Nutrition

The nutrition assessment, counseling, and support (NACS) approach aims to improve the nutritional status of individuals and populations by integrating nutrition into policies, programs, and the health service delivery infrastructure.  Improvement methods can help to strengthen the linkage between communities and points of care for nutritional services to improve the coverage, compliance, referral, and follow-up of people of all ages with special nutritional needs, including pregnant and lactating women, young children, and persons living with HIV or tuberculosis.

Nutrition MUAC

Integrating nutrition support into existing health services can be challenging. Health care providers may lack the technical knowledge and skills to deliver the correct care; high staff turnover make one-off training in nutrition assessment and follow-up unsustainable; low staff numbers make it hard for clinics to handle the increased workload required to integrate a new service into their already busy clinics; and supply chain issues mean that supplies of specialized food products are not always available at clinics. These challenges can be addressed by improvement interventions to build technical skills, improve the efficiency and effectiveness of service delivery, and strengthen data systems at all levels.

NACS: A User Guide

The NACS User’s Guide is a series of modules, developed by the USAID-funded Food and Nutrition Technical Assistance Project (FANTA), that provide program managers and implementers with a package of essential information and resources on nutrition and counseling services (NACS).

ASSIST developed Module 6, which discusses how to use improvement methods to assess and improve the quality of nutrition and counseling services.

Module 1. What Is NACS?
Module 1 describes the NACS approach, its components, the evidence supporting the approach, as well as the importance of NACS throughout the life cycle.

Module 2. Nutrition Assessment and Classification
Module 2 explains the rationale for and different types of nutrition assessment and provides guidance on when and how to conduct assessments.

Module 3. Nutrition Education and Counseling
Module 3 offers an overview of nutrition education as well as information and tips on providing effective nutrition counseling and developing nutrition care plans. The module covers topics including nutrition during pregnancy and illness; infant and young child feeding; and water, sanitation, and hygiene.

Module 4. Nutrition Support
Module 4 covers the main nutrition-specific and nutrition-sensitive interventions for preventing and treating malnutrition.

Module 5. Monitoring and Evaluation of NACS Services
Module 5 introduces the basic principles of monitoring and evaluation (M&E) and explains why they are important for NACS activities. It provides guidance on selecting indicators to include in an M&E plan and how to collect, analyze, and use these data.

Module 6. Quality Improvement for NACS
Module 6, written by the USAID ASSIST Project, provides guidance on using quality improvement methods to assess the quality of NACS services, identify gaps in care, and strategize effective ways to address those gaps and improve outcomes for patients receiving NACS services.

Module 7. NACS Planning (coming in 2018)
Module 7 provides guidance on planning the integration of nutrition services into routine facility-based health care and community-based services using the NACS approach. It draws from the experience of countries and practitioners that integrated NACS into health systems and references tools such as the coming NACS Planning and Costing Tool (also coming in 2018).

These modules are living documents and will be updated as appropriate when new evidence, guidelines, or field experience emerges. Readers are invited to submit comments and suggestions for improving or updating the guidance.

USAID ASSIST Project Semi-Annual Performance Monitoring Report FY18

University Research Co., LLC (URC) and its partners have completed 5.5 years of implementation of the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. This report is the eleventh Semi-Annual Performance Monitoring Report for ASSIST, summarizing the project’s accomplishments and results during the first two quarters (Q1-2) of Fiscal Year 2018 (FY18).  In late September 2017, the project was awarded a two-year costed extension with additional funding for Zika-related activities.  No further funding was provided for non-Zika work.  The project’s FY18 work plan thus focuses mainly on Zika-related support in eight countries and completion of previously funded work in other countries.

Overall goals
The USAID ASSIST Project fosters improvements in a range of health care processes through the application of modern improvement methods by host country providers and managers in USAID-assisted countries. The project’s central purpose is to build the capacity of host country health and social service systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the services they provide. In addition to supporting the implementation of improvement strategies, the project seeks to generate new knowledge to increase the effectiveness and efficiency of applying improvement methods in low- and middle-income countries.
USAID ASSIST country programs align with the goals of United States Government’s global initiatives and policies, including preventing child and maternal deaths, achieving HIV epidemic control, combating other public health threats, protecting life, and addressing gender inequalities.

Where we work
During the first half of FY18, USAID ASSIST provided technical support in 23 countries through field and core funding. USAID Mission funds supported work in nine countries: Cambodia, Côte d’Ivoire, India, Indonesia, Lesotho, Mali, Swaziland, Tanzania, and Uganda. USAID core funds from the Office of HIV/AIDS supported activities in seven countries: Kenya, Lesotho, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe.  Funds for Neglected Tropical Diseases supported improvement work to combat the Zika virus in the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, and Peru.  USAID cross-bureau-funded activities, through the Office of Health Systems, supported malaria prevention activities in Malawi and global and regional initiatives that contribute to local and global learning in improvement.

FY18 Q1-2 accomplishments and results:

  • Improvement in key indicators: As discussed in this report, ASSIST-supported programs demonstrated improved care and outcomes for a range of services, including antenatal and postnatal care, essential obstetric and newborn care, screening of pregnant women and newborns for Zika-related signs and symptoms, Zika care and support, PMTCT, and HIV prevention.
  • Research and evaluation studies: At of the end of the reporting period, the project had 29 research studies in planning, underway or completed in 14 countries. Three are multi-country studies.
  • Promoting the use of improvement methods: During the reporting period, project staff published nine peer-reviewed articles; seven case studies; four technical and research reports; and 10 guides, tools, and job aids. ASSIST staff led six sessions and made eight oral presentations at six regional and international conferences. ASSIST’s work continued to be promoted through the project’s website and social media engagement, with some 27,867 visitors viewing 61,572 pages within the ASSIST Knowledge Portal during the past two quarters.

USAID ASSIST Project Annual Performance Monitoring Report FY17

University Research Co., LLC (URC) and its partners have completed the fifth year of implementation of the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. This report is the tenth Semi-Annual Performance Monitoring Report for the project and aims to summarize the accomplishments and results toward the program objectives of USAID ASSIST activities during quarter (Q) 1 through 4 of Fiscal Year 2017 (FY17).

Scale of USAID ASSIST work, FY17

FY17 Accomplishments and Results

  • Improvement in key indicators: As discussed in this report, ASSIST-supported programs demonstrated improved care and outcomes for a range of services, including antenatal and postnatal care, essential obstetric and newborn care, family planning, PMTCT, HIV care and treatment, HIV prevention, NACS, TB diagnosis and treatment, malaria diagnosis and case management, and services for vulnerable children and families.
  • Gender integration: Onsite gender training and technical support was provided to country teams in Burundi, Cote d’Ivoire, DRC, Lesotho, Mali, South Africa, and Uganda to integrate gender considerations into their improvement work. Ongoing gender support was provided to all field offices with improvement activities to collect and analyze sex-disaggregated indicators, identify gender-related gaps affecting outcomes, and respond to those gaps.
  • Research and evaluation studies: At of the end of the reporting period, the project had 37 studies underway or completed in 15 countries. Four are multi-country studies.
  • Promoting the use of improvement methods: In FY17, project staff published 14 peer-reviewed articles; 23 case studies; 11 technical and research reports; 42 guides and tools, six short reports; 29 annual reports, and seven multimedia products describing project-supported work and results as well as gender integration learning videos. ASSIST had an active presence at 16 international and national conferences. In all, project staff led 18 sessions and workshops and delivered 14 oral and 14 poster presentations. ASSIST’s work continued to be promoted through strategic engagement in Twitter chats, reaching close to 2,374 followers (26% increase from FY16) and an average of 26,500 unique Twitter users per month (impressions). We continued sharing resources via the ASSIST Facebook page (over 6,200 likes) as well as publishing engaging blog content (28 blogs in FY17).

SUSTAIN's Nutrition Services Change Package

Since 2010, the United States Agency for International Development (USAID) has been working with Uganda’s Ministry of Health (MoH) to improve HIV and AIDS service delivery at select health facilities through the Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project.

The SUSTAIN project provided technical assistance to 12 high-volume hospitals to integrate nutrition service delivery into HIV care in order to prevent and address malnutrition. The project’s objectives were two-fold; to increase the proportion of HIV positive clients undergoing nutritional assessments and to improve access to ready-to-use therapeutic foods for HIV positive malnourished clients.

The purpose of this quality improvement change package is to provide a synthesis of the most robust and effective QI interventions to improve nutrition services in SUSTAIN-supported hospitals in Uganda.


This change package is part of a series of quality improvement change packages developed by the SUSTAIN project based on their work in Uganda. Other technical areas include: prevention of mother-to-child transmission of HIV, laboratory, monitoring and evaluation, adolescent friendly health services, voluntary medical male circumcision, HIV care and treatment, supply chain, tuberculosis, and quality improvement.

SUSTAIN's Adolescent Friendly Health Services Change Package

Since 2010, the United States Agency for International Development (USAID) has been working with Uganda’s Ministry of Health (MoH) to improve HIV and AIDS service delivery at select health facilities through the Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project.

The project supported six regional referral hospitals to implement interventions aimed at improving the provision of adolescent friendly health services (AFHS) through the application of continuous quality improvement methods and techniques. QI teams were supported to increase the proportion of adolescents: (a) attending AFHS centers, (b) newly testing for HIV, (c) assessed for their nutritional status, (d) provided with family planning services, (e) and linking those who test HIV positive to HIV care.

The purpose of this quality improvement change package is to provide a synthesis of the most robust and effective QI interventions to improve Adolescent Friendly Health Services in SUSTAIN-supported hospitals in Uganda.


This change package is part of a series of quality improvement change packages developed by the SUSTAIN project based on their work in Uganda. Other technical areas include: prevention of mother-to-child transmission of HIV, laboratory, monitoring and evaluation, voluntary medical male circumcision, nutrition, HIV care and treatment, supply chain, tuberculosis, and quality improvement.

Tested Changes to Improve Nutrition Assessment, Counseling, and Support in HIV Care in Zambia

From 2014-2017, the USAID ASSIST Project collaborated with FANTA III and LIFT II to support the Government of Zambia to pilot nutrition assessment, counseling, and support (NACS) as part of HIV care in Kitwe and Mkushi districts, representing both urban and rural districts. The pilot activity was funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID and designed to support the continued adoption, adaptation, and scale-up of NACS as a standard of care within national HIV/AIDS programs in Zambia. Using the NACS platform, ASSIST, FANTA III, and LIFT II also implemented an activity with the objectives of strengthening engagement, adherence, and retention (EAR) of PLHIV in HIV care and ultimately improving the wellness of adults and pediatric HIV patients.

A key component of this work was to improve the delivery of NACS services, share implementation experiences, and identify a set of practices and interventions that lead to desired outcomes and can eventually can be spread to other sites. This report describes the results achieved in Kitwe and Mkushi districts, explains how the quality improvement (QI) work was carried out, and details the effective practices tested by teams in the two districts that can be readily applied by others in Zambia and elsewhere.  It describes simple steps that have been proven to work in the Zambian context through the efforts of improvement teams at the facilities, supported by district supervisors and coaches.  The changes can be grouped in three areas:

  1. Changes in data recording and management, including the introduction of new data tools
  2. Changes in staff roles, task shifting, and engagement of the community volunteers
  3. Changes in patient flow

Addressing the Therapeutic Feeding Gap for PLHIV with Nutrition and Self-Management Support: A Case of Aboke Health Center IV

Poor nutrition remains a key challenge for people living with HIV (PLHIV), especially those on antiretroviral therapy (ART).

This case study highlights how health workers at Aboke Health Center IV, a site that has not received ready-to-use therapeutic food from the medical supply chain, leveraged self-management support (SMS) and nutrition counselling to support PLHIV diagnosed with malnutrition.

Changes focused on instituting and streamlining systems and processes around patient flow, assessing nutritional status at each clinic visit, improving documentation, and providing patient-level support to those enrolled into SMS. This case study provides key information for rural health units on how they can improve identification and support for malnourished PLHIV using available local resources.

Learn more.

La prise en charge de l’anémie chez les femmes enceintes, allaitantes et les enfants de moins de 5 ans (in French)

Selon l’Enquête Démographique et de Santé EDSM- V, la région de Sikasso affiche une situation nutritionnelle préoccupante avec des taux de malnutrition aigüe globale souvent dépassant le seuil d’alerte. Toutes choses qui ont causé un taux élevé d’anémie chez les femmes enceintes et les enfants de moins de 5 ans, occasionnant un risque élevé de mortalité maternelle, néo-natale et infantile. Face à cette situation qui pénalise le développement de toute une nation,  l’USAID à travers le projet ASSIST a décidé avec la sollicitude du Ministère de la santé et de l’hygiène publique, d’agir dans la région de Sikasso notamment dans le district sanitaire de Bougouni pour la prévention et la prise en charge de l’anémie chez les femmes enceintes, allaitantes et les enfants de moins de 5 ans. Le projet travaille en étroite collaboration avec les services du Ministère de la Santé et de l’hygiène Publique. Pour assurer la mise en œuvre des activités, le projet a mis en place une approche d’amélioration de la qualité qui consiste à mettre en réseau les Equipes d’amélioration de la Qualité (EAQ) au niveau des centres de santé et au niveau communautaire. Dans la région de Sikasso et principalement dans le district sanitaire de Bougouni, les activités du projet ont porté sur la prévention et le contrôle de l’anémie dans 44 centres de santé et au sein de 42 communautés. Au niveau des agents de santé, plusieurs activités de renforcement de capacité ont été initiées notamment la formation, le coaching et les sessions d’apprentissage. Une approche innovante.

Pour son volet communautaire, les comités communautaires constituent des groupes de femmes déjà organisés et fonctionnels dans les villages, se regroupant de façon régulière pour échanger et se conseiller mutuellement. Le projet utilise ces groupes en renforçant leurs capacités pour assurer la sensibilisation sur l’anémie, son dépistage et la référence des cas dépistés vers les centres de santé  pour une prise en charge correcte et rapide. Ces comités, par leur propre initiative, ont développé beaucoup de stratégies comme l’instauration de jardins communautaires et privés, des théâtres, des sketchs des poèmes, des  chants entre autres…des initiatives qui ont fait de chaque habitant même les tous petits de véritables agents sanitaires.

Après plus de 3 ans de mise en œuvre donc, il est indéniable que le projet USAID ASSIST, au regard des succès enregistrés au niveau des centres de santé et des comités communautaires a fait du chemin pour l’atteinte de son idéal. Selon le médecin chef du district sanitaire de Bougouni, l’avènement du projet USAIS ASSSIT avec son approche innovante est une aubaine pour la vie sanitaire des populations. Ces réussites sont une illustration parfaite de l’approche changement de comportement et d’une garantie d’impact à long terme.

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Management of anemia in pregnant women and children under 5 years of age

This short film discusses the project’s contribution at the community level with interviews from community members, families, providers and decision makers on project results and achievements in the health district of Bougouni in the Sikasso region of Mali.

According to the Demographic and Health Survey (DHS), the Sikasso region has a worrying nutritional status with overall acute malnutrition rates. There is a high rate of anemia in pregnant women and children under 5 years, causing a high risk of maternal, neonatal and infant mortality. Hence, at the request of the Ministry of Health and Public Hygiene, USAID decided to work, through the USAID ASSIST project, on the prevention and management of anemia in pregnant and lactating women and children under 5 years of age in the region of Sikasso. In order to ensure the implementation of the activities, ASSIST has put in place a quality improvement approach which consists of Quality Improvement Teams (QAs) at the health center and community level. In the Sikasso region and mainly in the health district of Bougouni, the project activities focused on the prevention and control of anemia in 44 health centers and in 42 communities. At the level of health workers, several capacity-building activities were initiated, including training, coaching and learning sessions.


For additional information about ASSIST work reducing anemia in Mali:
Synthèse des bonnes pratiques de la mise en oeuvre de l’approche d’amélioration de la qualité appliquée à l’anémie au Mali

 

 

 

 

 

 

 

 

 

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