A review of nutrition-related service delivery packages: What they train providers to deliver

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Summary of research¹

By Sascha Lamstein and Kelsey Torres

Sascha Lamstein is a senior technical advisor for the United States Agency for International Development Advancing Nutrition project.

Kelsey Torres is a technical project officer for the United States Agency for International Development Advancing Nutrition project.

This article was produced for the United States Agency for International Development (USAID). It was prepared under the terms of contract 7200AA18C00070 awarded to JSI Research & Training Institute, Inc. (JSI). The contents are the responsibility of JSI and do not necessarily reflect the views of USAID or the U.S. Government.

Background

To increase coverage of the nutrition and health needs of infants and young children, governments, donors and implementing organisations have developed a range of service delivery packages – often including training materials, job aids such as counselling cards or decision algorithms and monitoring and supervision tools. Unfortunately, these service delivery packages are rarely rolled out at scale and, therefore, services are inconsistent across countries and even regions within the same country (Lutter et al., 2011; Gillespie et al., 2015; WHO, 2018; Development Initiatives, 2020). In response, the United States Agency for International Development (USAID) Advancing Nutrition project reviewed prominent, globally recognised service delivery packages to enable government and non-governmental implementing partners and their programme managers to better harmonise, combine or adapt the packages or to introduce, strengthen or expand them. The review also focuses on assessment, treatment and counselling knowledge and skills that providers are taught to support infant and young child nutrition (IYCN).

This paper summarises the findings from our review of six of those packages, detailed in Table 1 ²

Table 1: List of service delivery packages reviewed

While all the packages reviewed focus on frontline services, they have distinct target audiences, objectives, intended beneficiaries and trainees. Some are designed for community volunteers and others are for paid health workers (primarily nurses and auxiliary nurses), some are for services delivered in homes and community meeting points while others are to be delivered in health facilities. Therefore, one would not expect the content to be the same. All six packages give significant attention to IYCN. However, some of the packages focus more on the assessment, treatment or management of malnutrition while others focus on prevention. The C-IYCF and ENA/EHA training packages focus almost exclusively on counselling.

Findings

Assessment of nutritional status and development milestones

Providers are taught to use a variety of measures of the nutritional status for children under five years of age: mid-upper arm circumference (CMAM/MAMI, NACS and CNCC [Caring for the Sick Child course only]), weight-for-length/height (CMAM/MAMI and NACS), weight-for-age (CMAM/MAMI and IMNCI) and bilateral pitting oedema of the feet (CMAM/MAMI and NACS). Only the IMNCI training suggests assessing children for vitamin A deficiency and classifying anaemia. The CMAM/MAMI, NACS and IMNCI packages teach providers to assess children for anaemia by looking at the palmar pallor. The CMAM/MAMI package is the only one that teaches providers to assess children for feeding difficulties (e.g., cleft lip or palate, tongue tie, abnormal tone or posture, excessively open/clenched jaw, unable to support head or poor trunk control, body stiff and hard to move or coughing and eye tearing while feeding [signs of unsafe swallowing]). Only the NACS training for facility-based providers and the CNCC Caring for the Newborn at Home course train providers to assess birth weight and classify low birth weight. Only the CMAM/MAMI training and the CNCC Caring for the Newborn at Home course teach providers to assess breastfeeding positioning and technique.

Treatment of anaemia and micronutrient deficiencies and the management of malnutrition

The C-IYCF and ENA/EHA packages focus exclusively on teaching providers to counsel caregivers of children under two years of age on optimal nutrition practices. Only the CMAM/MAMI, IMNCI and NACS training packages teach providers how to treat malnutrition and provide iron and vitamin A supplements. The IMNCI training also teaches providers to treat a number of common childhood illnesses, demonstrate optimal breastfeeding positioning and treat breastfeeding problems.

Counselling, promotion and support are critical for improving IYCN

For quality counselling, providers need a number of interpersonal communication (IPC) skills and to be familiar with priority behaviours. The C-IYCF training, as well as the ENA/EHA and NACS training for health workers, teach almost all the IPC skills needed for counselling. The IMNCI training, ENA training for community workers, the NACS training for community volunteers and CMAM/MAMI package teach relatively few counselling skills.

Providers are also taught to model, promote and support specific behaviours during health facility visits, home visits, mothers’ group meetings and/or other events. Some of the packages provide counselling cards and key messages (C-IYCF, CNCC and CMAM/MAMI) while others (ENA/EHA, NACS and IMNCI) teach providers the importance of those behaviours with the assumption that they use their counselling skills to promote them. This is what we found:

Breastfeeding practices

Almost all the training packages teach providers to counsel women on optimal breastfeeding practices including early initiation of breastfeeding, feeding infants colostrum, avoiding prelacteal feeding, avoiding the use of artificial teats, pacifiers or bottles, breastfeeding positioning and attachment, breastfeeding on demand/responsively, breastfeeding exclusively for six months, continuing breastfeeding for at least 24 months and breastfeeding before and after a child is ill. Fewer training packages taught providers to explain the early signs of hunger (only the C-IYCF training), how to express breast milk and feed an infant with a cup (C-IYCF and CMAM training, ENA/EHA training for health workers and CNCC course on Caring for the Child's Healthy Growth and Development) or breastfeeding of children born preterm, with a low birth weight or small-for-gestational-age (C-IYCF and CMAM training). All but the NACS training prepared providers to counsel women on breastfeeding difficulties such as cracked nipples, engorgement or mastitis. However, only the C-IYCF, CMAM and CNCC training went into detail about how to prevent and manage these. All but the IMNCI and CNCC training provide for considerations for breastfeeding while HIV-positive and none address breastfeeding in the context of emergencies.

Complementary feeding practices

All the training packages cover complementary feeding practices, emphasising the introduction of complementary foods at six months, feeding children a diverse diet and feeding children actively or responsively the right quantity of food and at the right frequency. All packages except for the IMNCI training specifically mention the need to feed children plenty of fruit and vegetables. However, only the ENA/EHA, CMAM and NACS training packages mention feeding children fortified complementary foods. Only the NACS package mentions reducing the intake of free sugars and avoiding sugar-sweetened beverages. None of the packages discuss the need to control salt intake, increase potassium intake and avoid processed meats and high-fat foods with limited nutritional value.

Learnings

Based on this review, USAID Advancing Nutrition makes the following recommendations to government and non-governmental implementing partners to support effective implementation:

Responsive caregiving, early learning and supporting the growth and development of children with disabilities are all critically important in their own right and indirectly contribute to nutrition practices and outcomes. When using any of the packages reviewed, trainers may wish to look at the CNCC course on Caring for the Child's Healthy Growth and Development to teach providers how to assess early childhood development (ECD) milestones and at the counselling materials being developed by USAID Advancing Nutrition for the promotion of responsive caregiving and early learning.

Training health workers on the full slate of IPC skills needed for counselling can be done with C-IYCF, ENA/EHA or NACS. When using the other packages or training for frontline health workers and volunteers, it may be helpful to supplement the training with the counselling skills outlined in these packages to ensure thorough and detailed coverage.

Although breastfeeding counselling is included in almost all of the training packages, guidance on how to deal with breastfeeding challenges was less common. Trainers may wish to look at the MAMI tool (which goes further than other packages) and seek supplemental materials (such as the forthcoming WHO training on breastfeeding counselling and the Global Health Media videos³ on breastfeeding) to ensure that health workers are adequately trained to tailor the counselling to personal breastfeeding challenges, especially in an emergency context.

Depending on context, additional supplementary training may be required to encourage reductions in the intake of sugar-sweetened beverages, salt, processed meats and high-fat foods with limited nutritional value and increases in the consumption of unprocessed or minimally processed fruit, vegetables, legumes and animal-source foods.

Conclusion

This review has demonstrated the abundance of packages of materials for the delivery of nutrition services for the prevention and treatment of malnutrition – both underweight and overweight – and included the multitude of micronutrient deficiencies. It has also drawn attention to the need to harmonise, sustain, scale and strengthen these in certain critical areas including breastfeeding support, overcoming breastfeeding challenges, responsive care and early learning as well as adaptations needed when working with children with disabilities.

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Endnotes

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Emergency Nutrition Network (ENN), GOAL, London School of Hygiene and Tropical Medicine (LSHTM), and Save the Children. (2018). C-MAMI Tool. Ver. 2. Oxford: ENN.

Food and Nutrition Technical Assistance III (FANTA) Project. (2016). Nutrition Assessment, Counseling, and Support (NACS): A User’s Guide. Ver. 2. Washington, DC: FHI 360/FANTA.

Food and Nutrition Technical Assistance III (FANTA) Project. (2018). Training Guide for Community-Based Management of Acute Malnutrition (CMAM). Washington, DC: FHI 360/FANTA.

Gillespie, Stuart, Purnima Menon, and Andrew L Kennedy. (2015). Scaling up impact on nutrition: what will it take?. Advances in nutrition 6(4), 440–451. https://doi.org/10.3945/an.115.008276 

Lutter CK, Daelmans BMEG, de Onis M, Kothari MT, Ruel MT, Arimond M, Deitchler M, Dewey KG, Blössner M, Borghi E. (2011). Undernutrition, poor feeding practices, and low coverage of key nutrition interventions. Pediatrics 128:e1418–27.

United Nations Children Fund (UNICEF). (2012). Community Based Infant and Young Child Feeding. New York: UNICEF.

United States Agency for International Development (USAID), John Snow, Inc. (JSI), Helen Keller International (HKI), and CORE Group. 2015. Essential Nutrition Actions and Essential Hygiene Actions Framework. Washington, DC: USAID.

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World Health Organization (WHO) and United Nations Children’s Fund (UNICEF). (1999). Guidelines for Follow-Up after Training in the WHO/UNICEF Course on Integrated Management of Childhood Illness (IMCI) for First-Level Health Workers. Geneva: WHO.

World Health Organization (WHO) and United Nations Children’s Fund (UNICEF). (2006). Integrated Management of Childhood Illness (IMCI) Complementary Course on HIV/AIDS. Geneva: WHO.

World Health Organization (WHO). (2014). Integrated Management of Childhood Illness (IMCI) Set of Distance Learning Modules. Geneva: WHO.

World Health Organization (WHO). (2015). Caring for Newborns and Children in the Community: Package of Resources. Geneva: WHO.

World Health Organization (WHO). (2018). Global nutrition policy review 2016–2017: country progress in creating enabling policy environments for promoting healthy diets and nutrition. Geneva: WHO.