On the Job Training (OJT) Guideline For Frontline Health and Family Planning Supervisors on

Nutrition Interventions

Improving Delivery and Uptake of Essential Nutrition Interventions through the

Health and Food System and in the Community (IAHBI) Project,

CARE Bangladesh.

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Report prepared by:

Md. Anowarul Arif Khan, Manager-Monitoring and evaluation,

CARE Bangladesh

Dr. Md. Sarbojit Anwar Kamal, Program Manager-Nutrition,

CARE Bangladesh

Edited by:

Dr. Salahuddin Ahmed, National Nutrition Coordinator,

CARE Bangladesh

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This simple guide basically has been developed to use by the GoB front line health and family planning supervisors. By using this guide they can easily provide OJT to their respective service providers. IAHBI project has facilitated to develop this guide.

Overview The Direct Nutrition Interventions (DNI) comprises a package of sixteen evidence based proven interventions to improve maternal and child nutrition when delivered at scale. The interventions are: Infant and Young Child Feeding (IYCF):

1. Early initiation of breastfeeding within first hour after birth 2. Exclusive breastfeeding from birth up to 6 months 3. Age appropriate complementary feeding of children from 6-23 months

Hygiene:

4. Hand washing with soap at critical times – before eating/preparing food, before feeding a child and after defecation

Micronutrient supplementation:

5. Vitamin A supplementation for children 6-59 months once every six months 6. Iron Folic Acid (IFA) supplementation for Pregnant and Lactating Women (PLWs) and

adolescent girls 7. Multiple Micronutrient Powder (MNP) supplementation for children 6-23 months 8. ORS with zinc in management of acute diarrhoea

Deworming:

9. Deworming for children 24-59 months once every six months Consumption of nutrient-rich, fortified foods

10. Consumption of foods rich in Iron and Vitamin A by PLWs, adolescent girls 11. Household consumption of iodized salt, fortified oil with Vitamin A

Management of acute malnutrition:

12. Screening and referral of acute malnutrition in children 0-59 months 13. In-patient and out-patient management of children 0-59 months with acute malnutrition

according to national protocols. Maternal Nutrition:

14. Adequate food intake and rest during pregnancy and lactation 15. Micronutrient supplementation (including iron folic acid, calcium) 16. Consumption of nutrient-rich foods

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Objectives of On Job Training The OJT for DNI will focus on the following objectives:

1. To facilitate service providers to enhance knowledge, competence and skills to implement a comprehensive package of Direct Nutrition Interventions integrated with other health services

2. To enhance supportive supervision with feedback mechanisms by the front line health and family planning supervisors and

3. To improve health and nutrition outcomes

Intended Users of the OJT Guide Health workers/providers play a key role in supporting optimal nutrition practices and also ensuring that children and women access high quality interventions. Therefore this tool can be used by any health facility supervisor particularly the frontlines who is competent in and knowledgeable about the key components of DNI. The frontline health and family planning supervisors include Assistant Health Inspector (AHI), Health Inspector (HI), and Family Planning Inspector (FPI).

How can the OJT be used? After identify the knowledge gaps of service providers including Community Health Care Providers (CHCP), Family Welfare Visitor (FWV), Family welfare Assistant (FWA), the supervisors will use this guide toenhance their knowledgeon DNI. Identified knowledge gaps can be addressed through theoretical sessions arranged for individuals or groups in the work-place, modeling on the methods used for Continuous Education, where a new concept is introduced to the health worker or Mentorship, where the supervisor guides a health worker through explanation and demonstration in the work-place. This simple guide will be used by frontline health and family planning supervisors during regular facility/field visit.After completion of the visit supervisor will share the key observation/findings with the service provider and based on the observation/findings supervisor will provide onsite technical assistance to correct the deviation that is feasible. Findings/observations those need to discuss at the broader forum, supervisor will take the opportunity of those forums like monthly meeting of health providers at the upazila and union level.

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OJT guide for some specific issues

Guideline 1: Provide and promote Iron Folic Acid (IFA) tablet

Target Population: Pregnant and lactating women, adolescent girls

Key messages • Mothers should be encouraged to take IFA tablets

daily to prevent anemia during pregnancy irrespective of their hemoglobin levels (60mg of iron and 400 μg folic acid every day)

• Counsel and encourage lactating women to take IFA tablet after delivery to till 03 months

• Counsel and encourage the adolescent girls to take IFA tablet according to national guideline

• Provide information on possible side effects and how to avoid trouble-some side-effects when dispense IFA

• Promote an adequate diet rich in iron. Rich sources of iron include liver, meat, fish, eggs etc. • Encourage to intake of Vitamin C rich fruits and vegetables such as tomato, guava, mango,

pineapple, orange as they enhance iron absorption • Encourage and promote good hygiene practices.

Table 1: National guideline for dispensing IFA tablet

Target Group Dose Duration Adolescent girls (13-19 years) and not pregnant women

Elemental iron 60 mg + folic acid 400 µg Per week- 02 tablet

03 month continue Next 03 month stop Again next 03 month continue

Pregnant women Elemental iron 60 mg + folic acid 400 µg Per day- 01 tablet

After confirmation of pregnancy to during the whole pregnancy period

Lactating women Elemental iron 60 mg + folic acid 400 µg Per day- 01 tablet

After delivery to till 03 months

Children (06-24 months) Elemental iron 12.5 mg + folic acid 50 µg Per day- 01 time Or, Micro Nutrient Powder (MNP-05 ingradients) Per day- 01 sachet with food

02 month continue Next 04 month stop Again next 02 month continue

Children (02-05 years) Elemental iron 20- 30 mg + folic acid 200 µg Per week- 01 time

03 month continue Next 03 month stop Again next 03 month continue

Children (05-12 years) Elemental iron 45 mg + folic acid 400 µg Per week- 01 time

03 month continue Next 03 month stop Again next 03 month continue

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Guideline2: Promote, protect and support exclusive breastfeeding for the first six months of life and continued breastfeeding for two years Target population: Mothers of 0-24 months old children

Key messages • Counsel mothers on the benefits and importance of breastfeeding during antenatal and

postnatal visits

Importance of breastfeeding Breast milk:

• Saves infants’ lives • Human breast milk perfectly meets the needs of human infants • Is a whole food for the infant, and covers all babies’ needs for the first 6 months • Promotes adequate growth and development, thus helping to prevent stunting • Is always clean • Contains antibodies that protect against diseases, especially against diarrhoea and respiratory infections • Is always ready and at the right temperature • Is easy to digest • Nutrients are well absorbed • Contains enough water for the baby’s needs • The infant benefits from the colostrum, which protects him/her from diseases (Colostrum is the yellow or

golden [first] milk the baby receives in his or her first few days of life.

• Counsel mothers on and practice optimal breastfeeding practices • Counsel mothers on early initiation of breastfeeding • Encourage and promote exclusive breastfeeding for infants from birth up to six months • Encourage mothers to continue breastfeeding for 2 years of age • Counsel mothers to avoid feeding bottles.

Guideline3: Promote, protect and support appropriate and optimal complementary feeding for 6 to 24 months through the use of locally available home based foods for complementary feeding Target population: Mother of 6-24 months old children

Key messages

• Counsel and encourage the mothers to introduce complementary feeds at six months and continue breastfeeding for 2 years

• Counsel mother for practicing Infant and young child feeding (IYCF) practices include initiating timely feeding of solid or semisolid foods at age 6 months and increasing the amount and variety of foods and frequency of feeding with maintain minimum dietary diversity

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Minimum dietary diversity means feeding the child food from at least four food groups. This cut off was selected because it is associated with better-quality diets for both breastfed and non breastfed children. The four food groups should come from a list of seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry, and liver/organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables.

Table 2: Amounts of foods to offer

Age Texture Frequency Amount of food per meal

6-8 months Start with thick porridge, well mashed foods. Continue with mashed family foods

2-3 meals per day plus frequent breastfeeds Depending on the child’s appetite 1-2 snacks may be offered

Start with 2-3 table spoonfull per feed increasing gradually to ½ of a 250 ml cup

9-11 months

Finely chopped or mashed foods and foods that baby can pick up

3-4 meals plus breastfeeds depending on the child’s appetite1-2 snacks may be offered

1/2 of a 250 ml cup/bowl

12-23 months

Family foods, chopped or mashed if necessary

3-4 meals plus breastfeeds depending on the child’s appetite1-2 snacks may be offered

3/4 to one 250 ml cup/ bowl

If baby is not breastfed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals per day Use multiple micronutrient powders with complementary foods Source: WHO/UNICEF (2006), Infant and Young Child Feeding Counseling Guide

• Encourage the mother to breastfeed more to her child and continue eating during illness and provide extra food after illness

• Counsel mother for wash hands with soap at 3 critical times(during handling/ preparing food, after cleaning [bathing, defecation] the child, after own defecation)

Guideline4: Provide and promote Multiple Micro Nutrient Powder (MNP) for 6 to 24 months old children

Target population: Mother of 6-24 months old children

Key messages

• Counsel mothers for consumption of MNP for 06 to 24 months old children

• Informed mothers the appropriate guideline for MNP consumption

• Informed mothers the benefits of MNP • Counsel the caregiver how to prepare it • Provide mothers the adequate sachet of MNP and make follow-

up during the next visit

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Guideline5: Strengthen regular Growth Monitoring and Promotion (GMP) for 0-59 months old children for prevention and early detection of malnutrition

Target population: 0-59 months old children Key messages

• Monitor the growth of every child visiting the health facility for any reason

• Children should be weighed every month until they are five years and therefore parents should be given follow-up dates until their children are five years old

• GMP card should be distributed free of charge and every 0-59 months old child should have one

• Record the child name, sex and date of birth in the GMP card

• Weigh the child • Measure the child’s length or height • Plot the weight and length/height on the

GMP card

Fig: weight and height measuring

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Measuring Mid Upper Arms Circumference (MUAC) for Severe Acute Malnutrition (SAM)/Moderate Acute Malnutrition (MAM) screening Through using MUAC tape the service provider can easily identify the SAM/MAM children. Instructions on how to take MUAC is demonstrated below:

How to use a MUAC tape 1. The child will be age 6 months up to 5 years 2. Gently outstretch the child’s left arm to straighten it 3. On the upper arm, find the midpoint between the shoulder and the elbow 4. Hold the large end of the strap against the upper arm at the midpoint 5. Put the other end of the strap around the child’s arm and thread the green end of the strap through the second small slit in the strap—coming up from below the strap 6. Pull both ends until the strap fits closely, but not so tight that it makes folds in the skin 7. Press the window at the wide end onto the strap, and note the color at the marks 8. The color indicates the child’s nutritional status. If the color is RED at the two marks on the strap, the child has SEVERE MALNUTRITION.

Table3: MUAC criteria to identify malnutrition of children <5 years SAM MAM Normal < 11.5 cm 11.5 to 12.4 cm 12.5 to above Feed-back and counseling 1. If the child is growing well, the next step is to provide appropriate feeding advice for the Child’s upcoming age group, so that the child will continue to grow well 2. If there is a growth problem, or a trend towards a problem (at risk), interview the mother to Identify possible causes of the problem and Provide information on Infant and young child feeding and if thing critical then referred to nearest hospital.

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Annex 1:

Observation Checklist Information collection and observation checklist for Exclusive breastfeeding for 0 – 180 days of child

Name of child: .............................. Age of child: ............................... Location:..................................

Mother’s name:..............................Father’s name: .......................................... Date:......................................

Supervisor will ask mother from A to C before starting counseling

Sl # Subject Yes No Comments

A When you start to breastfeed your child after delivery? (If mother response that just after delivery of within one hour of birth put tick mark in “Yes” column, otherwise “No” column)

B

What types of food you feed your child from birth to three days of child? (If mother response that “colostrums” put tick mark in “Yes” column. If mother response that “water / honey / sugar water / other milk” put tick mark in “No”)

C What types of food you feed your child in last 24 hour? (If mother response that only breast milk put tick mark in “Yes” otherwise put tick mark in “No”).

Now health service provider will counseling mother and do demonstration. Supervisor will observe the counseling session and fill up the following checklist from 1 - 10

1 Is the age of the child counted properly? (If needed use EPI card or based on other special event)

2 Does the health care provider confirm about exclusive breastfeeding?

3

Mother gets enough inspiration from the counselor about exclusive breast feeding (Not a single drop of water). Counselor support mother to understand about the difficulties of feeding other food except breast milk.

4 Health care provider assesses and counsels on positioning and attachment and provide hands on support that how to improve.

5

Health care provider discussed with mother that how mother can understand about enough milk for child like –

- Child will pass water at least six time in a day - Enough growth

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- Child will be happy and play - Sleep well.

6

Health care provider discussed with mother about producing and supplying enough breast milk for child like –

- Take enough time for feeding - Repeatedly feeding - Feeding at night - Don’t feed other food except breast milk

7

Health care provider discussed with mother about express breast milk like

- Thumb will on the top of the breast and other four fingers will under the breast. Press slightly and do it repeatedly

- Press in the middle of the skin of breast and areola. Don’t perss in nipple.

- Press different side of the breast like up, down, side etc - Continue expression up to 3 – 5 minutes. After finishing

one breast do the same for other breast.

8

Health care provider asked mother about difficulties of breast feeding like

- How to overcome the difficulties or refer health center. - Ask about support from other family member about

breast feeding

9 Health provider listened mothers’ concerns and difficulties by taking enough time.

10 Health care provider assess the understanding level about the above discussing issues

Please write here the important problems / difficulties of mother in here

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....................

..........................................................................................................................................................................

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Note: Observer gave feedback to the health provider in a friendly manner

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Annex 2:

Observation Checklist

Feeding complementary food with breastfeeding

Information collection and observation checklist for complementary feeding with breastfeeding for 6 – 24 month of child

Name of child: .............................. Age of child: ............................... Location:.................................

Mother’s name:..............................Father’s name: .......................................... Date:......................................

Supervisor will ask mother from A to C before starting counseling

Sl # Subject Yes No Comments

A In last 24 hour, what amount of food (show 250 ml bowl) you feed your child? (Write response in comments column)

B In last 24 hour, what types of food you feed your child? (Rice / Bread, Dal, Vegetables, Animal protein – Fish, Meat, Egg, Liver) (Write response in comments column)

C How and what amount of food you feed your child during sickness and after recover? (Write response in comments column)

Now health care provider will counseling mother and do demonstration. Supervisor will observe the counseling session and fill up the following checklist

1 Is the age of the child counted properly? (If needed use EPI card or based on other special event)

2 Health care provider ask mother about what types of food she feed her child?

3 Health care provider asks about the amount of food for the child.

4 Health care provider confirmed about age specific texture of food for child

5 Health care provider asked and counseled mother about preparing food for child using different 4 types of food.

6 Health care provider told mother about feeding at least one animal food (Fish, meat, egg, liver) from four types of food

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7

Health care provider demonstrate preparing food (Amount, Texture, at least one time one animal food fish / meat / egg) for child from that food which are already prepare or will prepare for family.

8

Health care provider discussed with mother about responsive feeding like

- Inspire child for eating - Don’t force the child - Provide nutritious food which s/he like - Feed when the child is hungry or wants to eat - Take time and be passionate - Don’t feed liquid food, biscuit, Juice or other food so

that s/he is full.

9

Health care provider discussed with mother about feeding during illness of child like

- Feed more time with small amount - Feed breast milk repeatedly - 7 – 10 days after recovery, feed child more than the

normal meal

10 Health care provider remind mother about hand washing with soap before preparing food for child and feed for child

11 Health care provider ask about support from other family member

12 Health care provider provide not more than 2 / 3 advice to mother during single visit

13 Health provider listened mothers’ concerns and difficulties by taking enough time.

14 Health care provider appreciate mother for her good practices.

15 Health care provider assess the understanding level about the above discussing issues

Please write here the important problems / difficulties of mother in here

........................................................................................................................................................................

......................

........................................................................................................................................................................

......................

Note: Observer gave feedback to the health provider in a friendly manner

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For more information, please contact: CARE Bangladesh Pragati Insurance Bhaban , 9th to 13th Floor, 20-21 Kawran Bazar, Dhaka-1000, Bangladesh. Phone: 88-02-9112315, Ex 347, Fax: + (880) 2 9118374, E-mail: info@bd.care.org, Website: www.carebangladesh.org