Lessons Learned From Integrating Infant and Young Child Feeding Counseling and Iron-Folic Acid Distribution Into Routine Immunization Services in Ethiopia

Study Rationale and Methodology

The pilot study used a qualitative descriptive design to answer the following questions.

1. How did integrated planning influence planning for immunization and nutrition services?

   1. What was the experience of respondents at regional, district, and facility levels?

   2. Which aspects of integrated planning worked well and which presented challenges?

2. How did integrated service delivery influence immunization and nutrition service delivery?

   1. What was the experience of respondents at regional, district, and facility levels?

   2. Which aspects of integrated service delivery worked well and which presented challenges?

Data Collection, Management, and Analysis

Data collection methods included key informant interviews (KIIs), observations, and document review.

1. KIIs with HF HWs, regional health bureaus nutrition officers and EPI focal persons, woreda health office EPI focal persons, nutrition partners, and immunization specialists from UI-FHS. The KIIs were designed to elicit respondents’ experiences and perceptions related to integrating IYCF counseling and IFA supplementation into immunization services. Key informants were selected to capture the perspectives of those responsible for managing the program and those with direct service delivery experience who could share insights into community perceptions of integrated services.

2. Observations of integrated sessions to document whether HWs provided integrated services and completed data collection forms in accordance with the guideline.

3. Document reviews to verify the availability of integrated microplans; up-to-date session plans for static, outreach, and mobile immunization sessions; and session tally sheets. Session observations and document reviews were used to triangulate learnings from the KIIs.

From December 2020 to January 2021, the team conducted 43 KIIs, observed 4 integrated sessions, and completed document reviews at 17 HFs. Document review data were not available from 5 health facilities in Benishangul-Gumuz due to security concerns at the time of data collection that prevented site visits; KIIs for these facilities were conducted over the phone. To avoid conflict of interest and bias during data collection, staff involved in implementing the pilot were not members of UI-FHS data collection teams. Four researchers with advanced degrees in public health, expertise in qualitative research, and fluency in Amharic and Somali conducted data collection. They underwent a 2-day training on study objectives, the project’s background, qualitative research, data collection tools, and immunization and nutrition programming in Ethiopia. Respondents gave their written informed consent to participate. Data collectors used interview guides and audio-recorded interviews. The audio files were transcribed in English and transcripts were imported into NVivo 12 for coding and analysis. An inductive content and thematic analysis approach was used to identify themes related to the main research questions. Team members divided the transcripts and independently coded interviews. Kappa coefficient scores were compared to gauge the consistency of coding. Researchers discussed scores that fell below 80 and recoded the data based on consensus. To triangulate data from the KIIs, the team analyzed Excel data from document reviews and observations.

Ethical Approval

The JSI Institutional Review Board (IRB) (IRB #20-51E) determined that the study was exempt based on the U.S. Code of Federal Regulations CFR 46.101 (b) (2), which covers study activities without identifiers or sensitive questions that could result in harm. No participants in the study were aged younger than 18 years. All of the regional health bureaus approved the implementation of this study.

Collaborative Planning and Target Setting

Microplanning for integrating IYCF counseling and IFA supplementation and immunization programs requires mapping where communities are located and determining how best to reach populations through shared resources. Respondents explained that before the pilot, nutrition and immunization activities were planned independently by each program, resulting in siloed and parallel planning and service delivery systems.

Key informants noted that microplans were developed by the woreda health office, HFs, community members, and immunization and nutrition partners using a participatory approach, which resulted in the incorporation of diverse views in planning. The HFs used the microplans to develop plans for static, outreach, and mobile immunization sessions that incorporated counseling for IYCF and distribution of IFA. Because respondents considered integrated microplanning more efficient and cost effective than planning for immunization and nutrition services separately, they suggested integrating additional interventions into the microplanning process. Respondents from Afar specifically shared an interest in integrating family planning services to expand the reach of those services. The document review revealed that 16 of the 17 HFs had a copy of the integrated microplans and session plans.

The integrated plan makes work easier because 2 things [are] done at single time. —HW, Somali

Fifteen microplans included target numbers for all population categories (pregnant women, children aged 0–6 months, and children aged 6–23 months) to be reached with integrated services. Although some key informants did not experience challenges setting targets during microplanning, others reported difficulty setting targets for large nomadic populations, which resulted in a mismatch between the actual number of children who attended mobile and outreach sessions and the number of children HWs had estimated in microplans. Respondents recommended updating microplans every month to keep pace with changes in catchment area populations. Notably, challenges with establishing accurate targets are not unique to integrated microplanning but common in immunization microplanning.

The challenge is mainly the initial data gathering at those hard to reach areas to come up with clear eligible target counting. —EPI Officer, Benishangul-Gumuz

Managing Supplies, Clients, and Reporting

The pilot study assessed changes in workflow, reporting, and supply management that resulted from integrating immunization and nutrition services. Combining IYCF and IFA with immunization services required HWs to reorganize their service delivery workflow. For example, they needed to adjust the sequence in which services were offered to optimize the flow of clients and deliver all required services without compromising quality. All of the HWs reported that they offered IYCF counseling before vaccinating because when caregivers focus on soothing a child who is crying after immunization, they were less able to pay attention to nutrition counseling. HWs noted that when integrated sessions got busy, they required additional HWs to provide services. In these situations, respondents recommended training community members or volunteers to conduct counseling to enable HWs and nurses to focus on immunizations.

KIIs with HWs and session observations suggest that HWs determined whether to offer a mother individual or group IYCF counseling based on the number of clients present, the amount of time available to complete tasks, the number of HWs present to complete the tasks, and the child’s weight. HWs were trained to offer individual counseling but often provided group counseling, resulting in inconsistent service quality. However, in all 4 observed sessions, HWs consistently communicated the 5 key immunization messages. Of the 4 sessions, 2 sessions included women eligible for IYCF counseling which they received as planned.

In addition to service considerations, integrating immunization and nutrition services requires effective management of multiple supplies—vaccine carriers, scales, counseling cards, IFA tablets, vaccines, immunization registers, and data recording forms. HWs reported that it was easier to conduct integrated services at static sites than through outreach and mobile services because all of the necessary supplies were present in the HFs. HWs noted that carrying supplies to outreach sessions was challenging, but community volunteers often helped them.

We do go for outreach and carry many things, including the registration books, all required supplies, safety box. [And] it is not easy to carry all these things since we don’t have a vehicle to drop us at the outreach site. —HW, Somali

HWs also stated that while integrated outreach sessions took longer, they did not have to make separate trips to a community to provide nutrition and immunization services. Overall, they found it beneficial to reach communities with both services in 1 visit.

Through the integrated work we saved time and energy because instead of going 2 times to deliver immunization and nutrition services, we just do it once. It is also kind of waste of time if you travel a long distance and only provide immunization services and come back without providing nutrition services to the children and pregnant women. —HW, Somali

While HWs requested per diems and transport for outreach and mobile services and funds to cover these costs were typically included in microplans, the funds were not consistently provided to HWs. This is a systemic challenge that is not unique to integrated services.

HWs were tasked with completing the reporting requirements for all services provided during integrated sessions. In 2 of the 4 observed sessions, HWs did not complete the integrated reporting forms during the session. Instead, they recorded immunization service data in the EPI register and tally sheet and made informal notes about specific nutrition services, intending to complete the integrated reports after the session. The team could not confirm whether HWs followed through on this plan.

The integration requires more of a teamwork to register, screen, and counsel, provide vaccine, IFA for pregnant mothers, and tally services offered. Therefore, it requires more human resource for effective session. This is mostly true for outreach and mobile sites. [We] don’t have a problem at static one. —EPI focal person, Benishangul-Gumuz

Importance of Supportive Supervision and Mentorship

The HWs interviewed expressed appreciation for the supportive supervision they received during the early months of the pilot. During these visits, HWs learned to plan for and manage integration activities and complete the integration-related reporting forms. HWs recommended that these visits be scheduled more frequently, a minimum of once monthly. Of 17 HFs, 15 received supportive supervision visits focused on integration during the time of the pilot study.

We were making mistakes while completing the format because we did not understand it well… [woreda health office and JSI] showed us all the things in the format on the spot during the static session. It has not been a challenge once we have understood it well. —HW, Gambela

Strengthened Linkages Between Services and Increased Reach of Nutrition Services

Integration strengthened linkages between nutrition and immunization services. Before this activity, key informants explained that IYCF counseling, IFA tablet distribution, and immunization operated as siloed services, and counseling on EBF and complementary feeding were provided in an ad hoc manner. By integrating the services, HWs reported that they were more organized and consistent in providing IYCF counseling to all clients.

We used to teach mothers about exclusive breastfeeding and complementary feeding. However, it was not regular like this, but it was only provided when mothers came to health posts. —HW, Afar

HWs noted that when a child presented for immunization services, they offered IYCF counseling, and when a pregnant woman sought immunization services, such as tetanus toxoid immunization, they offered IFA tablets and encouraged completion of all ANC visits. Women who gave birth at home were advised to complete their child’s immunization schedule and counseled on IYCF.

The integrated approach helps to provide iron for pregnant women who do not attend ANC services, and for the immunization program, it helps to find newborns that are born at home. —HW, Afar

In addition to providing immunization and nutrition services, some HWs screened children for malnutrition. Children identified as malnourished during integrated outreach sessions were referred to the Outpatient Therapeutic Programme. In some instances, HWs who managed Outpatient Therapeutic Programme services also checked the immunization status of children and referred unvaccinated children to an integrated outreach session or static clinic. HWs reported that these connections between nutrition and immunization services did not occur before integration. It is worth noting that the intervention focused on IYCF and IFA; screening for malnutrition was an unexpected adaptation that some HWs incorporated organically into their work.

Mixed Community Response

During KIIs, HWs were asked for their perceptions of community responses to providing integrated services. HWs indicated that the community response was mixed. Community members reported to HWs that they preferred integrated services because they enabled them to access multiple services in a single visit. However, HWs also reported that they received several complaints about integrated sessions taking too long and that some communities felt that IYCF counseling was not critical. Communities reported a preference for outreach sessions (where services were brought to them) over static service delivery. HWs also reported that they perceived an overall increase in community awareness about immunization and nutrition services because each service reinforced the other. For example, pregnant women began to request IFA tablets.

First of all, the EPI and nutrition services and I have seen significant changes. [These] include mothers who come to the health post to receive vaccination and nutrition services, and the mothers kept their appointments at the health post, and understanding of IFA tabs and its benefits for pregnant women, and [pregnant] mothers come to us and ask for IFA tabs, which means that the understanding of the community is very good. —HW, Somali

Some of them find it interesting but many of them say, “Let me go, I have to return and cook food for the family, I have long walk ahead…” So they don’t want to stay long, rather they ask for another appointment. —HW, Afar

HWs also reported that the engagement of community members was essential for integrated service uptake. Quality improvement teams composed of HWs and community members supported integration by communicating the time and location of integrated outreach sessions. Of 17 facilities, 13 reported having a quality improvement team that discussed integrated nutrition and immunization services.

Every work we do with the kebele [community] leader, the community volunteers and other community are part of it and we cannot [do] anything without involving them… They are the one[s] who are close to the community and they [know] the best way to deal with the community. —HW, Somali