Reinforcing the Quality of Counseling at the Health

Facility Level

Sascha Lamstein, PhDNutrition Programs M&E Advisor

SPRING Project

Outline• Background• Process• Content• Questions / next

steps

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Background of the Reinforcement Visits

• Nutrition services and supervision of those services at the facility level are limited

• SPRING works to expand and strengthen the integration of nutrition assessment, counseling and support (NACS) into existing health programs in selected countries

• In Haiti, SPRING was asked to strengthen NACS, including infant and young child feed counseling, in targeted tertiary care facilities (currently 12) through training and quality improvement processes

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Background: Why undertake a “reinforcement visit”?

• Increasing knowledge and awareness of good nutrition practices rarely leads to sustained behavior change

• The importance of how interventions are implemented on effectiveness is gaining increased attention– Management– Training … is not enough– Supervision and/or coaching… is essential– Incentives

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Background: Objectives of the Reinforcement Visits

• Assess quality of care and client satisfaction with NACS services

• Provide healthcare providers with direction and support in applying guidelines to their day-to-day work

• Increase healthcare providers’ knowledge and skills • Improve the quality of NACS services

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Process of the Reinforcement Visit

• SPRING staff play the role of “facilitator” or “coach”, not a “supervisor”

• Collaboratively measure:– what providers reported doing– what can be observed of facility infrastructure and provide practices– what clients reported was done during their visits

• Present results in auto-generated graphs (dashboard plus presentation)

• Meet with facility staff to compare desired and actual performance, identify the root causes of gaps/problems, and develop action plans

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Content: Reinforcement Visit Tool Development

• Conducted an inventory of existing tools for content related to facility-level nutrition services

• Reviewed existing standard operating procedures for NACS as well as general counseling guidance (UNICEF IYCF counseling package, ENA framework, GATHER, etc.)

• Solicited feedback from Haiti and Uganda regarding challenging questions and useful data

• Solicited input from health systems strengthening experts

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Content: Reinforcement Visit Tool Development

• Reviewed and revised operational definitions of NACS at the health facility level using globally-recognized indicators whenever appropriate

• Developed tools to…– interview facility staff and clients– observe client-provider interactions– review records

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Content: Nutrition counseling indicators measured through RVs

• Counseling indicators, measured primarily through observation, include:– % of clients who received counseling conducted with key

counseling techniques (communicating, listening, encouraging, etc.)

– % of clients who received counseling on appropriate nutrition topic (varies by client type)

– % of clients supported in developing/reviewing a nutrition care plan

– % of clients asked to commit to at least one action item

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Example: Haiti observations

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Example: Haiti observations

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Example: Haiti observations

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Questions and next steps• What is realistic to expect with regard to nutrition

counseling at the secondary and tertiary care level?• What are the key elements (“must haves”) for

effective nutrition counseling at the secondary and tertiary care level?

• Which elements of counseling are particularly challenging in this setting?

• What can be done to ensure that this process is sustained and scaled (built into existing MOH systems)?

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