Blended Integrated Nutrition Learning Module (BINLM) - USAID

Feed the Future Ethiopia Growth through Nutrition Activity

Blended Integrated Nutrition Learning Module (BINLM):

Review of training material, training approach, knowledge

and skill retention among participants and related factors

March 2019

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Contents List of Tables and Figures ....................................................................................................................... 2 Acronym ..................................................................................................................................................... 4 Acknowledgement ................................................................................................................................... 4 Executive Summary ................................................................................................................................. 5 Background and Rationale ..................................................................................................................... 8 Objective .................................................................................................................................................... 9 Methods ...................................................................................................................................................... 9 Result ......................................................................................................................................................... 12

1. Material Review........................................................................................................................... 12 1.1. Introduction Module .......................................................................................................... 12 1.2. Micronutrient Module ........................................................................................................ 13 1.3. Adolescent, Maternal, Infant and Young Child Nutrition ......................................... 14 1.4. Acute Malnutrition Module .............................................................................................. 14 1.5. Nutrition in Communicable, Non-communicable Diseases and Special Health

Conditions ........................................................................................................................................ 16 1.6. Nutrition Program Management .................................................................................... 16

2. Review of Training Approach .................................................................................................. 17 3. Knowledge and skill retention among trained health workers ........................................ 21

3.1. General Characteristics of Respondents ....................................................................... 21 3.2. Introduction Module .......................................................................................................... 22 3.3. Micronutrient Module ........................................................................................................ 23 3.4. AMIYCN Module ................................................................................................................ 24 3.5. Acute Malnutrition Module .............................................................................................. 25 3.6. Nutrition and Communicable Diseases Module.......................................................... 27 3.7. Program management ...................................................................................................... 27

4. Potential personal and institutional factors contributing to training effectiveness and

health workers’ preferences ............................................................................................................ 28

Conclusion .................................................................................................................................................. 31 Recommendations ..................................................................................................................................... 33 Annexes ...................................................................................................................................................... 34

Annex I: Material Review Checklist ......................................................................................................... 34 Annex II: Knowledge and Related Factors Assessment Questionnaire .................................................. 37 Annex III: Skill Assessment Questionnaire .............................................................................................. 48 Annex IV: Observation Guide at Health Facility Level ............................................................................. 51 Annex V: Semi-structured KII Guide........................................................................................................ 55 Annex VI: Frequency tables of aggregated score of study participants for each module and general scores ...................................................................................................................................................... 58

List of Tables and Figures

Table 1: Major findings from Introduction Module review, September 2018 ........................................... 12

Table 2: Major findings from Micronutrient module review, September 2018. ........................................ 13

Table 3: Major findings from the AMIYCN Module review, September 2018 ............................................ 14

Table 4: Major findings from the Acute Malnutrition Module review, September 2018 .......................... 15

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Table 5: Major findings from Nutrition in Diseases and Special Health Conditions Module review,

September 2018 .......................................................................................................................................... 16

Table 6: Major findings from Nutrition Program Management Module review, September 2018 ........... 17

Table 7: Variations in attendance of knowledge and skill session among surveyed health workers in the

four regions, October 2018 ......................................................................................................................... 18

Table 8: General characteristics of health workers who participated in the study in the four regions,

October 2018 .............................................................................................................................................. 22

Table 9: Proportion of health workers who performed tasks listed in conducting prioritized skill in the

micronutrient module in the four regions, October 2018 .......................................................................... 24


AMIYCN module in the four regions, October 2018 ................................................................................... 25


MUAC measurement in the four regions, October 2018 ............................................................................ 26

Table 12: Proportion of health workers who performed expected tasks during preparation of F-75 and F-

100, October 2018 ...................................................................................................................................... 28

Table 13: Proportion of health workers who responded to potential individual attributes that can affect

delivery of BINLM training, October 2018 .................................................................................................. 29

Table 14: Proportion of health centers with key inputs for quality delivery of BINLM and subsequent

knowledge and skill retention, October 2018 ............................................................................................ 30

Table 15: Proportion of health centers with key inputs for quality delivery of BINLM and subsequent

knowledge and skill retention, October 2018 ............................................................................................ 30

Figure 1: Proportion of BINLM trained health workers who responded correctly for undernutrition

related questions in the four regions, October 2018 ................................................................................. 22

Figure 2: Percentage of BINLM trained health workers who responded correctly for selected question

from the micronutrient module in the four regions, October 2018 ........................................................... 23


from the AMIYCN module in the four regions, October 2018 .................................................................... 24


from the Acute Malnutrition module in the four regions, October 2018 .................................................. 26





Figure 7: Percentage of BINLM trained health workers who shared to colleagues, October 2018 ........... 29

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Acronym

AMIYCN Adolescent, Maternal, infant and Young Child Nutrition

BINLM Blended, integrated Nutrition Learning Module

PHCU Primary Health Care Unit

FMoH Federal Ministry of Health

KII Key Informant Interview

e-based Electronic based

SNNPR Southern Nations nationalities and Peoples Regional State

SURE Sustainable Undernutrition Reduction in Ethiopia

ENGINE Empowering the New Generation to Improve Nutrition and Economic opportunities

NNP National Nutrition Program

NGO Non-governmental Organization

UNICEF United Nations Children’s Fund

WaSH Water, Sanitation and Hygiene

HC Health Center

HW Health Worker

ToT Training of Trainers

RHB Regional Health Bureau

WrHO Woreda Health Office

CD Computer Disc

TVET Technical and Vocational Education and Training

ICT Information and Communication Technology

OTP Outpatient Therapeutic Program

SC Stabilization Center

MUAC Mid-upper Arm Circumference

F-75, F-100 Therapeutic milks for children admitted to health centers as in-patient

Acknowledgement

We are thankful to the Nutrition Case Team of FMoH for its determination to see this task concluded

before the start of BINLM revision and supported it from inception to completion. The support letter

from the Ministry and presence of two members of the case team as supervisors during data collection

facilitated the whole process. Our thanks also goes to the members of the technical working group who

participated in the initial meeting called by the nutrition case team and forwarded valuable feedback on

the study methods and tools. The role of the study coordinators and nutrition experts, who engaged in

final revisions of the study tools, as reviewers of the modules and in data collection on the ground, was

central to the success of this task and they deserve huge appreciation. This assessment would not also

come to fruition without participation and genuine reflections of KII respondents from regional health

bureau, woreda health offices, nutrition partners as well as health workers. Let our heartfelt gratitude

reach them.

We believe this output is a step towards ensuring that those mothers and children who visited our

health centers today, seeking for quality health services yet missed some elements, are to enjoy much

better services when they come back tomorrow.

Growth through Nutrition Activity

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Executive Summary

Background: The National Nutrition Program (NNP) II of Ethiopia specifically recommends provision

of in-service nutrition trainings to health workers through use of blended integrated nutrition learning

module (BINLM). The blended training approach combines self-paced, e-based knowledge sessions

learning with face-to-face learning focused on practical sessions while ‘integration’ brings multiple

training modules that used to be delivered separately, into one package. The modules include, an

introduction; Micronutrients; Adolescent, Maternal, Infant and Young Child Nutrition; Management of

Acute Malnutrition; Nutrition in Communicable, Non-Communicable Diseases and Special Health

Conditions and Nutrition Program Management.

Since its endorsement in 2015, FMoH, regional health bureaus and partners have applied this

standardized approach to deliver in-service nutrition training to health workers. Growth through

Nutrition is one of the multi-regional nutrition projects that adhere to this standard approach to build

capacity of health workers at PHCUs jointly with health authorities at different levels. Its predecessor

project, ENGINE, has also contributed to the development and finalization of BINLM. In 2017 and early

2018, Growth through Nutrition has provided training to more than 1100 health workers.

Rationale and Objectives: As the BINLM-based training gets rolled out across regions, however,

challenges related to its unique features of being ‘e-based’ and ‘integrated’ started surfacing out from

anecdotal reports of nutrition program implementers and preliminary assessment conducted by

Transform PHC. Hence, in discussion with FMoH that planned to revise the training material in 2019/20,

Growth through Nutrition conducted an operational research with the aim of ensuring effectiveness of

BINLM training. Specific objectives of the assessment included; to review all courses in the module, to

evaluate adherence of trainings conducted so far to the recommended approach, assessing knowledge

and skill retention among health workers trained and to identify potential individual and institutional

factors that contribute to the effectiveness of the training.

Methods: The operational research was a cross-sectional survey that applied mixed qualitative and

quantitative methods. In September and October 2018, Growth through Nutrition discussed on the

methods and tools with FMoH and nutrition partners and started the BINLM material review by

recruiting ten technical experts who worked as BINLM master trainers for the past two years. The

experts applied uniform checklist to review multiple attributes of the training module including its

design, content, user-friendliness and assessment mechanisms. After finalizing the desk review, experts

were deployed to Amhara, Oromiya, SNNPR and Tigray to conduct KII among purposively selected

regional and woreda nutrition focal persons on delivery of BINLM trainings, and to review training

reports. Led by principal investigator and two study coordinators from Save the Children, the reviewers

conducted a quantitative survey to assess knowledge and skill retention among health workers within a

year after taking BINLM training. The survey covered 127 health workers from 51 health centers in the

four regions. Experts also conducted observation of health facilities using a checklist. Data from

qualitative assessment were summarized into frequently appearing themes and quantitative data was

entered into SPSS 20.0, cleaned and analyzed using descriptive statistics.

Findings: Training material review component of the assessment has identified both strengths and areas

of improvement. Most of the courses were reported to have clear learning outcomes, contents aligned

with learning outcomes and proper assessment mechanism. Commonly reported gaps included bulkiness

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of specific courses, lack of readily downloadable/alternative content materials, outdated epidemiological

content, initiatives and programs; failure to show linkage between knowledge and skill sessions; slow

navigability and freezing presentation slides. Reading speed and pronunciation of the narrator and

relevance of courses such as the Program Management course to nutrition service providers were also

suggested to be re-considered.

Regarding evaluation of adherence to recommended training approaches in trainings conducted so far,

variation in delivery was observed across regions and zones within regions. Reported practices included;

ToTs tended to adhere to recommended duration and self-paced approach, but not most of the cascade

trainings. More than a quarter of skill session participants were not asked for knowledge course

certificates before proceeding to skill sessions. Both knowledge and skill sessions were consecutively

facilitated in a single event. And, skill sessions were in some cases facilitated in venues that did not allow

for adequate practical exercise.

Assessment of individual and institutional factors showed gaps that can contribute to training

effectiveness. Nearly half (49.2%) of the health workers lacked basic computer skills. They could access

computer either sometimes (57%) or not at all (22%). Slightly higher than one in ten of the participants

rated their English proficiency as low and thus could miss some spoken or written language. At health

facility level, a tenth of the health centers where trainees were from lacked electric power and slightly

more (14%) functional computers. Observation findings disclosed absence of stabilization centers in

more than half of the facilities, lack of anthropometric measurement tool – length/height board in 55% of

the HCs, counseling materials and therapeutic foods. Institutional culture as characterized by not

supervising training sessions and limited coaching and mentoring practices in the health system were also

cited to affect retention of basic knowledge and skill elements among the trained.

Finally, analysis of knowledge and skill retention in all components of the training module among trained

health workers trained has brought up findings that demand immediate attention. More than half of the

participants (56%) could not score equal to or above the half mark, 50%, for the entire knowledge

module. Similarly, significant proportion of them failed to perform recommended skill tests/tasks for

major nutrition services such as anthropometric measurement, nutrition counseling and therapeutic milk

preparation.

Recommendations:

When working on BINLM material revision:

Use gaps identified and recommendations from course reviewers as general guidance alongside

applying the review checklist to complement and enrich their outputs

Go beyond reviewing and revising technical content of knowledge session by paying equal attention

to other attributes of the training material including the skill sessions. Use of the review checklist at

the start of the revision process helps for this purpose

While addressing specific technical content of specific courses, technical working groups also need

to equally work on commonly identified areas of improvement including:

o Availing of alternative learning tools

o Reducing the bulk of course material by focusing on practical aspects

o Modulating the speed of the narrator and check for pronunciation related complaints

o Linking knowledge sessions with skill training by alerting participants on areas they should

focus at

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o Setting minimum quality standards for skill sessions including recommending venue,

minimum duration and expertise/experience of facilitators

o Incorporating tips for sharing knowledge and skills and also including sharing of acquired

competencies as one objective of the training

On training delivery approach:

If health authorities are to apply different approaches pressed by the local context, different

approaches for integrated training need to be pre identified and

o Minimum quality standards should be set for the alternatives to which training

organizers that opted for these alternatives must adhere.

o Training guides (Training facilitation tips) for alternatives such as; computer-based group

sessions, which is one of the alternatives approaches currently mostly practiced, need to

be prepared

Compulsory completion of the entire package also need to be weighed against need-based

specific course training attendance

Training sessions need to be supervised by higher level authorities for fulfilling minimum

standards

Technical report of trainings need to be availed by implementing partners as it helps to audit

quality

To address potential individual and institutional factors that affect effectiveness:

Identify and support trainees that require tutoring to go through knowledge sessions

Provide need-based coaching and mentoring

Design alternative training approach, as recommended above, that lack essential amenities

(electric power, computer access)

On case-by-case basis address key gaps of health centers that lack essential services and

basic equipment/supplies that affect overall health service quality

Addressing the broader context and further investigation:

Continue working to improve quality of pre-service nutrition education

Instill the culture of e-based learning during pre-service education

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Background and Rationale

The National Nutrition Program (NNP) II of Ethiopia underlines the need for providing competency-based

capacity building to health professionals to operationalize nutrition initiatives of the health sector,

effectively. The program specifically recommends provision of in-service trainings to health workers

through use of blended integrated nutrition learning material (BINLM). The blended training approach

combines self-paced, e-based learning with face-to-face learning while ‘integration’ brings multiple training

modules that used to be delivered separately, into one package.

In Ethiopia, the blended and integrated nutrition learning material was finalized and endorsed by Federal

Ministry of Health (FMoH) in 2015. It comprises of an e- (computer)-based self-learning that takes 10-21

days and a face-to-face skills training of 5 days. The modules include, an introduction; Micronutrients;

Adolescent, Maternal, Infant and Young Child Nutrition; Management of Acute Malnutrition; Nutrition in

Communicable, Non-Communicable Diseases and Special Health Conditions and Nutrition Program

Management.

Currently, most nutrition stakeholders supporting nutrition-related in-service trainings of health workers

in Ethiopia apply the BINLM based approach. Growth through Nutrition is one of the multi-regional

nutrition projects that adhere to this standard approach. A USAID-funded multisectoral nutrition project

(2016-2021) that aims to reduce stunting by supporting multiple sectors to implement their roles in the

NNP. The project, led by Save the Children Ethiopia and run in partnership with international and local

NGOs1, is being implemented in 102 woredas across four regions; Amhara, Oromiya, SNNPR and Tigray.

It primarily targets mothers and children in ‘the first 1000 days’ through supportive agriculture/livelihood,

WASH, SBCC, nutrition-specific and multisectoral nutrition coordination efforts that mainstream gender,

research and learning and strategic coordination with other nutrition related projects. Need-based

capacity building to health workers in project-targeted woredas by using standard training approach is one

of the major activities that it carries out with the health sector.

Growth through Nutrition continued supporting the BINLM training approach by building off the technical

role of its predecessor project (ENGINE, 2011-2016) played to the development and finalization of the

blended learning material. By March 2018, through application of the recommended training approach and

using ToT trained facilitators from the health sector, Growth through Nutrition provided BINLM-based

training to more than 1100 health workers across the four intervention regions.

As the BINLM-based training gets rolled out across regions, however, challenges related to its unique

features of being ‘e-based’ and ‘integrated’ started surfacing out. Electricity coverage and access to

computers including computer skill of potential trainees, which are key elements for completing the

knowledge part of the training, started posing challenges in some areas. This was reported to force training

organizers to shift training approach back to the traditional way of inviting trainees to where they can

access computers together. Secondly, the ‘integrated’ approach that brings separate trainings into one

package was questioned from the point of relevance to some of the trainees and the lack of ‘focus’ that

may diminish effectiveness of the training. Growth through Nutrition thus proposed to conduct

operational research that compiles lessons and challenges in running the training as recommended and

1 International NGOs: Jhpiego, Tufts University, The Manoff Group, Land O’Lakes International Development, PSI

and World Vision, Local NGOs: EOTC-DICAC, EMERDA, FIDO, Mums for Mums, CVDA

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assesses effectiveness of the training in terms of knowledge and skill retention among participants. As

FMoH plans to revise the BINLM in 2019, findings of this assessment would be an input for the revision.

This assessment was also informed and driven by findings of a qualitative assessment conducted in Oromiya

and SNNPR by TRANSFORM PHC2, a USAID funded health project that mainly assessed effectiveness of

the training approach with regard to feasibility related issues and views of trainees on the training

approach. The study found out that the training approach is regarded as interesting by trainees whereas -

access to computers and electricity, doubts on its effectiveness in building essential skills, contrasting views

on integration of several modules in one package, irregularities in implementing trainings across different

areas were cited as major concerns. The assessment also recommended a quantitative assessment that

looks into effectiveness of the training. Growth through Nutrition, together with FMoH and other

nutrition stakeholders invested on this study to comprehensively dive into the concerns, challenges and,

thus, see how the BINLM-based training is enabling health workers to provide quality nutrition-specific

services.

Objective

General Objective: To ensure effectiveness of the BINLM training in building capacity of health

workers to deliver quality nutrition services

Specific Objectives:

1. To review contents of the training in terms of being fit-for-purpose and target audience

2. Evaluate level of adherence to the recommended approach of applying ‘blended’ and ‘integrated’

training in woredas of varying contexts in the four regions

3. Assess retention of key knowledge and skill competencies among BINLM trained health workers

4. Identify potential individual and institutional factors that can affect effectiveness of BINLM training

Methods

After discussion with FMoH’s Nutrition Case Team in August 2018, Growth through Nutrition proceeded

towards a comprehensive BINLM assessment starting from September 2018.

Study Design: The study applied a cross-sectional mixed approach study design with qualitative and

quantitative components was applied.

Qualitative component consisted of -

Desk review- review of the BINLM training module components and technical reports of BINLM-

based trainings facilitated by government and nutrition partners mainly UNICEF, Growth through

Nutrition, Transform PHC and SURE program

Key informants interview: Regional Health Bureau and woreda health office nutrition focal persons,

training organizers and facilitators

Quantitative survey: Cross-sectional survey among randomly selected BINLM trained health workers

and observation of health centers they work in

2 BINLM effectiveness: Preliminary Assessment: Qualitative assessment findings and proposal for further

investigations/studies. USAID: Transform Primary Health Care

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Study period: September-October 2018

Study Area: Growth through Nutrition implementation region I.e., all 101 intervention woredas and

health centers where health workers were trained from constituted sampling frame of the study

Study population: For the qualitative assessment, regional and woreda level nutrition focal persons and

training organizers and facilitators from UNICEF, Growth through Nutrition Project regional managers

and Transform PHC relevant staff. For the quantitative survey, those health workers trained via training

sessions that Growth through Nutrition jointly organized with regional health bureaus and woreda health

offices, from June 2017 to March 2018, and health centers where the trainees practice

Sampling Method:

Qualitative: All components of the training module and available training reports were included for the

qualitative review. KIIs included purposively selected respondents from the four regions and all woredas:

RHB and WrHO nutrition focal persons or their delegates, training facilitators/their representative from

BINLM implementing bodies (government/partners). This added up to 29 key informants.

Quantitative: A list of all trainees who completed BINLM course in trainings facilitated by Growth

through Nutrition from June 2017 to March 2018 across all regions was used as a sampling frame. Sample

size was calculated using a single population proportion formula. Assuming a proportion of knowledgeable

participants, trained health workers with an average score of 80% in the e-based knowledge courses as

90%, the standard formula was applied.

n = Z2

p(1-p) = (1.96)²0.90(1-0.90) => 136

w2 (0.05)²

Where Z = Z value, which is 1.96, P = the proportion of trained health workers for passing score

have >80% to 100%, w= the margin of error, N = sample population and n = sample size

Finite population correction formula = n/ (1+n/N) = 136/1+136/1108 => 121

Non-response rate of 5% was assumed resulting in final sample size of 127. Samples were distributed

across regions based on number of trained health workers and considering resources, 10 woredas were

selected purposefully, targeting those woredas where larger number of trained health workers could be

reached at a time. All HCs where study participants worked in were included in the survey.

Study Tools:

Desk review: A checklist to review the e-based BINLM course was adopted from an evaluation checklist

prepared for a related e-based course.3 The tool was commented upon by the technical working group

led by FMoH’s nutrition team at the start of the assessment. (Annex I)

KII Guide: A semi-structured interview guide was developed with sections on respondents background,

training related experience and views. (Annex V)

Quantitative survey questionnaires: This included individual questionnaire and facility-based

observation checklist. The individual questionnaire had three major components: a section on general

socio-demographic characteristics, personal and training related factors; a second part on knowledge

3 University of New Hampshire: Course Review Checklist

file:///C:/Users/L.Berhanu/Downloads/UNH_Course_Review_Checklist%20(1).pdf

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questions extracted from the BINLM manual (mostly in line with practice questions presented in the

module) and a third section with observation checklist that assesses practice level of selected skill sets

among sampled respondents. (Annex II and III) The facility-based observation checklist had sections that

assessed availability of electricity, computers, and services (in-patient management for acute

malnutrition/SC and outpatient management/OTP) and key nutrition commodities. (Annex IV)

Data Collection: Nutrition Advisor of Growth through Nutrition was principal investigator and two

experienced study coordinators from Save the Children, Ethiopia Office managed the whole assessment

process. Ten experienced BINLM ToT trainers including two experts from FMoH nutrition team were

recruited by Save the Children. They participated in finalization of data collection tools, conducted KIIs

at regional and woreda levels and reviewed training reports. Each module was independently reviewed

by two experts. Two observers per participant assessed skill.

Data Quality Management, Data Entry and Analysis: Selection of nutrition experts for material

review and skill assessment was merit-based and three days orientation and material finalization session

was done involving all assessment team. Supervisors, one per each region, provided on-site support to

data collectors by checking data for completeness and consistency on daily basis. At field level, study

participants were given adequate time to complete the self-administered knowledge questions. Data

were initially entered into EPI 3.5.3 Software Package. Data analysis was done using SPSS 20.

Ethical Consideration: FMoH issued support letter that outlined the purpose of the study. Individual

informed consent was taken from all qualitative and quantitative study participants. Health workers with

identified skill gaps were coached on correct procedure after the skill-sets tests were finalized.

Limitations of the Assessment: For the quantitative component, woredas included in the survey were

purposively selected considering operational constraints. While random selection of trained professionals

from the sampling frame could allow acceptable generalizability, likely inclusion of less remote sites in the

study might allow assuming findings from assessed health facilities are relatively better estimates. Experts’

review of the training module, two per course, while it provides a reasonable evaluation of the course

along multiple attributes, it is not expected to be technically exhaustive. The actual module revision will

benefit more from similar exercise by technical experts who participate in the revision. For the qualitative

assessment, absence of appropriate respondents in some cases and training reports might have affected

quality of output. Finally, measurement of knowledge and skill retention among health workers trained in

the past is not the best method to measure training effectiveness. However, given the BINLM approach is

currently the standard for in-service capacity building on nutrition, study outcomes can be taken as proxy

indicators for BINLM effectiveness.

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Result

This chapter is structured into four sections that respond for each study objective by applying mixed

methods. The Material Review section presents findings from the exercise where each module was

reviewed on multiple attributes by two BINLM master trainers. The Review of Training Approach section

looks into adherence to recommended training approach as reported by key informants in the four

regions, documented in reviewed written reports and reported by trained health workers. The

Knowledge and Skill among trained health workers presents quantitative findings from the knowledge and

skill survey of trained health workers. ‘Potential personal and institutional factors contributing to training

effectiveness and participants’ preference’ presents findings from the health workers survey and

observation of the health facilities and sets the context in which BINLM training takes place.

1. Material Review

Two reviewers applied a uniform checklist per each six module to evaluate content, design, user-

friendliness and presentation of the learning materials. They used the version of the training modules

that FMoH and TRANSFORM PHC revised in 2018. Findings are presented for each module as follows.

1.1. Introduction Module

Reviewers appreciated the level of information given in the general course overview. The technology

used (e-based learning) was, by principle, deemed appropriate to transfer introductory knowledge on

nutrition and for the learning objectives set in the module. Besides, learning outcomes were rated as

clear, concise and measureable. Content of the module is also well aligned with expected outcomes.

Assessment and feedback components are also in a good shape and need no or minimal revision.

Table 1: Major findings from Introduction Module review, September 2018

Reviewed Attribute Gaps

Course overview

Lacks information on -

Minimum and maximum days to cover knowledge and skill

part of the whole course

Facilitation skills to transfer knowledge and skills by

facilitators/among trained,

What is expected from training organizers and trainees at

different levels

How to install the module

Prerequisites- minimum level of computer and language skill,

materials for practice where required

How knowledge sessions link with knowledge

Course technology

and tools

Lack of access to computers among trainees

Trainees need to have computer skills

Takes time to browse through material- sometimes fails to

resume to the next page or go back

Lack alternative tools: easily downloadable/printable version

(as PPT,DOC,PDF) for use as reference or refreshment

purpose

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Design and layout

There are some unreadable texts in the slides.

Few slides in need of being more eye caching

Content

Pronunciation of the narrator might be difficult those with

lower English proficiency

Epidemiological data need to be updated using latest global

and local figures

Volume/bulk of content need to be checked from

introductory session perspective

Session goes beyond comprehensive introduction and delves

deeper into nutrition education and counseling.

Make sessions more local and focus on easily doable points

Some contents lack source documents

Course summarizes key facts of the session before ending

Assessment and

Feedback

No need for revision on methods (content to be reviewed

with overall introductory part revision

1.2. Micronutrient Module

Reviewers acknowledged the general information given on purpose, structure and tasks, who developed

the course and citation of key references in the overview section. They believed that technology applied

to transfer knowledge related to the module is appropriate, learning outcomes are clear and

measureable, written from participant’s perspective. Content is mostly directly related to objectives and

exercises for practice are aligned with specific course objectives. Table xx summarizes major concerns

raised by the reviewers.

Table 2: Major findings from Micronutrient module review, September 2018.


Course overview Lacks information on time required for completion of the

session and how the course links with practical/skill sessions

Course technology

and tools

Session requires computer skill & competencies, availability

of computer, access to electric power

No printable materials- solely dependent on e-learning

(computer based)

Design and layout Font size of content is, mostly, very small & slides cannot be

easily zoomed

It is not easily to navigate or proceed from one page to the

next. Trying to do so sometimes results in re-opening of the

whole module.

Hyperlinked information cannot be easily opened and viewed

Content All sessions are very vast and take longer to complete

Some of the content more appropriate to program managers

than HWs

Not updated data (Epidemiology of Vit A, goiter from 2005)

Some of the language not easily understandable (fast reading)

Sources not cited for some of the references

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Focuses more on facts and less likely to drive trainees to

action

Assessment and

Feedback

Fails to provide certificate, and in some cases prefer

computers with appropriate applications to do so.

1.3. Adolescent, Maternal, Infant and Young Child Nutrition

Reviewers noted that the course overview captures purpose, structure of the course and tasks due. The

technology used is also believed to be appropriate to transfer knowledge in AMIYCN and help trainees

meet set competencies. The course presents learning outcomes clearly and content is directly related to

learning outcomes. The volume of the material is believed to be manageable within the assumed

workload of target trainees. Module consists of practical exercises and provides additional and relevant

material for further reading. In general, reviewers reported that this section is improved compared to

the earlier version that they have used to provide training.

Table 3: Major findings from the AMIYCN Module review, September 2018


Course overview Information on how to access different sections not available

Lacks information on how knowledge session links with

practical/skill sessions

Course technology

and tools

Technology appropriate to transfer AMIYCN related

knowledge, however,

Better if a word or PDF document was prepared as

alternative for easy access

Good to put instruction on how to access different sections

easily

Design and layout

Font size (e.g. conceptual framework and other diagrams) is

small. Notes & menu section less visible

Content

Update figures based on latest epidemiological data

Areas like counseling(GALIDRAA) need more detail

Adolescent nutrition needs to be presented in a practical

way

Preparation of CF recipes (particularly, for12-24months)

lacking

No demonstration on how to prepare varieties of CF

recipes such as shiro, firfir from locally available food items

besides porridge

Sections on the introduction module on counseling can best

fit here

Assessment and

Feedback Requires establishing effective mechanism not to

systematically cheat exams

1.4. Acute Malnutrition Module

The need for slight revision across multiple attributes is emphasized here. Reviewers appreciated

presence of clear and measureable learning outcomes and direct relation of content with learning

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objectives. The volume and depth of content is deemed appropriate for the primary targets though they

are not clearly defined. Case scenarios and case stories are clearly presented and relevant for local

context, which allowed content to focus on applicable knowledge rather than simple facts. Content also

provides further reading materials and summarizes key points in the sessions before proceeding to

assessment part. The skill sessions have appropriate objectives and content well aligned with the

knowledge component.

Table 4: Major findings from the Acute Malnutrition Module review, September 2018


Course

overview

Lacks information on

Minimum hours/time period recommended to complete knowledge

session

Who the module is primarily targeting

How to easily resume the course from where one has stopped,

What trainees are expected to prepare to attend training

effectively, and

how to access additional references

Course

technology and

tools

Unreadable contents on some slides-

Charts, scenarios on Daily care and patient monitoring session not

readable

Contents can’t be zoomed

Session stops/freezes repeatedly at some slides

Power point not printable- limits better access to trainees without

computers and constant access to electric power

Also consider other alternatives such as making material accessible

via smart phone

Design and

layout

Difficult to scroll up and down e.g. the patho-physiology content

and contents can’t be zoomed,

Not easy to proceed to next sections after completing quizzes

Sessions on pathophysiology of malnutrition, multi charts for in-

patient monitoring cannot be fully read and easily zoomed

Content

Pronunciation of words might be difficult to lower level health

workers

Some slides do not have notes

Recommends Cotrimoxazole to treat pneumonia that WHO

currently disagree with, recommend referral of cases when there is

no physician/skilled senior staff in case of danger sign,

Update with the new way of preparing F-75 & F-100

Repetition of similar scenarios in daily care and patient monitoring

session

Less emphasis on use of recording and reporting formats and

documented patient monitoring as a whole

Assessment

and Feedback

Some parts of the questions are not accessible e.g. multi chart

(Monitoring patient and ward session)

Daily care session and Monitoring sessions do not allow review of

responses

Wrong answers for quizzes in daily care session

16

1.5. Nutrition in Communicable, Non-communicable Diseases and Special

Health Conditions

According to the reviewers, course-level learning outcomes of this module are clear, concise and

measureable. The course is directly related to the learning outcomes. Content is believed to be

appropriate to the needs of health workers in terms of volume and depth. Sessions include relevant

material for further reading and conclude with key facts before proceeding to assessment part. Frequent

and appropriate methods are applied to assess participants understanding except that it is still possible

to cheat for certification.

Table 5: Major findings from Nutrition in Diseases and Special Health Conditions Module review, September 2018


Course overview

The purpose of the module is not clearly stated

Primary target groups for the training not mentioned

Training norms, how to proceed, and how to access

references not clearly stated

Course technology

and tools

Computer based training not that feasible in most rural

health centers which may have only one or no computer

Hard copies of training materials not readily available, easily

downloadable/printable version (as PPT,DOC,PDF) the HW

may use as reference or refreshment purpose also

Possible to consider access via smart phones?

Design and layout

Unreadable contents: Difficult to read Module 4B table three

section repeatedly stuck at some points especially module

4A

Zooming not possible at some points.

Module 4A freezes repeatedly

Content

Pronunciation of words might be difficult to lower level

health workers

It is better to up-to-date sources (EDHS 2016),

Give precise information: E.g. how much alcohol is

considered modest use (cc, bottle), Cigarette use (how

many packs?)

It is better to make the volume and depth shorter and

focused (avoid repetition)

Case scenarios and presentations need improvement

Include video clips ( e.g. on physical exercise, on how to

prepare healthy diet in local context)

Assessment and

Feedback Cheating is possible

1.6. Nutrition Program Management

Reviewers praised this module for its content that aligns well with stated learning objectives and the

materials it provides for further reading despite needs for updating. Reviewers also acknowledged

presence of practical exercises with detailed instructions. The module also incorporates appropriate

methods to assess mastery of content aligned with stated learning objectives.

17

Table 6: Major findings from Nutrition Program Management Module review, September 2018


Course overview

No overview on Nutrition Program Management and its

contents.

No Information on to whom this module is primary

targeted

Course technology

and tools

Check appropriateness against,

Trainees’ lack of basic computer skills

Access to computer

Access to power/ electricity at rural HCs.

Consider alternatives such as hard copy and mobile

application

Design and layout

Guideline part not navigable

Hyperlinks not accessible (NNCB,NNCC)

Missing audio records(Components of Supply management)

Nutrition Supply Management Assessment (Questions not

reviewed, and Finish button freezes)

Content

Narration may not understood by trainees for their lack of

language competency

Updated NNP II (2016-2020) not availed

Health Workers at Facility level may not be primary targets

for the program management module

Better if focus on major duties of the front line service

provider (HW).

Content more befitting to the duties of nutrition program

manager

Assessment and

Feedback

Short answer Questions cannot be reviewed at least against

a strongly suggested response/ ( e.g. Principle to lubricate

the Mechanism of Coordination)

2. Review of Training Approach

This section presents findings health workers responses for quantitative and qualitative questions on the

way training sessions were conducted, responses of KIIs who organized/supervised trainings as well as

from review of accessible training reports of regional health bureaus and nutrition partners.

All four regions provided BINLM-based trainings in the past two years. According to the survey among

health workers, irrespective of the region they are from, apparent variation was observed in the way

participants attended the trainings. As shown in Table 7, a fifth (22%) of the participants attended all

knowledge modules together and a quarter of the participants (27.6%) did have certificates only for

some of the modules or none.

Average duration for attending self-paced knowledge sessions was 14 days (range of two days to three

months) whereas a third of the trainees (33.6%) reported of attending skill sessions for three or less

days. Slightly more than a quarter (27%) of the respondents felt cases were not adequate for practical

session whereas majority of them (86.6%) rated skill of facilitators either as good or very good.

18

Table 7: Variations in attendance of knowledge and skill session among surveyed health workers in the four regions, October 2018

Variable Response Frequency Percent

Took part in knowledge orientation

session (n=125)

116 92.8

Attended knowledge sessions

Alone and where convenient 55 43.3

With a colleague 38 30

All together where computer is

available

28 22

Other 6 4.7

Certified for knowledge session

Yes for all, verified 76 59.8

Yes for all but not verified 14 11.0

Yes, for some 17 13.4

No 18 14.2

Duration of Skill training in Days

One 11 8.8

Two 21 16.8

Three 10 8.0

Four to Five 83 66.41

Location of skill training

Training center/Hotel with

attachment at health facility

67 53.1

Hospital 5 3.9

Health Center 39 30.1

Other 15 11.9

Perceived adequacy of cases to practice

at skill sessions

90 72

Perceived skill of facilitators of the skill

sessions

Very good 54 42.9

Good 55 43.7

Not good 17 13.5

As there was significant variation in mode of training delivery across regions, KII findings are presented

separately for the four regions.

Oromiya: Six KII respondents who responded to the survey reported that trainings were provided by

government, in collaboration with UNICEF, Growth through Nutrition, Transform PHCU and SURE

Program. Three rounds of trainings are provided in the region in the past two years at regional level

claimed that there was no variation during this period. Orientation of two days was provided for the

knowledge part and 30 days were given for self-learning. Skill training was provided for five days.

Respondents reported that self-learning method in BINLM is a good for adult learning and time saving.

The training material consists of rich reference materials. All respondents claimed that the skill part of

the training relatively went well. Study participants did clinical attachments at hospital and health posts.

They also believed that the training was effective in equipping HWs with the appropriate knowledge and

skill though they feel that the knowledge part requires revision in mode of delivery and content.

However, they also noted challenges that particularly affected the knowledge part of the training such as

lack of personal computers and computers at health facilities. Time constraint of health workers also

affected timely completion of courses. One respondent noted that provision of knowledge and skill

19

components separately by itself time taking. Failure of some modules to provide certificate, presence of

duplicated questions and presence of some questions without response were also reported.

KII participants also pointed the need to reduce the volume of some modules and updating resources.

Other suggestions included, providing knowledge and skill phases in one, making hard copies of the

training resources accessible, increasing access through other alternatives such as smart phones,

translating training material into local languages and improving the security issues for some modules.

Follow-up after trainings was also recommended. (However, it is not clear (They were not probed on

whether they have been using the revised version of the training material or not.). Training reports were

not available for review.

Health workers who responded to the question on general feedback on the training frequently

mentioned the need to reduce volume of the modules, increasing training duration, providing the

trainings in the traditional manner, improving the format of the presentations, particularly font size and

making the language simple and clear. They also recommended availing hard copies of the training

materials and allowing specific modules to be taken by specific trainees.

SNNPR: Seven KII respondent reported that BINLM-based trainings were provided in the past two

years mainly by FMoH in collaboration with UNICEF, Growth through Nutrition, Transform PHC and

regional health bureau and zonal health department.

They claimed that there was variation in the way that ToT and cascade trainings were provided. The

CD-based Knowledge part orientation and skill sessions were provided separately during the ToT

whereas in most of the cascade trainings the two sessions were mostly delivered consecutively.

Trainings also varied in the number of days allocated for knowledge and skill sessions. In general, the

ToTs were often adhered to the standard but not the cascade trainings.

None of the KII respondents thought the training was effective in meeting its objectives. They claimed

that most of the trainees did not understand the knowledge component fully, much attention is not

given to the quality of the training, the training is bulky to finish in the given period and health facilities

were not well equipped to practice skill from the trainings. Lack of computer access at health facility and

woreda, limited HWs language and computer skills were noted to affect effectiveness of the knowledge

component. Lack of equipment for skill session such as length board and materials for food preparation.

Participants suggested that training can be improved by conducting proper need and capacity assessment

before providing trainings including addressing challenges of access to computers and HWs capacity,

preparing hard copies of the training materials and if possible increasing access by adapting material to

smart phone application, translating into local language and reducing the size of the training materials.

Improving follow up activities and mentoring after trainings were also recommended.

A training report from a project showed that training was provided according to the recommended

approach with two days orientation on knowledge component and skill session was provided to those

who came with certificates. Challenges faced include lack of computers and power interruptions.

Training facilitators agreed with woreda health offices to use computers at health facilities, where

available, to address this challenge.

Amhara: Seven respondents participated in the KIIs. According to them, FMoH and RHBs, UNICEF,

SCI/Growth through Nutrition, SURE project and TRANSFORM PHC provided BINLM trainings.

Nonetheless, interviewees reported that there was variation in the way the trainings are provided. The

orientation on knowledge sessions lasted for 1-2 days and self-learning from two weeks to one-month.

20

Skill sessions also lasted for three to five days. In other cases, both knowledge and skill sessions were

provided combined. There were also cases where participants did not take part in skill sessions at health

facilities, as trainings were limited to training rooms. Some reported being trained for skills without

being certified on the knowledge modules. In one case, knowledge sessions were provided without CDs

or in a TVET, ICT room, which brought all trainees together.

Despite all such variations, participants believed that trainees could still acquire knowledge and refresh

their pre-service knowledge from the trainings. Most of them are however skeptical about the quality of

the skill sessions and do not believe BINLM alone will not equip health workers with skills to manage

nutritional problems such as acute malnutrition cases.

Challenges faced during trainings include access to computers and lack of computer skills by the

trainees. Difficulties in opening some of the modules and certifying trainees were also reported (did not

specific whether they faced this challenge while using the revised version). Some participants did not

complete the knowledge sessions when they join for the skill part and the skill sessions were affected by

time shortage that left some sessions uncovered. The case of participants being certified without

completing the module were also reported.

As factors that affect the quality of the trainings, respondents mentioned participation in skill sessions

without completion of knowledge sessions, focus on getting certified without reading among trainees,

lack of computers and computer skills, lack of electric power in as nearly 40% of the health centers in

rural areas and lack constant power supply. Quality of skill sessions were also affected by sessions being

limited to classroom demonstrations, caseload for facility level practice being dependent on where the

sessions take place and facilitation of trainings by limited number of, usually two, facilitators. Not all

participants were also asked for knowledge session certificates to proceed to skill trainings.

On the way forward, respondents suggested the need to review the duration given for the training,

supervising the trainings closely and providing comprehensive exam before proceeding to skills session.

To improve knowledge sessions, providing adequate inputs including computers, CDs, earphones were

suggested. Follow up during and after trainings were believed to be vital to maintain in-training quality

and subsequent application of knowledge and skills. Arrangement of skill session also should factor in

days where there will be adequate number of cases for practice. Participants also suggested extra days

for skill sessions. Most of the participants also underscored the need to provide training for more health

workers and as a gap filler.

According to a training report availed from Growth through Nutrition, a two-day orientation on

knowledge sessions and 15 days CD-based self-learning was followed by skill training. The report

claimed that training was conducted according to BINLM recommendations and no major challenges

were faced.

Health workers responding to qualitative feedback on trainings they participated in suggested the need

to increase duration of training and allocating sufficient period, updating particularly the AM module,

making the sessions under this module simple and clear and assigning facilitators with better knowledge

and skill. They recommended reducing the bulk of the material, availing hard copies, separating trainees

based on need and providing knowledge and skill sessions consecutively as the time gap between the

two sessions creates memory lapse.

Tigray: Eight KII respondents participated in the survey and according to them regional health bureau

together with UNICEF, Save the Children/ Growth through Nutrition and Transform Primary Health

Care facilitated BINLM-based trainings over the past two years.

21

All of them mentioned that trainings were provided using the traditional approach where knowledge and

skill components were delivered consecutively. Duration of the training also varied from five to ten days.

Most of the trainings did not have the skills sessions being limited to providing knowledge sessions in a

classroom. In the cascade training, knowledge sessions were mainly delivered in groups at ICT centers.

Respondents acknowledged the presentation of nutrition in a comprehensive manner in the BINLM.

They appreciated attributes including its role in making HWs assess their computer skills and being

familiar with self-learning. Other positive traits included preparation of the training material with

abundant reference materials, practical exercises, and delivery of knowledge session that will not be

affected by facilitators’ variations.

Most respondents, however, reflected negative attitude when it comes to effectiveness of the trainings.

The major reason forwarded was delivery of the training that is not in line with the intended delivery

approach. This has made the training liable to group based training, which may not be helpful for

individual capacity building. Other factors believed to affect effectiveness included language barrier, lack

of commitment and responsibility by training organizers particularly for the skill part, facilitators’

competence, particularly experience on the area that they are assigned on, provision of the whole

course to all types of health workers and lack of equipment and supplies.

Challenges faced include lack of computers and computer skills by trainees, irregularity in power supply,

language barrier and limited time for knowledge sessions. Material related challenges including corrupted

CDs, readability of training materials, sessions that freeze were some practical problems they faced to

attending the e-based course.

Respondents highlighted that focus should be given to the effectiveness of the training. They believe this

can be done by organizing trainings based on profession of health workers, reducing the volume of the

training material, making the material friendlier and the format readable, assigning well-experienced skill

session facilitators. If possible, translating material into local language and preparing hard copies were

also recommended.

Technical training reports were shared from projects but not from RHBs or woreda health offices.

Challenges highlighted in the reports include inability to finalize knowledge sessions of all modules in

four days (as the whole training was delivered consecutively within eight days), language capacity of

trainees, limited computer skills and computer access, repeated power interruptions and participation of

some health workers in courses less relevant to their routine work. Limited capacity of skill session

facilitators was also noted in the Transform PHC report. Training organizers tried to address these

challenges via intensive support during training period.

3. Knowledge and skill retention among trained health workers

3.1. General Characteristics of Respondents

From 51 health centers, 127 health workers participated in the study with slight majority being female

(56%). Half of them were Diploma holders (51%) and the majority clinical Nurses by profession (47.2%).

The majority of the trained (61.9%) were working in maternal and child health units during the time of

the survey. Participants had an average of five years of professional experience and have stayed for

nearly three years at the health facility they were working at the time of the assessment.

22

Table 8: General characteristics of health workers who participated in the study in the four regions, October 2018

Variable Category Frequency Percent

Sex Male 56 44.1

Female 71 55.9

Mean age 27.5 Years

Education level

Diploma holder 65 51.2

B.Sc. Degree 57 44.9

MD/Master’s Degree 3 2.4

Other 2 1.6

Profession

Clinical Nurse 60 47.2

Health Officer 31 24.4

Midwife 28 22.0

Physician 4 3.1

Other 4 3.1

Current department

Under five Clinic 39 30.9

Immunization 8 6.3

ANC/PNC/FP 31 24.6

Others(eg, OPD,TB etc) 48 38.1

Mean year of

professional

experience

5 Years

Mean duration of

stay at the health

facility

2.9 Years

3.2. Introduction Module

This module mainly explained the concept of nutrition, malnutrition and level incidence and prevalence

of major nutritional problems at global and local levels. Out of eight questions, responses to those

related to the definition of stunting, its prevalence, and understanding on immediate and underlying

causes of malnutrition are presented in the figure below. In general, 40-60% of the participants failed to

respond correctly to questions related to these variables.

Figure 1: Proportion of BINLM trained health workers who responded correctly for undernutrition related questions in the four regions, October 2018

On remaining questions related to nutrition education and counseling, which the introduction module

addresses in relative detail, more than two thirds (70% of the respondents identified assessing nutrition

51%

60%

44%40%

Correct definition of stunting Stunting the most prevalentform in Ethiopia

Identified disease asimmediate cause of

malnutrition

Identified HH food insecurityas immediate cause

23

problem of clients as the first step to conduct nutrition education. Around 60% of the respondents also

identified nutrition counseling as a process that helps to assess, analyze and plan solutions for nutrition

related problems. Majority rejected the option of attempting to convince a client is a component of

GALIDRAA approach. (For frequency table for responses on these variables, see Annex xx).

In general, nearly four fifth (79%) of the participants responded correctly four or more out of the eight

questions (≥ 50%) in the introductory module. (See scores in Annex VI.)

3.3. Micronutrient Module

Out of 126 health workers who responded to all questions for this module, the role of zinc as a

micronutrient that decreases incidence and duration of diarrhea, consequences of iron deficiency on

maternal and newborn health and pregnant women as the most vulnerable group for iron deficiency

anemia were responded correctly by more than 85% of the participants. The least proportion of

participants came for timing for deworming during pregnancy and the role of delayed cord clamping in

improving iron status during early infancy, 25% and 11% respectively. Frequencies worth further

reflection are highlighted in red in the figure below.

Figure 2: Percentage of BINLM trained health workers who responded correctly for selected question from the micronutrient module in the four regions, October 2018

Nearly two-thirds (78%) of the participants scored a passing mark, more than 50%, for this module. (See

detail aggregate score in Annex VI).

87

32

92

87

25

67

43

54

71

11

0 10 20 30 40 50 60 70 80 90 100

Iron deficiency- consequence

Vitamin A Role

Zinc in diarrhea management

Group that requres more iron

Deworming starts from the first trimester

Right advice on IFA side effect

Continued IFA postnatally IFA supplementation

Folic acid deficiency

Care for Iodized salt

Delayed cord clamping improves iron status during early…

24

Regarding demonstration of skill in Vitamin A delivery for 6-23 months old infants and children, at least

two-thirds of the participants performed expected tasks for all evaluated tasks. (Table 9)

Table 9: Proportion of health workers who performed tasks listed in conducting prioritized skill in the micronutrient module in the four regions, October 2018

Task Percent

Greet mother 75.6

Asked for age of child 89.0

Asked if child received in the last one month 69.3

Selected appropriate dose 83.5

Cut nipple at the middle 85.0

Asked care taker to hold the child firmly 74.8

Checked if the child is comfortable after swallowing drops 63.8

Discarded capsule into bag and wipe hands clean 67.7

Recorded on tally sheet 68.5

3.4. AMIYCN Module

Twelve questions were presented to assess knowledge retention under this module. The question

related to the need for increased breastfeeding for a sick infant was responded by the highest majority

(84%). Questions on weight gain during pregnancy, nutrient requirements during pregnancy and lactation

as well as the recommended mix for complementary food (porridge) preparation were responded by

less than a third of the participants.

Figure 3: Percentage of BINLM trained health workers who responded correctly for selected question from the AMIYCN module in the four regions, October 2018

Slightly more than half (54.3%) of the participants scored ≥ 50% on this module. (See Annex VI for

aggregate scores.)

42

31

73

33

52

47

47

32

48

84

46

65

0 10 20 30 40 50 60 70 80 90

Disease as Immediate cause of maternal malnutrition

Nutrient requirement of PLW

Care and nutrition during P&L

Weight gain during pregnancy

Intervention for adolescents

Proper positioning during breast feeding

Complementary food for 12-24 month child

Mix recommended for child's porridge

Benefit of adequate nutrient during Pregnancy

Infant feeding during sickness

Feeding low-birth weight babies

Community involvement for nutrition

25

Skill of participants was assessed on application of the GALIDRAA approach in counseling for optimal

maternal infant and young child feeding. As shown in Table 10, relatively higher proportion of the

respondents (>60%) identified the most important problem. However, around a third of the health

workers were evaluated to be poor listeners. Majority failed to use of counseling cards and in more than

a quarter of the cases there was no discussion on whether recommended practices were do-able, and in

letting mothers repeat agreed upon recommendations. More than a third of the health workers also

failed to appoint the mother for the next meeting.

Table 10: Proportion of health workers who performed tasks listed in conducting prioritized skill in the AMIYCN module in the four regions, October 2018

Task

Rating

Not Done Good Not Good

Greet the mother 9.4 55.1 35.4

Asked key questions for a child 12.6 52.8 27.6

Asked key questions for P/L mother 11.8 47.2 22.8

Listened attentively 13.4 54.3 32.3

Identified difficulty and prioritized the most important problem 26.0 61.4 11.8

Used counseling cards properly 61.4 31.5 7.1

Discussed simple doable actions based on identified and

prioritized problems 23.6 67.7 8.7

Discuss optimal breastfeeding/complementary feeding options

appropriate to the age of the child 19.7 62.2 15.7

Discussed if suggestions are easy or not to practice 29.9 55.9 11.8

Help the mother/care giver to agree and to try one of the options, and

asks them to repeat the agreed-upon actions. 26.8 59.8 11.8

Appointed the mother 36.2 44.1 17.3

3.5. Acute Malnutrition Module

Participants responded for ten questions under this module starting with definition of wasting and

focusing on acute malnutrition case classification and case management. Except for a question, where

they correctly classified a case as normal and selected the right mode of management, less than half of

the participants failed to choose the correct answer for the remaining nine questions. Cumulative

scores showed that less than half (44.9%) of the respondents scored greater than 50% for this module.

(See annex VI for detail)

26

Figure 4: Percentage of BINLM trained health workers who responded correctly for selected question from the Acute Malnutrition module in the four regions, October 2018

For assessing skill in acute malnutrition identification and case management, anthropometric

measurement and preparation of F-75 and F-100 feeds were selected. Observation of health workers in

demonstration of skills showed that procedures are not often followed as recommended. MUAC

measurement showed that gaps are observed mostly in identifying the mid-point (performed correctly

by <50%).

Table 11: Proportion of health workers who performed tasks listed in conducting prioritized skill in the MUAC measurement in the four regions, October 2018

Activity Performed (%)

Located tip of shoulder 55.9

Located tip of elbow 52.0

Placed tape at tip of shoulder 51.2

Pulled tape past tip of bent elbow 44.9

Marked mid-point 46.5

Wrapped the tape on the arm across the marked point 71.7

Corrected tape tension 70.9

Corrected tape position for arm circumference 63.0

Measured MUAC to the last completed 0.1 cm and record it

immediately. 60.6

Regarding skill assessment, as shown in table 11, less than 40% of the respondents performed key tasks

expected in preparation of F-75 and F-100 feeds for acute malnutrition cases managed under Phase 1

and Transition phases.

26

40

28

61

49

39

44

38

23

14

0 10 20 30 40 50 60 70

Definition of wasting

OTP case definition

Inpatient-case classification

Normal case management

OTP case classification

Under 6 months SAM classification

SAM management

Misdiagnosis as Commonest cause of death

Mangement of common complications

Under six months SAM case management

27

Table 12: Proportion of health workers who performed expected tasks during preparation of F-75 and F-100, October 2018

Task Performed (%)

Summarized total ml of milk to be prepared for both Phase 1 and transition 40.9

Calculated the number of red scoops and amount of water accurately 37.8

Washed hands 37.8

Measured the amount of water for each phase 41.7

Put the right number of red scoops for each phase 37

Used whisk and prepared the milk 40.9

Measured the right amount and (to) offer to the children 38.6

3.6. Nutrition and Communicable Diseases Module

Seven questions were forwarded to test knowledge for this module. White refined flour as a risk factor

for increased total blood cholesterol was identified by the least proportion of participants (29%),

whereas the majority responded correctly for no need of administering insulin in management of Type 2

diabetes. Nearly half (49%) of the respondents scored above 50% under this module. (See Annex VI for

detail.)


3.7. Program management

Six questions on concepts of nutrition-specific and –sensitive interventions, multisectoral coordination

and crosscutting issues such as communication and supply related issues were focused at under this

module. As shown in Figure 6, majority of the respondents (60%) failed to identify the concept behind

nutrition-specific intervention. A quarter of the study participants (25%) scored above 50% for this

module.

38

51 50

65

79

49

29

Correct aboutHIV/TB andmalnutriton

Not CriticalNutrition

Practice forPLHIV

Dietarymanagement of

diarrhea

BMI basedclassification

Type 2 diabetesmanagement

Directcontributer to

chronic diseasein developing

countries

White refinedflour as a risk

factor

28


Finally, aggregated score of each study participant showed that 45% of the participants scored above

50% for all six modules. (See Annex VI for aggregate scores)

4. Potential personal and institutional factors contributing to training

effectiveness and health workers’ preferences

Knowledge and skill retention among respondents is likely to be affected by different factors including

exposure to nutrition related trainings. Responding to the question whether they have participated in

modular trainings similar to the one in BINLM, more than a fifth (23%) replied positively. Acute

malnutrition management and Adolescent malnutrition were the topics on which most of the

participants were trained.

Table 12: Proportion of health workers who performed expected tasks during preparation of F-75 and F-100, October 2018

Item Response Percent

Participated in separate modular trainings 29 23.2

Type of training

Acute Malnutrition 11 8.7

AMIYCN 9 7.1

Micronutrient 4 3.1

SBCC 4 3.1

Specific to BINLM training, as a computer-based training to transfer knowledge, it is expected to be

affected by trainees access to computer, computer skill and being a self-teaching one with less chance

for translation a good command of English language. As presented in Table xx, nearly half of the study

participants self-reported of lacking basic skills in use of common computer applications such as word,

excel and internet. Around a fifth of them (22%) can access computers all the time whereas one in ten

founds it hard to understand written and spoken English.

31

48

33

2630

13

Nutrition-specificintervention

defintion

Concept ofnutriton-specific

and -sensitive

Types of nutritioncommunication

Multisectoralcoordination

concept

Supplymanagement

NNP strategicobjective to address

underlying causes

29

Table 13: Proportion of health workers who responded to potential individual attributes that can affect delivery of BINLM training, October 2018

Training Inputs Category Frequency Percent

Computer skill

No expertise in using either MS word, excel,

internet

62 49.2%

Basic skill in using either MS word, excel,

internet

53 42%

Proficient in using either MS word, excel,

internet

12 9.5%

Computer Access

Yes, always 28 22.0%

Yes, sometimes 72 56.7%

Not at all 27 21.3%

Perceived English

Language Skill

Very good (Can fully understand written and

spoken English and is quite OK to be trained

with English)

25 19.8%

Good (understand most of written and spoken

English and does not mind to be trained with

English)

86 68%

Not bad (Finds it somehow hard to fully

understand written and spoken English)

14 11.1%

Not good (Finds it hard to understand written

and spoken English and prefer to be trained

with another language)

1 0.01%

Sharing of knowledge and skills garnered from

trainings also helps in better retention of trained

individuals in addition to extending the reach of key

competencies to other staff not taking part in

formal in-service trainings. The assessment showed

that training materials and acquired knowledge in a

form of on-the-job training was shared by nearly

60% of the study participants.

Figure 7: Percentage of BINLM trained health workers who shared learning to colleagues, October 2018

Other potential factor that affects quality delivery of BINLM training and retention of knowledge and

skill among study participants is the institutional environment they work in. Slightly more than a tenth of

the health centers do not have access to uninterrupted electric power and functional computer.

Therapeutic foods are the least available supplies mainly due to limited presence of stabilization centers,

in less than half of the health centers (47%), followed by lack of nutrition counseling materials in nearly

half (50%-60%) of the health centers.

58.9

59.3

28.1

0.0 20.0 40.0 60.0 80.0

Share training materials tountrained

Provided on-the job K&Straining

Did not get the chance toshare

30

Table 14: Proportion of health centers with key inputs for quality delivery of BINLM and subsequent knowledge and skill retention, October 2018

Available at Health Center Percent

Electric power 88.2

Computer 86.3

Stabilization center 47.1

Weight scale 100

Child MUAC 90.0

Separate room for SC 48.0

RUTF where OTP service provided 76.0

Length/height board 78.0

F75 45.1

F100 43.1

Nutrition counseling card 57.1

Growth monitoring Chart 54.2

Family Health Guide 57.8

Finally, when it comes to preference of trained health workers on ‘computer-based’ and ‘integrated’

nature of the training, around two-thirds (64%) preferred computer-based courses to classroom based

ones and integrated courses (60%) compared to separate modules.

Table 15: Proportion of health centers with key inputs for quality delivery of BINLM and subsequent knowledge and skill retention, October 2018

Item Category Percent

Computer based course vs. class-room based course

Strongly prefer 42 34.1

Prefer 37 30.1

Both are the same 2 1.6

Prefer class-room based course 23 18.7

Strongly prefer class-room based course 19 15.4

Integrated vs. separate courses

Strongly prefer integrated 47 37.3

Prefer integrated course 28 22.2

Both are the same 3 2.3

Prefer modular course 35 27.8

Strongly prefer modular course 13 10.3

31

Conclusion

Application of BINLM, a combination of e-based knowledge sessions and face-to-face skill training, is a

relatively new approach to capacity building efforts of health workers in Ethiopia. BINLM brings core

topics of nutrition under a single package and thereby contributes towards building health workers’

capacity towards FMoH’s ‘Comprehensive and Integrated Nutrition Services’ delivery approach.

Moreover, it avoids long absence of health workers from their duty station as computer-based and self-

paced study covers much part of the training. In contexts where high staff turnover and staff rotation

prevails, all-rounded basic knowledge and skill on nutrition services among all health workers may

guarantee uninterrupted services delivery at PHCUs. However, the benefits of any training approach can

be realized if only the training is effective in improving knowledge and skills of the trainees.

In general, this study has shown that knowledge and skill competencies directly related to the training

outcomes are low among the trained. More than half of the study participants did not achieve passing

mark for the entire knowledge module and significant proportion failed to perform key skill sets as

recommended. These quantitative findings are in line with another in-depth interview findings of a

qualitative assessment where key informants doubted effectiveness of BINLM. Although the method

applied in this study does not allow attributing positive or negative results directly to the BINLM

trainings, the BINLM approach being the current widely implemented in-service capacity building on

nutrition, study outcomes can be taken as proxy indicators for its effectiveness.

Effectiveness of a training is a factor of adequacy and quality of the training material, its mode of delivery,

and participants’ and institutional factors that are prerequisites for effective participation or practicing of

acquired knowledge and skill. The need for BINLM revision to upgrade quality of the training is already

acknowledged by FMoH. Together with Transform PHC, the material was revised mainly towards

making the module less vulnerable to certifying trainees who did not navigate through a given course

and pass the exams. The ministry has then planned for BINLM content revision in 2019/20.

The training material review of this study identified strengths and gaps to serve as input for the intended

revision. Most of the courses in the module have clear learning outcomes, course content aligned with

these outcomes, and proper assessment and feedback mechanism. On the contrary, commonly shared

gaps include bulkiness of specific courses, lack of readily downloadable/printable alternative content,

failure to show linkage between knowledge and skill sessions, outdated epidemiological data/programs/

strategies and policies, and speed and pronunciation of the narrator. Relevance of courses such as

‘Nutrition Program Management’ to all trainees was also questioned. Reviewers suggested the need to

inform actual revision by further comprehensive look into design, content, user friendliness of the

material by course-specific technical experts, using the checklist applied in this study.

Besides having the appropriate training material, mode of training delivery is another factor that

contributes to effectiveness. Review of the trainings conducted in the past one year by government,

often with UNICEF’s support; Growth through Nutrition and Transform PHC showed considerable

variation among regions, zones and woredas. Trainings mostly organized by government health

bureaus/offices did not adhere to recommended duration and delivery mechanisms. Self-paced feature of

the training was often replaced by group knowledge sessions. ToT trainings tended to adhere to the

standard but not cascade trainings. At times, study participants were not asked for certificates of

knowledge courses before they join skill sessions; both knowledge and skill sessions were delivered in a

32

single training event, and skill sessions were facilitated in locations that did not allow for acceptable level

of practical exercise. There was also no standard for number, mix and minimum experience of

facilitators required for the skill sessions. In general, there was lack of direction for alternative

approaches to BINLM, so that widely practiced trainings could meet minimum quality standards.

BINLM rapidly evolved as a sole approach for nutrition focused in-service capacity building of health

workers on nutrition, in Ethiopia. This relied on assumptions of expanded coverage of electric power,

better access to computers among rural health workers, better health workers’ exposure to basic

computer skills and good level of English language proficiency. However, this assessment showed that

majority of the study participants did not have access to computer; more than half did not have basic

computer skills; and, a tenth of the trainees and material reviewers pointed out language limitations even

recommending local language translation. These findings, as a whole, indicate the need for close support

some trainees may need during the knowledge sessions, if they are to attain desired outcomes.

At institutional level, a tenth of visited health centers lacked electric power and slightly higher

proportion did not have functional computers. Such situations, often likely to affect remote health

centers, call for reflecting on the effect of uniform approaches on equitable access to quality trainings.

Observation findings of health centers that revealed gaps in available service packages and/or key

supplies is expected to lead towards knowledge and skill depreciation among the trained.

Similarly, institutional culture that promotes continuous knowledge and skill building among health

workers and complements one-off training sessions was reported to be mostly absent. Training sessions

were not supervised and followed by mentoring. Trained health workers could fortify acquired

competence by sharing it to their peers and downwards to their supervisees (mainly HEWs). However,

the assessment showed substantial proportion of the trained did not report of knowledge and skill

sharing. Lack of such practices is likely to affect knowledge and skill retention.

At a broader level, the average years of experience of the study participants, 5 years, reminds one that,

at least, around half of the health workers joined the health sector in an era where better attention

started to be given to nutrition education. They might have attended their studies through a decade

where Essential Nutrition Actions and management of acute malnutrition were incorporated into pre-

service nutrition curricula of health cadres. They are also more likely to be members of the computer-

friendly generation. Hence, failure of majority to score pass mark on core knowledge and skill

parameters might call for in-depth look at the quality of pre-service nutrition education and students

exposure to contemporary technology that can advance technical knowledge and skills.

Going forward, since application of BINLM is a pioneer for in-service health workers training in Ethiopia

and is likely to be adopted by other health programs; it is advised to focus more on how to build on the

good start that exists. Study participants have also reported higher level of preference to this type of

training. Hence, improving BINLM-based trainings requires sustaining what is going well and

systematically addressing gaps that affect quality at the different layers of the system, identifying

alternative modes of training delivery where the recommended approach is shown to be less practical,

and setting standards for identified alternatives approaches. Most importantly, it demands going beyond

mere updating of material content when carrying out the BINLM revision.

33

Recommendations

When working on BINLM material revision:

Use gaps identified and recommendations from course reviewers as general guidance alongside

applying the review checklist to complement and enrich their outputs

Go beyond reviewing and revising technical content of knowledge session by paying equal attention

to other attributes of the training material including the skill sessions. Use of the review checklist at

the start of the revision process helps for this purpose

While addressing specific technical content of specific courses, technical working groups also need

to equally work on commonly identified areas of improvement including:

o Availing of alternative learning tools

o Reducing the bulk of course material by focusing on practical aspects

o Moderating the speed of the narrator and check for pronunciation related complaints

o Linking knowledge sessions with skill training by alerting participants on areas they should

focus at

o Setting minimum quality standards for skill sessions including recommending venue,

minimum duration and expertise/experience of facilitators

o Incorporating tips for sharing knowledge and skills and also including sharing of acquired

competencies as one objective of the training

On training delivery approach:

If health authorities are to apply different approaches pressed by the local context, different

approaches for integrated training need to be pre identified and

o Minimum quality standards should be set for the alternatives to which training

organizers that opted for these alternatives must adhere.

o Training guides (Training facilitation tips) for alternatives such as; computer-based group

sessions, which is one of the alternatives approaches currently mostly practiced, need to

be prepared

Compulsory completion of the entire package also need to be weighed against need-based

specific course training attendance

Training sessions need to be supervised by higher level authorities for fulfilling minimum

standards

Technical report of trainings need to be availed by implementing partners as it helps to audit

quality

To address potential individual and institutional factors that affect effectiveness:

Identify and support trainees that require tutoring to go through knowledge sessions

Provide need-based coaching and mentoring

Design alternative training approach, as recommended above, that lack essential amenities

(electric power, computer access)

On case-by-case basis address key gaps of health centers that lack essential services and

basic equipment/supplies that affect overall health service quality

Addressing the broader context and further investigation:

Continue working to improve quality of pre-service nutrition education

Instill the culture of e-based learning during pre-service education

34

Annexes

Annex I: Material Review Checklist Course evaluated: _________________________

Blended and Integrated Nutrition Learning Module (BINLM) Review Checklist to

Be Completed by Selected Experts

SECTION I: Respondent’s Identification and Course Related Information

S.N Question Response

1 Name of the evaluator

2 Sex

3 Profession

4 Current Position and Organization

5 BINLM related experience

1. Material content developer

2. ToT trainer (Master trainer)

3. ToT trained nutrition expert

4. Material designer

5. Other (specify)_________________

|___|

6 Period of evaluation ______to ___________(Month and Date)

7 Course evaluated

1. Introduction

2. Micronutrient

3. Adolescent, Maternal, Infant and Young Child

Nutrition

4. Acute Malnutrition

5. Nutrition and Communicable Diseases, Nutrition and

Non communicable diseases, Nutrition and Special

Health Conditions

6. Program Management

(DIRECTION: A single checklist is applied

for a specific Course in the Module)

|___|

SECTION II: Content and Design Review

DIRECTION: Dear Respondent, please give score to each parameter under the 2nd column with

the scores of 0, 1 and 2 or N/A as described under the 3rd column. Write all specific points you

noted for revision in the 4th column. PLEASE refer to the Skill Manual of the course for Q#24.

S.N

Review Components and Questions

Does not need revision=0

Needs minor revision=1

Needs major revision= 2

Not applicable= N/A

Remark:

I. COURSE OVERVIEW and GENERAL INFOMRATION

35

S.N





Not applicable= N/A

Remark:

1 An overview is provided for the Course which includes

purpose, structure, navigation and what major tasks are

due.

|___|

2 Information on who developed the Course and to whom

the courses are primarily targeted is provided.

|___|

3 Information on prerequisites, if any required, and key

references including on how to access them is stated.

|___|

II. COURSE TECHNOLOGY AND TOOLS

4 The technology used in the Course is appropriate for the

learning objectives and competencies expected.

|___|

5 The technology used to provide the Course can be easily

accessed by training targets.

|___|

6 The technology applied for the Course is appropriate to

the computer skill of the majority of the trainees.

|___|

7 The Course and specific sessions can be easily accessed,

do not ‘stuck’, frequently’ and allow back and forth

navigation.

|___|

8 Alternative tool (e.g. easily downloadable/printable

version) is suggested if primarily recommended

tool/approach does not work.

|___|

III. DESIGN and LAYOUT

9 A logical, consistent, and uncluttered layout is developed |___|

10 There is enough contrast between text and background

for the content to be easily viewed.

|___|

11 The title of the Course links to content and resources

working order.

|___|

12 The Course is easy to navigate: consistent color scheme

and icon layout, related content organized together.

|___|

13 Contents in the Course have visible slides, fonts are

readable and can be zoomed to improve visibility.

|___|

IV. CONTENT

14 The Course-level learning outcomes are clear, concise

and measurable, written from the participant's

perspective and appropriate for the level of the module.

|___|

15 Content is directly related to the learning

outcomes/objectives for the training.

|___|

16 Content is written and narrated in an understandable

language.

|___|

36

S.N





Not applicable= N/A

Remark:

17 Content is up-to-date, scientifically correct, locally

appropriate and logically coherent.

|___|

18 Content is appropriate to the needs of the primary

target /health worker/ in terms of volume and depth.

|___|

19 Volume and depth of the module considers the workload

of the primary target for the training.

|___|

20 Case scenarios, case stories and related examples

provided in the content are clear and relevant for the

local context.

|___|

21 Content drives trainees towards immediate application

of knowledge and behavior rather than focusing on facts.

|___|

22 Content provides additional and relevant material for

further reading.

|___|

23 Course summarizes/ concludes key facts of the session

before ending/ proceeding to the assessment part.

|___|

24 Skill sessions in the skill module for the Course, have

appropriate objectives and content aligned with the

knowledge component of the course.

|___|

V. ASSESSMENT and FEEDBACK

25 The module includes frequent and appropriate methods

to assess participants’ mastery of content.

|___|

26 Criteria for the assessment of a graded quizzes are

clearly articulated (instructions, examples given).

|___|

27 Participants have opportunities to review their

performance and assess their own learning throughout

the module (pre-tests, automated self-tests, etc.).

|___|

28 The assessments are structured to align with their stated

learning objectives.

|___|

29 Assessment questions have clear and specific answers.

|___|

30 Assessment and completion of the course is fairly

protected from cheating.

|___|

SECTION III: General Feedback on the Evaluated Course and the Whole Module

31. General feedback on the Evaluated Course or the Whole Module:

THANK YOU FOR YOUR SIGNIFICANT CONTRIBUTION!

37

Annex II: Knowledge and Related Factors Assessment Questionnaire Knowledge and Related Factors Assessment Questionnaire for Health Workers

Trained on the Blended and Integrated Nutrition Learning Module (BINLM)

Consent

Hello! My name is ______________. I am a member of a study team that assesses implementation and

effectiveness of the nationally standardized nutrition training for health workers which is delivered using Blended

and Integrated Nutrition Learning Module (BINLM). The study is overseen by Federal Ministry of Health (FMoH),

approved by regional health bureau and executed by Growth through Nutrition Project, a USAID funded and

Save the Children led multisectoral nutrition project. Findings of this study will provide key inputs for the revision

of the training material and approach that the FMoH planned to do this year. Hence, your participation will be

invaluable in improving the quality of ongoing capacity building efforts for health workers on nutrition.

Since your name will not be recorded anywhere in this document, results of an individual questionnaire will not be

related to personal performance and any reward or punishment mechanism. Before proceeding to specific

knowledge and skill related self-administered questions and exercises, I would like to ask you few questions that

may be linked with the outcomes of the training. The whole assessment will not take more than 1/1/2 hours.

There is no payment for participating in this assessment and you have the right either to participate in the study

fully or interrupt any time after starting if you are convinced to do so.

Are you willing to participate in the study? Yes_________ No__________

Date: ____/____/2011 Start time: ______________ End time: __________________

Name of interviewer: _____________________ Name of Supervisor: __________________

SECTION I: Assessment Area and Respondent Identification Questions (To be filled by assessor)


01 Region 1. Amhara 2. Oromiya

3. SNNPR 4. Tigray

|___|

02 Woreda

1. Enemay 2. Ebnat

3. Arsi Negele 4. Shala

4. Siraro 6. Mierab Azernet

7. Misrak Azernet 8. Misha

9. Medebay Zana 10. Asgede Tsimbila

|___|

03 Name of health center ______________

04 Health Center ID |___||___||___| Derived from Q #s 1,2 and 4

05 Respondent’s ID

|___||___||___||___|

Derived from Q #s 1,2,4 and 5

38

SECTION II: Socio-demographic and Selected Characteristics of Respondents

DIRECTION: Please WRITE the choice in the given space in the right column.


1 Sex

1. Female 2. Male

|___|

2 Age _____________

3 Highest attained level of education

1. Diploma 3. MD/M.Sc./MPH

2. B.Sc. 4. Other _______

|___|

_____________

4 Profession

1. Clinical Nurse

2. Health Officer

3. Midwife

4. Physician

5. Other (Specify)________________

|___|

______________

5 Current department you work in the health center:

1. Under-five clinic 3. ANC/PNC/FP

2. Immunization 4. Other

|___|

________________

6 Year of service __________________

7 Duration of stay in this health facility in completed months __________________

8 How do you rate your computer skills?

1. No expertise in using either MS word, excel, internet

2. Basic skill in using either MS word, excel, internet

3. Proficient in using either MS word, excel, internet

4. Other (level and type of skill, if any)

|___|

__________________

9 Do you have your own computer (desktop/laptop/tablet)?

1. Yes 2. No

|___|

10 Can you have access to computer at your work place or elsewhere when you

need it?

1. Yes, always 2. Yes, sometimes 3. Not at all

|___|

39


11 How do you rate your English language skill and language preference?

1. Very good (Can fully understand written and spoken English and is

quite OK to be trained with English)

2. Good (understand most of written and spoken English and does not

mind to be trained with English)

3. Not bad (Finds it somehow hard to fully understand written and

spoken English)

4. Not good (Finds it hard to understand written and spoken English and

prefer to be trained with another language)

|___|

SECTION III: Nutrition and BINLM-based Training Related Questions

S.N Questions Response

12 Did you participate in any training that focuses separately on any the following

technical areas in the past 1 year? (PAST one year refers to the period from Meskerem

2010-Meskerem 2011) 1. Yes 2. No

|___|

13 If Yes, to Q 12 what was the training on? READ all choices for respondent and

write choices for each. If ‘No’ to all SKIP to Q 15.

1. Acute malnutrition management 1. Yes 2. No

2. Adolescent, Maternal, Infant and Young Child Nutrition (A/MIYCN)

1. Yes 2. No

3. Micronutrient 1. Yes 2. No

4. Behavior change communication (S/BCC) on nutrition 1. Yes 2. No

5. Other

1. |___| 2. |___|

3. |___| 4. |___|

5. ____________

14 If any is chosen for Q 11, please specify Month(s) of training within 2010/11EC. Month _____ Year _________

Month _____ Year _________

15 Did you take the Orientation (introduction and start-up of first modules) at

the beginning of BINLM knowledge part of the training?

1. Yes 2. No

__________________

16 How long did you take to complete the KNOWLEDGE part of the training? __________________ (WRITE

in number of days) 17 How did you take the KNOWLEDGE part of the training?

1. Alone and where I found it convenient

2. With a colleague (s) where we found it convenient

3. All trainees together where computers are available

4. Other

|___|

__________________

18 Were you certified for the KNOWLEDGE part before starting the skill part?

1. Yes, for all modules and showed the certificates

2. Yes, for all modules but no certificate shown

3. Yes, for some of the modules

4. Not at all

|___|

40

S.N Questions Response

19

For how many days did you take the SKILL part of the training?

|___|

20 Where did you take the SKILL part of the training?

1. Training center/Hotel with attachment to health facility

2. Health center 3. Hospital 4. Other/Specify

|___|

__________________

21 When you take the SKILL part of the training, did you feel there were enough

cases to practice relevant skills?

1. Yes 2. No

|___|

22 How do you rate the skill of the trainers for the SKILL part of the training?

1. Very good 2. Good 3. Not bad 4. Bad

|___|

23

How do you compare the computer-based (e-learning) course with classroom-

based knowledge course?

1. I strongly prefer computer based course

2. I prefer computer based course

3. Both are the same

4. I prefer class-room based course

5. I strongly prefer class-room based knowledge course

|___|

24 How do you compare the integrated (all modules in one) course with separate

modules training?

1. I strongly prefer all-modules integrated course

2. I prefer all modules integrated course

3. Both separate and integrated module courses are the same for me.

4. I prefer trainings delivered separately for specific modules.

5. I strongly prefer separate course than integrated ones.

|___|

25 Did you shift/change your position in the health center (from one unit to

another) after you completed the training?

1. Yes 2. No

|___|

26

If Yes, from which Unit to which unit? If No, SKIP to Q#27.

__________________

27 If Yes, is the health workers that is working in your place trained on BINLM?

1. Yes 2. No

|___|

28 Is there a colleague working with you in the department/unit you are currently

working in?

1. Yes 2. No

|___|

29 If Yes, is s/he trained on BINLM?

1. Yes 2. No

|___|

30 After you completed the training, did you get the chance to

1. Share the training materials to untrained staff 1. Yes, 2. No

2. Give on-the job knowledge and skill training to the staff 1. Yes 2. No

3. Did not get the chance to share 1. Yes 2. No

1. |___|

2. |___|

3. |___|

41

SECTION IV: BINLM-based Knowledge Assessment Questions: PLEASE note that this is a SELF-

ADMINISTERED tool.

DIRECTION: Please WRITE your choice in the space provided in the right column.

S.N Questions per module Response

1. Introduction

1.1 Which one of the following is TRUE about types/indicators of malnutrition?

1. Shortness of a child with respect to its age refers to wasting and shows acute

malnutrition.

2. Wasting refers to rapid loss of weight with respect to child’s age and indicates chronic

malnutrition.

3. Shortness of child with respect to its age refers to stunting and shows chronic

malnutrition.

4. Below standard weight to age for child and shows chronic malnutrition.

|___|

1.2 Currently, which type of nutritional index has the highest level in Ethiopia?

1. Wasting

2. Stunting

3. Overweight

4. Underweight

|___|

1.3 Which of the following is an immediate cause of malnutrition?

1. Household food insecurity

2. Disease

3. Inadequate care

4. Unhealthy household environment

|___|

1.4 Choose the primary process in nutrition education among the following.

1. Selecting education delivery method

2. Assessing problems related with nutrition

3. Selecting follow-up method

4. Preparing nutrition education material

|___|

1.5 Which one of the following is a key element of counseling?

1. Building trust

2. Speaking too quickly

3. Forming working alliance

4. Telling the client what to do

|___|

1.6 One of the following is NOT a component of GALIDRAA counseling approach.

1. Greeting the client

2. Attempting/trying to convince the client

3. Listening to the client

4. Discussing options with the client

|___|

1.7 Which of the following is a COMMON ERROR in counseling?

1. Maintaining eye contact with the client.

2. Sitting in the same level with the client.

3. Finishing sentences of the client.

4. Avoiding physical barriers during counseling.

|___|

42


1.8 Which one of the following is TRUE about counseling?

1. It is a one-way communication system.

2. It is the same with nutrition education.

3. It happens when a more knowledgeable person tells a less knowledgeable person what

to do.

4. It helps to assess, analyze and plan solutions for nutrition related problems.

|___|

2. Micronutrient

2.1 Maternal mortality, low birth weight, preterm babies and anemia are highly related to:

1. Zinc deficiency

2. Iron deficiency

3. Vitamin A deficiency

4. Iodine deficiency

|___|

2.2 Which one of the following is TRUE about Vitamin A?

1. Plant source foods are the best source of Vitamin A for human body.

2. Mature breastmilk is the best source of Vit A compared to colostrum.

3. It plays role in immunity, reproduction and fetal development.

4. Dose and frequency of Vit. A supplementation is not affected by age of the child.

5. % of children 0-59 months supplemented with Vit A is an indicator of Vitamin A

supplementation/VAS.

|___|

2.3 Which of the following is TRUE about zinc?

1. Fruits and vegetables are the richest sources of zinc.

2. Currently there is a guideline for zinc supplementation to all children in Ethiopia.

3. Zinc deficiency results in impaired growth and development.

4. In Ethiopia, percentage of children supplemented with zinc helps monitor Zinc

supplementation coverage.

|___|

2.4 Provision of which micronutrient helps to decrease the incidence and duration of diarrhea?

1. Vitamin A

2. Iron

3. Zinc

4. Iodine

|___|

2.5 Which nutritionally vulnerable group requires the highest level of iron intake?

1. Adolescent boys

2. Adolescent girls

3. Pregnant women

4. Lactating women

|___|

2.6 Which of the following is TRUE regarding prevention and control iron deficiency anemia?

1. Deworming of pregnant women starting from the first trimester is recommended.

2. Intermittent IFA supplementation for menstruating women is recommended where

anemia among Women of Reproductive Age (WRA) p is </20%.

3. Delayed cord clamping improves iron status of infant for up to six months.

4. Promoting exclusive breastfeeding does not help as breastmilk has low iron content.

|___|

2.7 For a mother complaining of nausea and vomiting while taking iron supplements, you advise;

1. Drink less fluid

2. Take supplement with meal

3. Start with higher dose and decrease gradually

4. Stop taking supplement if you see dark stool

|___|

43


2.8 The National Iron Folic Acid (IFA) supplementation protocol of Ethiopia recommends,

1. To start iron supplementation during the second trimester of pregnancy

2. To discontinue taking IFA if a mother gave birth after taking iron for 90 days

3. To continue taking IFA postnatally if she gave birth before taking for 6 months

4. To take two doses together for a forgotten dose

|___|

2.9 Which of the following is TRUE regarding folic acid?

1. The highest daily requirement of folate occurs during adolescence.

2. Its deficiency results in neural tube defect, low birthweight and cardiovascular disease.

3. Iron and folate supplements are often given separately.

4. Folic acid supplementation is advised to start late during pregnancy.

|___|

2.10 Iodized salt,

1. Should be washed before use

2. Should be added at the start of cooking

3. Is not affected by direct exposure to moisture

4. Is affected by exposure to heat and sunlight

|___|

3. Adolescent Maternal, Infant and Young Child Nutrition

3.1 Which of the following is TRUE regarding nutrient requirement during pregnancy and lactation?

1. Pregnancy requires around 500 additional Kcal each day.

2. Pregnant woman should gain approximately 20 Kg during pregnancy.

3. Lactating women need additional 285 Kcal per day for the first six months.

4. Pregnancy requires less additional kcal per day than lactation.

|___|

3.2 Which of the following is an immediate cause of maternal malnutrition?

1. Ignorance

2. Uneven distribution of available food

3. Infectious disease

4. Insufficient food supply

|___|

3.3 Which of the following is TRUE regarding nutrition during pregnancy and lactation?

1. Exemption from any work is required during lactation and pregnancy.

2. Avoiding animal source food is advised to prevent big baby.

3. Iron folate supplement should not be provided during lactation if mother took 60

tablets during pregnancy.

4. Two extra meals are recommended during lactation and one extra meal during

pregnancy.

|___|

3.4 Regarding weight gain during pregnancy, which one of the following is TRUE?

1. Pre-pregnancy weight is important to estimate the amount of weight a pregnant woman

need to gain during pregnancy.

2. BMI for women can be calculated by dividing weight in Kg per height in cm

3. A normal healthy pregnant women gain at least 2Kg per month

4. Pregnant woman should gain approximately 20 Kg during pregnancy.

|___|

3.5 Which of the following intervention is NOT important for adolescents?

1. Health facility and school linkage

2. Healthy diet

3. Iron folate supplementation

4. Vitamin A supplementation

|___|

44


3.6 Which of the following phrases do NOT relate to proper positioning of baby during breast

feeding?

1. The mother’s hand must support the whole body of the baby at the back

2. Baby and mother should touch abdomen to abdomen

3. Baby’s head should be turned to the breast

4. Baby should be facing the breast

|___|

3.7 For a child of 12 up to 24 months of age, how much complementary food should be given per

day?

1. 2 full coffee cups and one-time snack

2. 3 full coffee cups and one-time snack

3. 4 full coffee cups and 1 to 2 snacks

4. 1 full coffee cup and 3 snacks

|___|

3.8 Which of the following example of mixture is recommended in preparing flour for a child’s

porridge?

1. Barley, red teff and wheat

2. Lentils, pea, chick pea and beans

3. Barley, teff, wheat and corn

4. Barely, chick pea and wheat

|___|

3.9 One of the following is NOT among the benefits of adequate nutrient intake during pregnancy.

1. Prevents intrauterine growth restriction

2. Ensures energy storage for lactation

3. Ensures normal presentation of the fetus

4. Decreases the risk of complications during pregnancy and delivery

|___|

3.10 Which of the following sentences relates to proper feeding recommendation during sickness for

children less than six months of age?

1. Breastfeeding should be increased

2. Any form of medication is possible

3. Fluid intake should be increased

4. Fluid intake should be decreased

|___|

3.11 Which of the following is TRUE regarding feeding of low birth weight (LBW) babies?

1. Give formula milk

2. Cup feed breastmilk if needed

3. LBW babies do not need to be followed while feeding

4. LBWs require less fluid and energy

|___|

3.12 Which of the following is NOT true about community involvement for nutrition?

1. Community leaders can be change agents to make behavior change towards IYCN.

2. Implementing IYCN program by consulting the community is a good strategy.

3. Community mobilization fosters collaboration between community and health facilities.

4. Discussion on optimal IYCF practices does not relate to fathers.

|___|

4. Acute Malnutrition

4.1 Wasting is defined as:

1. Weight for height <-2 Z score

2. Weight for age <-2 Z score

3. Weight for height -2 Z score to -2 Z score

4. Weight for age <-3 Z score

|___|

45


4.2 Which case of child malnutrition can be managed in OTP?

1. WFL/H <70% or MUAC<11 cm with medical complication and good appetite test

2. Edema of both feet (+, ++) without medical complication and good appetite

3. WFL/H ≥70% to <80% or ≥-3Z to -2Z score

4. WFL/H <70% or MUAC<11 cm without medical complication and fails appetite test

|___|

4.3 Which case of child malnutrition should be managed as in-patient?

1. WFL/H <70% or MUAC<11 cm without medical complication and fails appetite test

2. Edema of both feet (+, ++) and no medical complication and passes appetite test

3. WFL/H>/70% to <80% or ≥-3Z to -2Z score

4. WFL/H <70% or MUAC<11 cm without medical complication and passes appetite test

|___|

4.4 If WFL/H ≥ 80% or ≥-2Z, MUAC ≥12cm and no edema of both feet, a health worker should

1. Refer the case to supplementary feeding

2. Congratulate and counsel the mother on IYCF

3. Manage the case in OTP

4. Admit the case for in-patient management

|___|

4.5 Mulu is an 18-month-old girl with W/H <70% and has edema (+) of both feet. She has no other

medical complication and has good appetite. What is the appropriate classification and

management for Mulu? 1. Moderate Acute Malnutrition, refer to supplementary feeding program and start with

RUTF.

2. Complicated Severe Acute Malnutrition, admit for in-patient management and start with

F75.

3. Uncomplicated Severe Acute Malnutrition, manage in OTP and start with RUTF.

4. Complicated Severe Acute Malnutrition, admit for in-patient management and start with

F100

|___|

4.6 Abebe is a 4 months old infant. Upon examination, the nurse found out that he is clinically

stable without apparent medical condition except that his weight for height is below -3 Z score.

What is the appropriate classification and mode of management for Abebe?

1. Moderate acute malnutrition: refer to supplementary feeding program

2. No acute malnutrition: no need for treatment

3. Uncomplicated severe acute malnutrition: treat as outpatient

4. Complicated Severe Acute Malnutrition: treat as inpatient

|___|

4.7 Which of the following is NOT TRUE about management of severely malnourished children?

1. All severely malnourished children should be given antibiotics as most have hidden

bacterial infection.

2. Feeding should start slowly as the systems of the body slows down with severe

malnutrition.

3. Iron should not be given early in treatment as there is less iron stored in severely

malnourished child.

4. Sodium should be provided via ORS but not potassium.

|___|

4.8 Misdiagnosis and mistreatment of which of the following is the COMMONEST cause of death in

a child with SAM?

1. Hypoglycemia

2. Hypothermia

3. Dehydration

4. Abdominal distension

|___|

46


4.9 Which of the following is NOT correct about management of medical complication in a child

with SAM?

1. For alert child with hypoglycemia 50ml of 10% glucose can be given orally or via NG

tube

2. Kangaroo mother technique helps to actively re-warm a child with hypothermia

3. 5ml/kg/30 min of Resomal is given for 12 hours for a conscious and dehydrated child.

4. If no medical complication is present oral amoxicillin is preferable.

|___|

4.10 Which of the following applies for management of severe malnutrition in children>6 months of

age?

1. F75 is used in transition phase management.

2. F100 is used during phase 1 management.

3. Ready to use therapeutic food (RUTF) is introduced during the transition phase.

4. Iron can be given at the start of treatment.

|___|

5. Nutrition and communicable Diseases, Non, communicable Diseases and Nutrition in Special

Health Conditions

5.1 One of the following is CORRECT about HIV, TB and nutrition.

1. All HIV infected individuals are not at risk of weight loss and malnutrition.

2. Active TB decreases energy requirement of the body.

3. HIV infected individuals need high amount of proteins and vitamins.

4. Malnutrition increases mother to child transmission of HIV in pregnant women.

|___|

5.2 Which one of the following is NOT Critical Nutrition Practices for PLHIV?

1. Doing regular physical exercise

2. Regular nutritional assessment

3. Using herbal medications to treat HIV related symptoms

4. Eating variety of foods

|___|

5.3 Which of the following is NOT a means of dietary management of diarrhea?

1. Eating foods rich in soluble fiber (bananas, peas and lentils)

2. Drinking lots of fluids

3. Consuming too much sweet drinks

4. Consuming easily digestible rice, bread, potato

|___|

5.4 What is the classification of an adult with a BMI of less than 16?

1. Normal

2. Mild malnutrition

3. Severe malnutrition

4. Moderate malnutrition

|___|

5.5 In the management of Type 2 diabetes mellitus, one of the following is NOT required.

1. Physical exercise

2. Nutrition therapy

3. Insulin administration

4. Multidisciplinary approach

|___|

5.6 Which has a direct effect in the development of chronic diseases in developing countries?

1. Economic growth and technology transfer

2. Changing life styles and dietary practices

3. Persistence of food insecurity

4. Transformation from agrarian to industrial society

|___|

47


5.7 Which one of these grain products need to be limited or avoided not to increase one’s total

blood cholesterol?

1. Whole wheat flour

2. High fiber cereal

3. White refined flour

4. Whole grain pasta

|___|

6. Program Management

6.1 A term that refers to interventions that directly address the immediate causes of malnutrition:

1. Nutrition-sensitive interventions

2. Food security

3. Nutrition-specific interventions

4. Family planning

|___|

6.2 Which of the following shows a CORRECT match between specific intervention and category?

1. Treatment of severe acute malnutrition: Nutrition-sensitive intervention

2. Optimal breastfeeding: Nutrition-specific intervention

3. Women empowerment: Nutrition-specific intervention

4. Social protection: Nutrition-specific intervention

|___|

6.3 Which one shows a CORRECT match for the different types of nutrition communication?

1. Advocacy: helps to change knowledge, attitude and practice of specific audience

2. Social mobilization: increases resources and political or social commitment

3. Social mobilization: best used when people are generally unaware of an issue

4. BCC: promotes wider participation, collective action and ownership

|___|

6.4 Which of the following is wrong about coordination?

1. Coordination is exchanging information and altering activities for mutual benefit and

to achieve a common purpose.

2. Multisectoral coordination means all sectors merge their plans and resources and

works together for a common objective.

3. Coordination, collaboration, cooperation differ in their scope of working together.

4. Multi-sector coordination increases program impact and lowers program costs.

|___|

6.5 Which one of the following is FALSE about supply management?

1. Quantification is a process that estimates the total quantities and costs of products

that will be used during a specific time period

2. Forecasting is estimating quantity and cost required of each product to meet

demand for the forecast period

3. Supply planning is a type of supply quantification that answers the question how

much to procure, when to receive and with what quantities.

4. During storage of supplies, supplies should be rotated on ‘first expiry, last out’ basis.

|___|

6.6 Which of the following strategic objective of the NNP addresses the underlying causes of

malnutrition?

1. Improve the nutritional status of women and adolescents

2. Improve the nutritional status of infants, young children and children under 5

3. Improved the delivery of nutrition services of communicable and non-

communicable diseases

4. Strengthen implementation of nutrition sensitive intervention across sectors

5. Improve multisectoral coordination and capacity to ensure NNP implementation

|___|

48

SECTION V: General Feedback on the whole BINLM-based Course

1. General suggestion to improve the BINLM-based training

Annex III: Skill Assessment Questionnaire Skill Assessment Checklist for Health Workers Trained on the Blended and

Integrated Nutrition Learning Material (BINLM)

I. Vitamin A Administration

Step Task/Activity:

Did the Health worker,

Yes=1

No=0

1 Greet the caregiver and introduce his/herself? |___|

2 Ask for the age of the child? |___|

3 Ask the caretaker if the child has received vitamin A capsule in the last one month. If the

answer is YES, confirmed that and did not administer Vitamin A?

|___|

4

Select appropriate dose based on child’s age, if the answer to STEP 3 is ‘NO’?

100,000 IU to child 6-11 months

200,000 IU to child 12-59 months

|___|

5 Cut the nipple of the capsule at the middle (NOT at the tip or bottom) with scissors and

immediately squeeze the drops of liquid into the child’s mouth?

|___|

6 Ask the caretaker to hold the child firmly, make sure the child is calm, give the appropriate dose

of vitamin A to the child?

|___|

7 Check if the child is comfortable after swallowing the drops? |___|

8 Put all capsules that have been used into a plastic bags and, Wipe your hands to clean off oil? |___|

9 Record the dose on the tally sheet. |___|

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II. Maternal and IYCF Counseling Skill

DIRECTION: Please ask the BINLM trained health worker to apply the procedures for

counseling on a real client at the visited health center. And rate performance as ‘Very Good=2’,

‘Good=1’ or ‘Not Done=0’. The client should be either a mother/caregiver with a child of

under two years of age or a pregnant/lactating women.

Step

Task/Activity: Did the Health worker,

Very Good=2

Good=1

Not Done= 0

1 Greet the mother/care giver of the child or the pregnant/lactating woman? |___|

2 Ask the mother/care giver/Pregnant/lactating women

2.1 For a child: Ask for age of the child, breastfeeding status, if the child has started

food or not, If ‘Yes’ what type of foods, If ‘No’, why not? Frequency of feeding?

general health condition? Foods available at home or locally accessible)

|___|

2.2 For a pregnant/lactating women: Ask for gestational age, ANC follow-up (If

pregnant); Frequency of maternal feeding, variety/types of food , IFA intake and

adherence, Foods available at home or locally accessible)

|___|

3 Listen attentively to what the parents said |___|

4

Identify difficulties & prioritize the most important one to work on based on

mother’s/caregivers

|___|

5 Discuss feeding options & Recommend simple doable actions.

5.1 Use counseling cards properly |___|

5.2 Discuss simple doable actions based on identified and prioritized problems (did

not mention all the recommended behaviors)

|___|

5.3 Discuss optimal breastfeeding/complementary feeding options appropriate to the

age of the child

|___|

5.4 Discussed if suggestions are easy or not to practice

|___|

5.5 Help the mother/care giver to agree and to try one of the options, and asks them

to repeat the agreed-upon actions.

|___|

6 Appoint mother/care giver for next visit |___|

III. Anthropometric measurement: Taking weight of children

Steps Task/activity: Did the Health worker, Yes=1

No=0

1 Remove the child's clothes, but keep the child warm with a blanket or cloth while carrying

to the scale.

|___|

2 Put a cloth in the scale pan to prevent chilling the child. |___|

50

3 Adjust the scale to zero with the cloth in the pan. (If using a scale with a sling or pants or

basin, adjust the scale to zero with that in place.)

|___|

4 Place the naked child gently in the pan (or in the sling or pants). |___|

5 Wait for the child to settle and the weight to stabilize. |___|

6 Measure weight to the nearest 100gm or as precisely as possible. Record immediately on

multi-chart.

|___|

7 Wrap the child immediately to re-warm. |___|

8 Make sure the weighing scale is calibrated to zero before each measurement is taken. |___|

9 Record the weight to the nearest 100 grams. |___|

51

Annex IV: Observation Guide at Health Facility Level Observation Guide on Blended and Integrated Nutrition Learning Module

(BINLM)-based Training

Name of Observer: _____________________

SECTION I: Assessment Area Identification Questions



5. SNNPR 4. Tigray

|___|

02 Woreda (Write N/A if respondent is at regional/zonal level)

2. Enemay 2. Ebnat





|___|

03 Name of Health Center

04 Health center ID |___||___||___

|

05 Health center provides OTP service 1. Yes 2. No

|___|

06 The health center has Stabilization Center 1. Yes 2. No

|___|

SECTION II: Observation Checklist by component

S.N Question Yes=1

No=0

1. General

1 Electric power available 24/7 |___|

2 Computers available at the HC 1=Yes 2=No |___|

3 If yes, how many? |___|

II. Key measurement tools and supplies

2.1 Weighing scale |___|

2.2 Length/Height board |___|

2.3 MUAC tape |___|

2.4 Zinc + Oral Rehydration Salt |___|

2.5 Iron/Folic acid |___|

2.6 Amoxicillin |___|

2.7 Albendazole/Mebendazole Tablets |___|

2.8 Vitamin A |___|

52

S.N Question Yes=1

No=0

2.9 If OTP service is provided, RUTF available |___|

2.10 OTP cards, registration book |___|

If SC service is provided

2.11 Separate SC room |___|

2.12 F-75 |___|

2.13 F-100 |___|

2.14 SC utensils ( cup, measuring jar e. t .c) |___|

2.15 SC cards, Registration book, reference charts |___|

III. Counseling related Job Aids

3.1 Counseling card on MIYCN available at under 5 clinic, ANC/PNC room |___|

3.2 Growth monitoring charts (both for boys and girls) |___|

3.3 Family Health Guide available

IV. Record Keeping, Data Compilation and Reporting:

Direction: Take a sample of 2 cards from each quarter in 2010 EC and two monthly reports where

SC service is available. Mark as ‘Yes’ if half of the sampled satisfies the stated criteria and ‘No’ if not. Filling out individual follow up chart (Multi-chart and OTP Card)

4.1 Identification part is completed fully

4.2 Anthropometry part is completed fully

4.3 History part is completed fully

4.4 Physical examination part is completed fully

4.5 The classification is indicated clearly

4.6 Routine medication part filled fully

Filling out registration book

4.7 Date recorded accurately

4.8 Anthropometric measurements completed for admission date

4.9 Date of discharge recorded appropriately

4.10 Outcome recorded accurately

Completing monthly reporting format

4.11 Identification of the facility recorded accurately

4.12 Total at the beginning of this month matches with total at the end of last month

4.13 Admission information filled our correctly

4.14 Discharge information filled our correctly

4.15 Total at the end of the month is calculated accurately

4.16 Average length of stay is accurately calculated from the registration book

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DIRECTION: The health worker will take either length or height depending on the age and

measure of the child (length between 85 to 110 cm). But not both skill tests.

IV. Anthropometric measurement: Taking LENGTH of children Steps Task/activity: Did the Health worker, Yes=1

No=0

1 Place the measuring board flat, preferably on a stable, level table |___|

2 Ensure cloths do not get in the way of measurement |___|

3 Let one person stand or kneel behind the head board and |___|

3.1 Position the child lying on his back on the measuring board, supporting the

head and placing it against the headboard.

|___|

3.2 Position the crown of the head against the headboard, compressing the hair |___|

3.3 Hold the head with two hands and tilt upwards until the eyes look straight up,

and the line of sight is perpendicular to the measuring board.

|___|

3.4 Check that the child lies straight along the center line of the measuring board

and does not change position.

|___|

4 Let himself/the other person stand alongside the measuring board and: |___|

4.1 Support the child's trunk as the child is positioned on the board. |___|

4.2 Place one hand on the shins or knees and press gently but firmly. |___|

4.2 Straighten the knees as much as possible without harming the child. |___|

4.3 With the other hand, place the foot piece firmly against the feet. The soles of

the feet should be flat on the foot piece, toes pointing up.

|___|

5 Measure length to the last completed 0.1 cm and record immediately on the Multi-

chart.

|___|

V. Anthropometric measurement: Taking HEIGHT of children Steps Task/activity: Did the Health worker, Yes=1

No=0

1 Place the stadiometer (height board) on a level floor. |___|

2 Remove the child’s socks and shoes for accurate measurement. Also remove hair

ornaments and undo braids IF they interfere with measurement.

|___|

3 Let one person kneel or crouch near the child’s feet and: |___|

54

Steps Task/activity: Did the Health worker, Yes=1

No=0

3.1 Help the child stand with back of the head, shoulder blades, buttocks, calves

and heels touching the vertical board.

|___|

3.2 Hold the child’s knees and ankles to keep the legs straight and feet flat. Prevent

children from standing on their toes.

|___|

4 Let himself/the other person bend to level of the child’s face and: |___|

4.1 Position the head so that the child is looking straight ahead (line of sight is

parallel to the base of the board).

|___|

4.2 Place thumb and forefinger over the child’s chin to help keep the head in an

upright position

|___|

4.3 With the other hand, pull down the head board to rest firmly on top of the

head and compress hair.

|___|

5 Measure the height to the last completed 0.1 cm and record it immediately on the Multi

chart.

|___|

VI. Anthropometric Measurement: Taking MUAC of Children Step Task/Activity:

Did the Health worker,

Yes=1

No=0

1 Locate tip of shoulder |___|

2 Locate tip of elbow |___|

3 Place tape at tip of shoulder

|___|

4

Pull tape past tip of bent elbow

|___|

5 Mark mid-point |___|

6 Wrap the tape on the arm across the marked point |___|

7 Correct tape tension |___|

8 Correct tape position for arm circumference |___|

9 Measure MUAC to the last completed 0.1 cm and record it immediately. |___|

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VII. Preparation of F100 and F75 Feeds

DIRECTION: Please provide the following case to the health worker, check the

calculated Total ml/day with the last column and use the checklist in the last table to

follow actual preparation.

Name Age in month Weight in Kg Phase Type of

Milk

Number

of feed

Total

ml/day

Asnake 14 months 6.2 1 F 75 6 840ml

Lema 12 months 5.7 Transition F 100 6 720ml

Step Task/Activity: Did the health worker, Yes=1

No=0

1 Summarize total ml of milk to be prepared for both Phase 1 and transition |___|

2 Calculate the number of red scoops and amount of water accurately |___|

3 Wash hands |___|

4 Measure the amount of water for each phase |___|

5 Put the right number of red scoops for each phase |___|

6 Use whisk and prepare the milk |___|

7 Measure the right amount and offer to the children |___|

Annex V: Semi-structured KII Guide

Semi-structured Key Informant Interview and Key Data Capturing Guide on

Blended and Integrated Nutrition Learning Module (BINLM)-based Training

Consent

Hello! My name is ______________. I am a member of a study team that assesses implementation and

effectiveness of the nationally standardized nutrition training for health workers which is delivered using Blended

and Integrated Nutrition Learning Module (BINLM). The study is overseen by Federal Ministry of Health,

approved by regional health bureau and executed by Growth through Nutrition Project, a USAID funded and

Save the Children led multisectoral nutrition project. Findings of this study will provide key inputs for the revision

of the training material and approach that the FMoH planned to do this year. Hence, your participation will be

invaluable in improving the quality of ongoing capacity building efforts for health workers on nutrition.

56

I will ask for your name here only to clarify on any information I might have missed or misunderstood from you

later; otherwise it will not be reported anywhere in the findings. To retain the most out of our communication, the

interview will be audio-recorded. I may ask for to see some relevant documentation for further desk review and

verification purpose and collect copies, if allowed. The interview takes around 40 minutes and it can be stopped

whenever you wish.

Are you willing to participate in the study? Yes_________ No__________

Date: ____/____/2011 Start time: ______________ End time: __________________

Name of interviewer: _____________________

SECTION I: Assessment Area and Respondent Identification Questions



7. SNNPR 4. Tigray

|___|

02 Woreda (Write N/A if respondent is at regional/zonal level)

3. Enemay 2. Ebnat





|___|

03 Respondent’s profession

04 Respondent’s organization and position

05 Duration of stay in the position (In months)

06 Took part in BINLM training or orientation in the past 2 years? (Meskerem

2008-Meskerem 2011/till now) as

1. Organizer 2. Trainer 3. Participant 4. None 5. Other (Specify)

|___|

SECTION II: BINLM-based Training Related Experience and Views

1. Was BINLM based training conducted in your region in the past two years?

2. If yes, which body supported the training/s? (Government itself or partner/Specify)

3. In what way were the ‘Knowledge’ and ‘Skill’ components of the training provided?

57

4. Was there any variation in the way the trainings were provided across time (in the Past 2 Years)

or was it similar?

5. If there were variations, can you tell me WHY and WHAT kind of variation was there?

6. Which part of the training often goes well? The Knowledge or the Skill part?

7. Which part of the training often faced a challenge, if any? Can you tell me WHAT the challenges

were? WHAT did you do to address these challenge?

8. What do you think are the major strengths/advantages of BINLM based training?

9. Do you think BINLM is effective in equipping HWs with the appropriate knowledge and skill? If

‘Yes’, WHY? If ‘No’, WHY?

10. What do you think are/can be major factors that affect quality of BINLM-based training? WHY?

58

11. Would you please tell me key areas of improvement that can make the BINLM training more

effective? (PROBE for clarity whenever required.)

12. Would it be possible to see a sample of the training reports?

THANK the Key Informant here as you have finished qualitative questions here and you

can stop audio recording.

13. Would you please provide me data on the following areas that are related to BINLM training

and its effectiveness? (Data can be available other units such as Plan and Program).


1 # of HC in the region/zone/woreda

2 # of HCs with regular electricity supply

3 # of HC with computer facility accessible by staff

4 # of HWs trained on BINLM in the past 2 years4 (if not available take for the past 1

year)

5 Any plan to train HWs on BINLM this year? (Yes/No)

6 If Yes to Q5, # of HWs planned to be trained

5 # of HWs trained on other specific nutrition trainings in the past two years1

1. CMAM

2. AMIYCN

3. Others

Annex VI: Frequency tables of aggregated score of study participants for each module

and general scores Scores for the introductory module

Scores for the micronutrient module –Knowledge section

4 Document for the time period available but SPECIFY time period in the remark column.

# of correct responses Frequency Valid Percent Cumulative Percent

1 5 4.0 4.0

2 11 8.7 12.7

3 10 7.9 20.6

4 31 24.6 45.2

5 25 19.8 65.1

6 22 17.5 82.5

7 13 10.3 92.9

8 9 7.1 100.0


0 1 .8 .8

2 4 3.1 3.9

3 11 8.7 12.6

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Aggregate scores for the AMIYCN module


0 2 1.6 1.6

1 2 1.6 3.1

2 4 3.1 6.3

3 13 10.2 16.5

4 14 11.0 27.6

5 23 18.1 45.7

6 16 12.6 58.3

7 16 12.6 70.9

8 18 14.2 85.0

9 10 7.9 92.9

10 2 1.6 94.5

11 4 3.1 97.6

12 3 2.4 100.0

Aggregate score for Acute Malnutrition Module


0 1 .8 .8

1 12 9.4 10.2

2 20 15.7 26.0

3 23 18.1 44.1

4 14 11.0 55.1

5 18 14.2 69.3

6 16 12.6 81.9

7 13 10.2 92.1

8 6 4.7 96.9

9 4 3.1 100.0

4 12 9.4 22.0

5 18 14.2 36.2

6 30 23.6 59.8

7 23 18.1 78.0

8 21 16.5 94.5

9 5 3.9 98.4

10 2 1.6 100.0

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Aggregate scores for Nutrition in communicable and non-communicable diseases module

Aggregate score for nutrition program management


0 18 14.2 14.2

1 48 37.8 52.0

2 29 22.8 74.8

3 25 19.7 94.5

4 4 3.1 97.6

5 3 2.4 100.0

Aggregated score for all six modules

Score Valid Percent Score Valid Percent Score Valid Percent

12 .8 24 9.5 35 1.6

13 2.4 25 4.8 36 1.6

14 4.0 26 4.0 37 .8

15 2.4 27 3.2 38 .8

17 1.6 28 6.3 39 .8

18 4.8 29 2.4 40 .8

19 2.4 30 6.3 43 2.4


0 3 2.4 2.4

1 9 7.1 9.4

2 24 18.9 28.3

3 29 22.8 51.2

4 27 21.3 72.4

5 14 11.0 83.5

6 15 11.8 95.3

7 6 4.7 100.0

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