How to Ensure Counseling is NOT a Mini-Lecture_Sergine Diene and Rebecca Egan_5.6.14

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  • Only the following key micronutrients are analyzed by Optifood:Minerals: iron, zinc, calciumVitamins: vitamin A, vitamin C, thiamine, riboflavin, niacin, vitamin B-6, folate, vitamin B-12Macronutrients: total fat, total protein)
  • This is how all three components fit together within the NACS continuum. The assessment starts first, leading to the counseling, and the support. The ideal continuum facilitates the flow from the clinic to the community and back.
  • Nutrition assessment: ALL clients, regardless of entry pointNutrition counseling: ALL clients, especially malnourished adults and adolescents and caregivers of infants and young children Support: TargetedSpecialized food support:Adult and adolescent clients with SAM and MAM meeting strict criteria (typically with HIV and/or TB)Pregnant and lactating women (PMTCT)Orphans and vulnerable children (OVCs)ES/L/FS support:Program dependent based on availability of services and client’s food security assessmentOthers (e.g., WASH support) may be given to all
  • FANTA has worked in multiple areas related to improving NACS counseling over the past 5-7 years in a variety of countries including the development and testing of:Training manuals with specific counseling sections (Cote d’Ivoire)Flipcharts for counselors to use (Zambia)Clinic cards (Ethiopia)Take home brochures (Namibia)Studies and evaluations on the effectiveness of counseling (Mozambique)
  • We still know little about truly effective nutrition counseling in a NACS setting. Looking at the research, we know that through counseling, certain messages can help change behavior to impact nutrition outcomes (e.g. improved exclusive breastfeeding or
  • Multiple levels need to be considered when developing and tailoring counseling messages. First, what are the cultural factors within a community that impact nutrition-related behaviors? Is there adequate time/funding to assess those behaviors?Secondly, at the health facility, who counsels clients? Do the counselors/health care workers have to deal with many types of clients (e.g, adults, children, etc)? These factors could make it difficult for counseling messages to be appropriately delivered. Also, clinicians may have many clients to see – and their time may be used for other activities.Third, clinicians may not have received education (pre-service or in-service) training on nutrition itself. Therefore, they may not be properly incentivized to deliver nutrition messages if they do not see the value.Lastly, messages may be too complicated for patients to understand. Or the negotiated behavior change may be too difficult to change.Constraints:Available time in healthcare worker’s schedule to counselQuality of training provided to healthcare workersCounseling is a skill unto itselfPre-service nutrition education for medical professionals is often weak or non-existentMultifaceted counseling - different populations treated through NACS require individual messaging (e.g. PMTCT, OVCs, etc)Messages aren’t always contextualized to address the cultural barriers to behavior changeThe type of behaviors to be changed –complex behaviors may not be feasibly changed through counseling sessions aloneWhat works:Contextualized messages (locally appropriate) Messages tailored to the individual – indentifying a client’s specific needs while understanding barriers to adoptionDeveloping and communicating messages that are easy to understand – (e.g., pictorial, fewer words)Reinforcing messages through other mediums (e.g. the media)Supportive supervision to the healthcare workers who are counselingLeverage existing services


  • 1. Food and Nutrition Technical Assistance III Project (FANTA) FHI 360 1825 Connecticut Ave., NW Washington, DC 20009 Tel: 202-884-8000 Fax: 202-884-8432 Email: Website: THE “C” IN NACS: Counseling as part of Nutrition, Assessment, Counseling and Support Sub-title Serigne Diene, PhD, MPH Technical Advisor – Nutrition & Infectious Diseases - Country programs Rebecca Egan Technical Advisor, Nutrition & Infectious Diseases CORE Group May 6, 2014
  • 2. Objectives  Introduction to NACS  Counseling approaches in NACS  Effectiveness of counseling and areas for improvement 2
  • 3. Objectives  Introduction to NACS  Counseling approaches in NACS  Effectiveness of counseling and areas for improvement 3
  • 4. 4 NACS: A platform for integrating nutrition into 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
  • 5. The three components within the NACS continuum of care: 1. Nutrition assessment 2. Counseling 3. Support 5
  • 6. NACS Hinges on Nutrition Assessment 1. 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.
  • 7. NACS Counseling Focus Areas 1. Understanding of client preferences, constraints, and options 2. Discuss the “Nutrition Care Plan” assigned 3. Optimal diet 4. Dietary management of symptoms and drug side-effects 5. Adherence to medications and clinical visit schedule 6. Chronic disease management 7. Exercise 8. Water, sanitation, and hygiene (WASH) 9. Referrals to additional services 5/12/2014 7
  • 8. 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
  • 9. 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 Food by prescription: therapeutic, supplementary, complementary foods Micronutrient supplements Point-of-use water treatment Anthropometric Biochemical Clinical Dietary Food security Support groups Community Health workers Economic strengthening, livelihoods, and food security
  • 10. Targeting NACS Services 10 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
  • 11. Objectives  Introduction to NACS  Counseling approach in NACS  Effectiveness of counseling and areas for improvement 11
  • 12. FANTA’s counseling products 12 Brochures Clinic Cards Flipcharts Training Research
  • 13. 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 13
  • 14. The NACS “Critical Nutrition Actions” messages 14
  • 15. Objectives  Introduction to NACS  Counseling approaches in NACS  Effectiveness of counseling and areas for improvement 15
  • 16. 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 16
  • 17. Making NACS counseling (more) effective 17 • 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
  • 18. 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 messages 18
  • 19. 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 19
  • 20. 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 20
  • 21. 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? 21
  • 22. 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? 22
  • 23. 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) • 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. 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. • 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. • 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. • Roy, Swapan Kumar, et al. "Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh." (2005). • 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. • 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. • 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., • 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. 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. question%C3%A1rio-Oct2013-ENG-2013.pdf 23
  • 24. 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. 24