REPORT ON HEALTH CARE WORKERS TRAINING FOR NUTRITIONAL ASSESSMENT

OF TUBERCULOSIS (TB) PATIENTS

FOR KAKAMEGA COUNTY

DATES: 6th

to 10TH

SEPTEMBER, 2015

ACTIVITY …….5.1………..

VENUE: WESTGATE INN BUNGOMA

Florence Emali - CNC, KAKAMEGA

9/14/2015

Email: dmohkksouth@gmail.com When replying, please quote Ref. No: TR. 1 VOL. III/012

County Director for Health Services

Kakamega County, P.O. Box 359,

Kakamega.

Date: 14th September, 2015

MINISTRY OF HEALTH

Group photo of the participants outside Westgate Inn

Participants performing a role play of a nutrition counseling session

EXECUTIVE SUMMARY

The Nutrition in TB training was supported by NEPHAK. It was held for four days i.e. 7th

to 10th

September 2015. Participants were drawn from all the twelve sub counties of Kakamega County.

National training guidelines were used for the training. The goal of the training was to equip

health care workers with nutrition knowledge and skills needed to prevent and intervene on

uncomplicated nutrition problems.

Various teaching methodologies were used including lecture, discussion, demonstration role

plays e.t.c. The topics covered were :- background information and basics of TB, Leprosy, PAL

and lung disease burden in Kenya, Nutrition assessment, Nutrition care process in TB Leprosy

and lung disease, and Nutritional management of COPD, Key definitions, Food security, Food

and Drug interactions among others. Practical were done in class for assessments and

demonstrations of data tools. Field visit was also organized for the participants to Bugoma

County Hospital. The post test results showed that learning had taken place among the

participants as there was marked improvement. Participants then made an action plan. Some of

the activities done are captured in photos within this report.

INTRODUCTION/ BACKGROUND

Kakamega County has a projected population of 1,660651 and a population growth rate of 2.54%

(KNBS 2009) annually with the population density of 3,050.3 per square km. It is located in

Western part of Kenya that is predominantly Luhya tribe, and it borders Trans Nzioa County to

the North, Nandi County to the East, Vihiga County to the South and Busia County to the West.

It is made up of twelve sub counties which are as follows:- Likuyani, Lugari, Malava,

Navakholo, Lurambi, Shinyalu, Ikolomani, Khwisero, Butere, Mumias East, Mumias west and

Matungu.

County Health Indicators

Among the top ten causes of morbidity and mortality among children under five are

ARI/Pneumonia, and severe acute malnutrition. Among adults, the top ten causes of morbidity

and mortality are Diseases of the respiratory system, ARI/Pneumonia/TB, and malnutrition.

Major risk factors causing morbidity and mortality in County

Micronutrient deficiencies, sub optimal feeding practices, unsafe deliveries, malnutrition are

some of the top ten risk factors causing morbidity and mortality in the County.

Nutrition and TB indicators

There is a lot of under nutrition in Kakamega County. Stunting among children under five is at

28.4%. KDHS 2014, 10.3% of them were underweight

There has been a knowledge gap among health workers attending to TB and malnourished

clients. Some clients would be put on food supplements but not as per the standard guidelines.

This would mean that though the client responded on treatment and became smear negative, he

or she would still be wasted.

Table 1: Status of TB and Nutrition Related MDGs for Kakamega County

Goal Status

Goal 4:

To reduce child mortality

95/1000

Goal 5:

To improve maternal health

Maternal Mortality 531/100,000

Goal 6:

To combat HIV/AIDS, TB Malaria and

other diseases

HIV Prevalence (5.7%)

PMTCT Prevalence (8.2%)

TB cure rate (86.3%)

TB Case detection rate (46%)

Source: Kakamega County Nutrition Action Plan 2013/2014- 2017/2018

Introduction to the Training

Under nutrition increases the risk of tuberculosis and in turn tuberculosis can lead to

malnutrition. Under nutrition is therefore highly prevalent among people with tuberculosis. It has

been demonstrated that under nutrition is a risk factor for progression from tuberculosis infection

to active tuberculosis disease and that under nutrition at the time of diagnosis of active

tuberculosis is a predictor of increased risk of death and tuberculosis relapse.

The training was supported by NEPHAK and was held in Westgate Inn, Bungoma County. A

total of twenty-five participants attended the meeting. The cadres were: Clinical Officers, Nurses

and nutritionists as per the attendance list. Four facilitators were used at county and sub county

level, 2 NEPHAK officer- Olivia Khakasa and Arnold Otieno

The training used the standard guidelines that were sent from National office. A pre and posttest

was administered to determine the level of knowledge gained.

The meeting started at 9.00am with a word of prayer form Nancy Muyeka. Introductions were

done using a standardized format. Norms set, leaders from among the participants were elected

and rapporteurs for the various days were also identified.

Leaders/roles

The leaders selected were as follows:

Chairman Nancy Muyeka

Timekeeper Bernard Kinara

Energizer Tatuli Simwa

Spiritual Leader Leah Aliela

Norms

Norms established by the class to guide them for the four days were:

Phones on silent mode

Start and end with a word of prayer

Punctuality: start at 8.30 am and end at 5.00pm

Respect each other’s opinion

Active participation

Goal

The goal of the training was to equip health care workers with nutrition knowledge and skills

needed to prevent and intervene on uncomplicated nutrition problems.

Carry out the nutrition care process during a field visit

Identify available linkages and referral systems in existence

Monitor and evaluate nutrition activities in the program

Specific Objectives

At the end of this course participants were be able to:

Understand TB in terms of epidemiology, patho physiology, classification, diagnosis and

treatment/intervention

Identify clients with Leprosy

Understand the nutrition care process for in and out patients and its integration in TB

management

Identify available linkages and the referral systems in existence

Monitor and evaluate nutrition activities in the program

Carry out the nutrition care process during a field visit

Methodology

Various training methodologies were used with the participants. The sessions were very

interactive and the participants participated actively. These methods were:

Lecture: For majority of the session especially when giving new information

Discussion: Issues were discussed based on the actual events happening in the facilities

guided by the facilitator.

Participatory: Clients were involved in the presentations

Field Visit: Participants were divided into 2 groups and went to Bugoma County Hospital

where they visited the TB clinic, CCC and Nutrition department.

Practicals: Participants were divided into 4 groups of which they worked in throughout

the training Topics Covered

Day 1

Topics covered included Background information and basics of TB including the history, how it

is spread and the associated risk factors. This included prevalence. Classification, Diagnosis and

treatment of TB then followed in children, specialized areas,. Participants were then taken

through the relationship between TB and HIV. Drug resistance TB was then discussed including

its epidemiology, classification, diagnosis and medications. Practical Approach to Lung health

approach was then introduced. Lastly, participants were taken through how to identify a leprosy

case and medications to give.

Day 2

Introduction to nutrition. Various definitions and aspects of nutrition were covered. Macro and

micronutrients requirements including examples and sources were addressed using both the plate

model and food guide pyramid. Categories of malnutrition, pathophysiology of malnutrition,

relationship between TB and Malnutrition and the Nutrition care process were tackled. After tea

break nutrition assessment methods were done. This was followed by classification of nutritional

status based on the findings and how to write a PES statement under nutrition diagnosis. The

session also tackled various types of interventions and the recommended intervention for each

situation based on the cut off points. There was a counseling session role play by the participants.

Lastly participants took measurements for weight height MUAC waist and hip Circumference,

and calculated Waist Hip ratios, BMI and Z scores.

Day 3

During the morning session, food and drug interactions were covered. Various terminologies

were defined, metabolism of drugs, risks of food drug interactions, benefits of minimizing risks,

patients at risk and drug related risk factors, drugs that increase/decrease appetite, cause diarrhea,

raise blood sugar, how food and drugs interact including for those on enteral feeding using

specific examples of drugs available in facilities. Food and Nutrition security were defined, and

methods of assessing them explained including ways and actions to improve food security.

Follow up, types and its importance, importance and reasons for referral, linkages, networking,

how to net work and who to network with were also covered. The participants were taken

through the commodities available for management of malnutrition and what to give based on

the classifications and quantities including entry and exit criteria.

Day 4

Management of Asthma and COPD were covered. This focused on locally available foods that

alleviate and those that trigger. Monitoring and evaluation was introduced. Participants were

taken through all the tools and how to fill them. They were then taken through the nutrition

reporting tools including those that capture nutrition in TB management data. Participants were

taken to Bungoma County referral hospital in two groups. They visited the TB clinic and CCC to

ascertain the actual practices on the ground based on what they had learned in class. Feedback of

the visit was then done in class including group work for other assignments

ANNEX

LIST OF PARTICIPANTS

Name Sex Age Id /no. Phone no. Desgn Station

1 Mourine Ndombi F 28 24639859 0724151140 KRHN Mumias H/C

2 Lucy W. Kinuthia F 35 21722243 0723220117 NUT. O Malava C. Hosp

3 Grace N. Githuku F 30 24255055 0720238556 KRHN Bukaya H/C

4 Maureen Ndanyo F 40 12846130 0724445009 N.O Malava C.Hosp

5 Jackline S. Isuluti F 25 28625101 0719832497 NUT. O CGH

6 Irene Muhande F 30 22475587 0722998611 NUT. O Likuyani

SC/Hosp

7 Moreen Nandwa F 34 22472808 0723442635 NUT. O Lumakanda C.

Hosp.

8 Reuben Chivini M 43 1103269 0710640405 N.O Lumakanda C.

Hosp.

9 Priscillah M. Sheri F 42 13007817 0724956325 KECHN Khwisero H/C

10 Leah M. Aliela F 28 24748256 0720043126 NUT. O Matungu C. Hosp

11 Julia N. Wenani F 35 22385367 0710519573 N.O Navakholo SC.H

12 Anjelyne Were F 33 23356025 0705080832 KECHN Iguhu C. Hosp

13 Rose Cherop F 31 23109259 0727325242 R.C.O CGH

14 Rebeccah Tsalwa F 52 0933143 0720272919 N.O CGH

15 Benard Kinara M 31 24122228 0725354071 N.O Navakholo SCH

16 Musungu K. Lydia F 28 26631495 0715785951 NUT. O Matungu C. Hosp

17 Renson L. Bulinya M 53 7956787 0711228298 KRN Shinyalu H/C

18 Linda Litunya F 28 25185785 0729872675 NUT.O Khwisero H/C

19 Nancy M. Muchuta F 30 23912383 0727944684 NUT.O Butere CH

20 Vincent O. Oronyi M 29 24799252 0710484389 N.O Ileho H/C

21 Noel Khatiala F 34 22073227 0722278768 NUT.O Butere CH

22 Tatuli Simwa M 25 27864696 0723601188 RCO Lusheya H/C

23 Odhiambo Collin M 26 276813 0719822558 RCO Makunga H/C

24 Florence N. Mutura F 54 3857378 0712317549 N.O Likuyani SCH

25 Milcah Onzere F 28 24606897 0726089540 NUT.O Iguhu CH

26 Emilly Vuguza F 40 21619545 0712984762 SCTLC CGH Lurambi

27 Josina Sikolia F 44 11041465 0712799063 SC.NUT.O Iguhu CH

Ikolomani

28 Andole L. Mwale M 58 2573150 0722446868 CTLC CGH Kakamega

29 Florence E. Amakobe F 45 9625418 0724389904 CNUT.O CDH Kakamega

30 Olivia Khakasa F 30 24100864 0725315860 P.A NEPHAK

Kakamega

31 Arnold Otieno M 32 23147262 0721808523 P.O NEPHAK

Pre and Post Test Results

All the sessions had 100% attendance since the participants had earlier been prepared and

advices to avoid missing sessions.

PRE & POST–TEST ANALYSIS

CODE PRE TEST POST TEST VARIANCE

1 50 88 38

2 60 77 17

3 57 87 30

4 40 90 50

5 63 67 4

6 53 83 30

7 40 67 27

8 43 87 44

9 40 73 33

10 50 67 17

11 53 80 27

12 40 63 23

13 47 73 26

14 57 87 30

15 50 80 30

16 50 60 10

17 57 90 33

18 63 70 7

19 57 70 13

20 53 80 27

21 40 83 43

22 43 70 27

23 33 67 34

24 40 90 50

25 77 93 16

MEAN SCORE 50.24 77.68 27.44

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Pe

rce

nta

ge %

Code

Chart Title

Series1

Series2

Series3

Challenges/ Constraints

Participants said that they still experience some erratic supply of nutrition supplements

Venue- there were a number of complaints raised by the participants. Food wasn’t

enough at some meals, some rooms had electrical flame e.t.c. The hotel manager

addressed some of the issues.

Some pages in the participants handouts could not be read as they print outs were too

small. This presented a challenge as some of it could have been used as a job aid in the

facilities.

Recommendations and Action Plans

Objective Activity Time Who indicator Resources

To

indensify

nutrition

assessment

and

effectively

manage all

TB clients

Feedback 30/09/15 Trained

staff

Minutes

Registration

list

Manual

Reference

cards

Registers

CME and OJT Continuous Trained

staff

Report

Attendance

list

Stationery

Manual

Improve and

Intensify taking

of

anthropometric

measurements

in patients

Continuous Focal

Person

Reporting

tools

No. assessed

as per tally

and nutrition

registers

Anthropometric

equipment

Human

resource

Manage the

malnourished

clients as per

the guidelines

Continuous Focal

Person

No.

adequately

managed

Nutrition

supplements

Reporting tools

Monitoring and

Evaluation

Continuous Focal

Person

No. of reports Registers

Reporting

forms

Annex 3: Training evaluation form

Please tell us how satisfied or dissatisfied you were with the following.

1) How satisfied were you with the registration process?

Very Dissatisfied

Dissatisfied 4

Satisfied 14

Very Satisfied 6

2) How satisfied were you with the training materials provided?

Very Dissatisfied

Dissatisfied

Satisfied 16

Very Satisfied 8

3) Overall, how satisfied were you with the speakers / presenters?

Very Dissatisfied

Dissatisfied

Satisfied 6

Very Satisfied 18

4) Overall, how satisfied were you with the conference facilities?

Very Dissatisfied

Dissatisfied 17

Satisfied 6

Very Satisfied 1

5) How many sessions did you attend? 24

6) Did you feel the length of conference sessions were too long, just about right, or too short?

Too long 1

Just about right 19

Too short 4

Please tell us how much you agree or disagree with the following statements.

7) The content of conference sessions was appropriate and informative.

Strongly Disagree

Disagree

Agree 18

Strongly Agree 6

8) The conference was well organized.

Strongly Disagree

Disagree 3

Agree 17

Strongly Agree 4

9) Conference staff was helpful and courteous.

Strongly Disagree 2

Disagree 2

Agree 15

Strongly Agree 5

10) What kinds of sessions would you like to see included at future conferences? -------------------

allocate more time 5days 15

No response 4

Perdiem/half board 3

More practical 2

ANNEX 5: PRE AND POST TEST

Code: _________________________________________

Pre and Post -course questionnaire

Circle the correct answer

1. Which one is not the aim of treating is TB?

A. To cure patient of TB

B. To prevent death from TB

C. To decrease TB transmission

D. To prolong life

2. Apart from one all the following are roles of nutrition service provider at the TB clinic

A. Weight monitoring

B. HIV testing for all TB patients

C. Counseling on nutrition and TB

D. Meal-drug planning

3. Name the factors that contribute to DR TB

Provider risk factors Patient risk factors

Programmatic risk factors

4. List the 3 hierarchy’s of TB infection prevention and control

Administrative controls

Environmental (engineering) controls

Respiratory protection

5. Name the two groups of WHO classification for Leprosy

Pauci-bacillary leprosy Multi-bacillary leprosy (MB)

6. Nutrition as an essential complementary intervention to anti-Tb therapy will NOT

enhance

A. Food drug interactions

B. Patient rehabilitation

C. The immunity

D. Adherence anti-Tb drugs

7. All TB patients with BMI <16kg/m2 should be put on.

A. Therapeutic feeds

B. High protein diet

C. Supplementary feeds

D. General food ration

8. These are some of actions that improve food insecurity, which one is not?

A. Promote production and consumption of indigenous foods

B. Provide short term food assistance

C. Provision of anti Tb drugs

D. Link households to programs and organizations (CBOs, FBOs, NGOs, GOK) that

provide services on food/nutrition security

TRUE (T) or FALSE (F)

1. Monthly nutritional assessment is a critical nutrition action to people with Tb. T

2. Tb patients should carry out vigorous physical activity or exercises to strengthen or build

muscles, increase appetite and health. F

3. Those on medication should be informed about managing the drug-food interactions and

side effects that can be managed by food and nutrition interventions. T

4. Loss of body weight may also be a side effect of anti-Tb therapy. T

5. Individuals with a BMI less than 18.5 kg/m², indicates under-nutrition and a high risk of

illness and require hospitalization. F

6. Monitoring and evaluation of nutrition interventions for TB patients helps to assess the

degree to which progress is made T

Short answers

7. Explain the relationship between Tb and malnutrition (4marks)

8. Outline steps in nutrition care process for TB patients (4marks)

a. Nutrition Assessment b. Nutrition Diagnosis c. Nutrition Intervention d. Monitoring and Evaluation

9. List different ways of nutrition assessments ( 6marks)

a) Anthropometric measurements b) Biochemical assessments c) Clinical assessment (signs of deficiencies) d) Dietary ( 24 hour recall, food diary,) e) Economic and social status f) Functional

ANNEX 6: TIMETABLE

NUTRITION IN TB TRAINING PROGRAMME

DAY ONE

TIME PRESENTATION/ GROUOP TIME FACILITATOR ACTIVITIES

8.00-8.15 am Registration 15 minutes

8.15-8.45 am Introduction

Participants expectations, norms, group leaders for each day

30 minutes

8.45-9:15 am Opening Remarks Course overview, Objectives of the course,

30 minutes

9:15-9:45 pretest 30minutes

9:45-10:30 • Background information and Basics of TB

45 minutes

TEA BREAK

10:30- 10:45am Classification, diagnosis and treatment of TB 1hour

10.45 -11.15am TB/ HIV relationship 30 minutes

11.15- 11:45am Drug resistance TB 30minutes

11:45-1:00pm PAL 1hour 15 minutes

LEPROSY

1.00-2.00 pm LUNCH

2.00 – 2.25pm Infection prevention and control 25 minutes

2.25- 2:55pm 30 minutes

3:00 – 3:30pm 30 minutes

3:30-4:00pm Introduction to nutrition 30 minutes

4.00-4.30 TEA BREAK

DAY TWO

TIME PRESENTATION TIME FACILITATOR ACTIVITIES

8.00-8.15 am Prayer, Recap 15 minutes

8:15-8:45am Introduction to nutrition and definitions 30minutes

8.45-9:15am Patho physiology of malnutrition 30minutes

9:15-10:00am Relationship between nutrition, leprosy, TB and lung

disease

45minutes

10:00-

10:15am

The link between nutrition and TB 15Minutes

10:15-

10:30am

The consequences of malnutrition in TB 15Minutes

10.30-11.00

am TEA BREAK

11.00 -

11:20am

Role of nutrition in leprosy 20 minutes

11;20-12-

05pm

Introduction to nutrition care process in TB

management

45minutes

12:05-1:00pm Nutrition assessment 55minutes

1.00-2.00 pm LUNCH

2:00 –5;00 pm Nutrition assessment practical 3hours

DAY THREE

TIME PRESENTATION FACILITATOR ACTIVITIES

8.00-8.15 am Prayer, Recap 15 minutes

8.15-9:15am Food- drug interactions 1 hour

9:15-10:00am Food and nutrition security in relation to TB 45Minutes

10.00-10.30 am

TEA BREAK

10.30-11.45 am Nutrition commodities in relation to TB 1 hour 15 min

11.45-1.00 pm Dietary management of lung disease 1 hour 15 min

1.00-2.00 pm LUNCH

2.00-3.00 pm Monitoring and Evaluation in Nutrition and TB 1 hour

3.00-4.00pm Identification, accuracy and completion of M&E

tools in DLTLD

1 hour

4.00 –5.00 pm Discussions

4.30 – 5.00 pm TEA BREAK

DAY FOUR

TIME PRESENTATION FACILITATOR ACTIVITIES

8.00-8.30 am Prayer and Recap 30 min

8.30-10.00 am Preparation steps 1 hour 15 min

TEA BREAK

10.30 -1.00pm Field Visit 2 hours 30 min

1.00-2.00 pm LUNCH

2.00 – 4.00 pm Post-test and Closing 2 hours

4.00-4.30 TEA BREAK

One of the participants receives her certificate from the CNC

Energizer session

Report by:

Florence Emali, CNC, Kakamega County

Signed:__________________________ Stamped:___________________________________

Andole Mwale, CTLC Kakamega County

Signed:______________________________Stamped:_________________________________

Report Received by NEPHAK