

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References• Penny, M et al. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young

children: a cluster-randomised controlled trial The Lancet - 28 May 2005 (Vol. 365, Issue 9474, Pages 1863-1872) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)66426-4/abstract

• Srivastava, Rachana, Anita Kochhar, and Rajbir Sachdeva. "Impact of Nutrition Counselling in the Management of Malnutrition among Juvenile Diabetics."Ethno-Med 3.1 (2009): 11-18. http://www.krepublishers.com/02-Journals/S-EM/EM-03-0-000-09-Web/EM-03-1-000-2009-Abst-PDF/EM-03-1-011-09-091-Srivastava-R/EM-03-1-011-09-091-Srivastava-R-Tt.pdf

• Santos, Iná, et al. "Nutrition counseling increases weight gain among Brazilian children." The Journal of nutrition 131.11 (2001): 2866-2873. http://jn.nutrition.org/content/131/11/2866.short

• Walsh, C. M., A. Dannhauser, and G. Joubert. "The impact of a nutrition education programme on the anthropometric nutritional status of low-income children in South Africa." Public health nutrition 5.01 (2002): 3-9. http://journals.cambridge.org/abstract_S1368980002000022

• Waters, Hugh R., et al. "The cost-effectiveness of a child nutrition education programme in Peru." Health Policy and Planning 21.4 (2006): 257-264. http://heapol.oxfordjournals.org/content/21/4/257.short

• Roy, Swapan Kumar, et al. "Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh." (2005). http://imsear.hellis.org/handle/123456789/778

• Guldan, Georgia S., et al. "Culturally appropriate nutrition education improves infant feeding and growth in rural Sichuan, China." The Journal of nutrition 130.5 (2000): 1204-1211. http://nutrition.highwire.org/content/130/5/1204.short

• Bhandari, Nita, et al. "An educational intervention to promote appropriate complementary feeding practices and physical growth in infants and young children in rural Haryana, India." The Journal of nutrition 134.9 (2004): 2342-2348. http://nutrition.highwire.org/content/134/9/2342.short

• Aidam, Bridget A., Rafael Pérez-Escamilla, and Anna Lartey. "Lactation counseling increases exclusive breast-feeding rates in Ghana." The Journal of nutrition 135.7 (2005): 1691-1695. http://nutrition.highwire.org/content/135/7/1691.shortBhandari,

• Nita, et al. "Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial." The Lancet 361.9367 (2003): 1418-1423. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13134-0

• Picolo, MR. “Results of the Survey to Prioritize Nutrition Counseling Messages for People Living with HIV and/or Tuberculosis in Mozambique .” FANTA Project, October, 2013. http://fantaproject.org/sites/default/files/resources/Relat%C3%B3rio-resultados-question%C3%A1rio-Oct2013-ENG-2013.pdf

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This presentation is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID) (also include any additional USAID Bureaus, Offices, and Missions that provided funding as needed), 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.

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