Use of Mentoring Relationships to Build Capacity for Multisectoral Nutrition Systems

What is the Issue?

Fifty-four countries are taking part in the Scaling Up Nutrition (SUN) movement, and are putting plans and strategies in place to use a multisectoral approach to reduce chronic malnutrition. Much attention in SUN has been dedicated to raising awareness, obtaining commitments, and coordinating stakeholders at the global and national levels. Although multisectoral nutrition policies continue to roll out, there is little information to date on how it is functioning below the regional level and how it is impacting communities.

SUN countriesTanzania has become one of the leading nations within the SUN MOVEMENT with a strong, progressive National Nutrition Strategy and growing commitment to nutrition across nine key ministries. In order to continue to raise the profile of nutrition and improve nutrition outcomes, it is paramount to support the newly created position of the District Nutrition Officer (DNuO) and ensure that the current scopes of practice, supervisory and reporting structures, technical capacities, and relationships among district officers and diverse cadres are aligned in strong and efficient ways to meet nutrition goals.

What do we aim to achieve?

Cornell researchers have partnered with representatives from five leading Tanzanian institutions and have jointly developed a strong action plan during a 2-week Collaborative Nutrition Workshop held at Cornell in Oct 2015.

Overall this project aims to increase knowledge at the district level in optimal approaches for:

 (1) Involving multiple sectors in addressing nutrition priorities; (2) Coordinating nutrition programming among the various sectors; and (3) Increasing the capacity to deliver effective nutrition interventions at the district and community levels.

Tz3

(From left) Haikael Martin, Mary Mosha, Sia Msuya and Clara Mollay discuss how to build capacity for District Nutrition Officers in Tanzania

This team will build and support the Tanzanian nutrition system in two rural districts, advocating for multisectoral action by establishing and supporting beneficial relationships between academic institutions, district officers, and natural community leaders.  To do this, we will:

  • Strengthen the capacity of the District Nutrition Officer (DNuO) to teach, support and advocate for nutrition activities within the district.
  • Collaboratively identify key areas to strengthen to increase nutrition capacity including the promotion of community-driven and community-led interventions.
  • Mentor the DNuO to identify key strengths and weaknesses and come up with tailored plans to capitalize on the strengths and minimize the weaknesses.

Experts from Kilimanjaro Christian Medical University College (KCMUCo), Nelson Mandela African Institution of Science and Technology (NM-AIST), Sokoine University of Agriculture (SUA), Muhimbili University of Health and Allied Sciences (MUHAS), and the Tanzanian Food and Nutrition Centre (TFNC) are structuring mentorship teams to be embedded in these 2 rural districts, and are systematically documenting their actions and outcomes, as a basis for recommending larger scale support to the local nutrition system throughout Tanzania.

Frequently asked questions: How can lessons learned from prenatal iron and folic acid supplementation inform new calcium supplementation initiatives?

Preeclampsia/eclampsia is one of the leading causes of maternal deaths worldwide. The WHO now recommends prenatal calcium supplementation for the prevention of preeclampsia in areas where calcium intake is low.

These recommendations are an important first step in preventing unnecessary deaths but there is little information to help policy and program planners determine how to put the recommendations on calcium into practice in communities. The Micronutrient Initiative and Cornell University’s FAQs for calcium supplementation are now available to assist countries and organizations looking to work to implement calcium supplementation programs.

View the Prenatal Calcium and Iron Folic Acid FAQs

Meet our “Building Strong Nutrition Systems” field research team in Tanzania!

Meet our “Building Strong Nutrition Systems” field research team in Tanzania!

BSNS formative res team

Left to right: Pili, Clara, Mary, Dorah, Akwilina, Julius and Rune

Workshops for the formative research stage are underway for the Building Strong Nutrition Systems in Tanzania!

Meet our fabulous field research team, shown here during pretesting in Marangu, Tanzania.

Fieldwork, Research, and Thick Onions

Fieldwork, Research, and Thick Onions

From Hope Craig

It’s hard to believe that nine weeks have passed since we stumbled, wide-eyed and eager, onto the Keystone campus in January. Looking back on our first week in Kotagiri, I can’t help but smile thinking of the awe and curiosity with which we readily soaked in the beauty of the Nilgiris hills, the warmth of the Keystone community, and every inkling of newness that Kotagiri offered. There were many novelties, and there still are! Nonetheless, it’s amazing to me how much has changed since our first day: how familiar we are with the area, how closely we have connected with one another, and how comfortable we have become with the routine unpredictability of each day. Though we have become so accustomed to our lives in Kotagiri, there are many questions and uncertainties that remain for the weeks ahead.

Craig_IMG_1593-1usnh26

With Becky, Jess, Andrew, Archana, Pratim, and Bala all here with us this week, it’s safe to say our classroom has been a powerhouse as we prepare to embrace the thick description of the weeks ahead. We began the week with momentum as we voiced our research goals, reviewed informed consent processes, and discussed research sites and household surveys for the weeks to come. Ranging from topics in infant feeding and dietary diversity to the Forest Rights Act or waste management, our research areas cover a variety of perspectives and concentrations in the Nilgiris Biosphere Reserve. I’m eager to embrace our coming weeks to try and better understand the many webs of meanings that layer and overlap our distinct research areas.

Among the many things this week has shown us, what strikes me most is the value of the naivety that remains a leading influence on our outlook and perspective. This was a leading message of Becky’s lectures this week. Though the complex and nuanced nature of the NBR continues to deepen (or as we would joke in class, our onion develops more layers of meaning), our mutual curiosity and interest in and out of the classroom provide a method of sharing knowledge and experiences. Seemingly endless, our questions stream during interviews and class discussions as we determinedly try to understand the thick description surrounding us.

Until this week, I had considered our naivety to be a disadvantage as we remained ignorant to much of the meaning underlying what we observed. After our field site visit to Gethaikadu earlier this week, however, I found that naivety and curiosity allowed me and my classmates to try to understand the deeper meaning underlying what we observed, heard, and felt. As we embark on part two of the semester, the novelty of our experiences has largely been renewed as step foot into the unchartered waters of fieldwork that lie ahead.

Coping with the uncertainty of the weeks to come, I am comforted by the tangible passion I share with my classmates and teachers, and am eager to continue to ‘peel the onion’ even if only one layer at a time.

 Read more student blogs from NFLC

Understanding medication non-adherence

Understanding medication non-adherence

From Gina Chapleau

Insights about patient-provider dialogue from research on prenatal calcium and iron-folic acid supplementation.

Many of CENTIR’s health projects focus on nutrition initiatives to improve maternal health and child survival. Taking micronutrient supplements in pregnancy has many health benefits and can protect women from developing dangerous conditions in pregnancy. In our global work, we’ve noticed that the behavior around taking (or not taking) supplements over time is — without question — a complicated process.

Two basic facts about the nature of non-adherence must be understood:

  1. Non-adherence arises from individual, community, and societal factors which are difficult to disentangle and classify during patient-provider consultation.
  2. The methods used to understand non-adherence and the dialogue used to address it are skills seldom found in formal health provider training.

Scientific evidence shows that programs and health systems that promote micronutrient supplements in pregnancy must target women’s own understanding of their health conditions and their prescribed treatment. Only when these two pillars are addressed can researchers and health practitioners begin to understand the behaviors associated with non-adherence.

In our research conducted in Kenya and Ethiopia in 2014, we provided pregnant women with calcium and iron folic-acid (IFA) supplements. We interviewed the participating women to better understand their experiences with the supplements, their knowledge and beliefs about the health conditions the supplements prevent, and their adherence behavior over a period of six weeks.

Calcium supplementation in Ethiopia

In-depth interview on experiences with calcium and iron-folic acid supplementation

 

We are learning just how complex the dialogue is around understanding and addressing non-adherence. For example, if a woman reports occasionally forgetting to take calcium, the cause for forgetting is ambiguous. Is the difficulty that she genuinely has trouble remembering? Alternatively, she may just be unconvinced about the benefits of calcium or she may not feel susceptible to the conditions calcium prevents. Such beliefs can result in a loose commitment to the recommended regimen, and occasional “forgetting” becomes an automated response.

In conducting interviews it has been interesting to see how difficult it is to effectively isolate each concern, and to assess whether the interviewee herself is fully aware of her reason for not wanting to take the calcium, and whether she is willing to answer honestly about the cause of her forgetful behavior.

In another example, a woman may decide not to take calcium either because she is asymptomatic and ‘feels fine’, or because she has concerns about side-effects and ‘feels sick after starting to take’. In these cases, how can the health provider engage in a dialogue where the patient’s perceptions are not merely dismissed and corrected, but where solutions are created collaboratively?

We know from decades of evidence that inadequate delivery of education, lack of training, lack of consultation time, and insufficient knowledge are related to lower utilization of medications. Yet these problems which surface within the patient-provider dialogue are not being addressed in a systematic and comprehensive way.

In order to create an integrated calcium and IFA supplementation program that is feasible to implement and that will maximize adherence, further research will build upon ours by investigating how the provider-patient dialogue can be improved in clinical practice. This dialogue must consider what approaches are most effective in determining an individual’s underlying beliefs in a respectful, caring and motivating way to improve pregnancy outcomes.

We are aware of many traditional and emerging strategies for optimizing medication adherence, including social support and reminder programs, innovations in packaging, and engagement with new technologies. However, it is our belief that a fundamental step for addressing the problem of non-adherence is to improve the execution of behavior change communication and incorporate personalized patient-focused dialogue into clinical practice.

Where do you think the most strategic opportunities lie in maximizing adherence and why?