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

"...insights into the perspectives of program managers, health workers, and community members which should inform countries as they consider integrating different health services over the life course." - Samantha Noor, JSI

Experience indicates that, for a primary health care system to be people centred and responsive to population needs throughout the life course, it must feature integrated health service delivery. In Ethiopia, JSI implemented the Universal Immunization through Improving Family Health Services (UI-FHS) project from 2011-2021 to reach zero-dose and underimmunised children in Ethiopia and strengthen the health system. This article describes pilot study learnings related to planning and delivering integrated services and shares recommendations for integrating immunisation and nutrition services in other settings.

As detailed here, UI-FHS used quality improvement (QI) tools to enable health personnel to identify local problems in immunisation services and to design solutions. In 2019, UI-FHS, Ethiopia's regional health bureaus, woreda (district) health offices, and nutrition partners began exploring integrating integrated young child feeding (IYCF) counseling and iron and folic acid (IFA) supplement distribution into immunisation service delivery. The pilot study was implemented from August 2019 to November 2020 in 47 health facilities, or HFs (all health centres and health posts within each district). During the pilot study, project staff implemented the following activities:

• Facilitated advocacy and orientation meetings and established a technical working group that engaged regional staff and implementing partners to monitor data and conduct supportive supervision;
• Adapted a microplanning tool and trained health workers (HWs) on how to provide nutrition and IYCF services, including counseling;
• Revised client flows for service delivery to ensure that HWs understood how to provide integrated services in a standardised manner;
• Assisted HWs around providing integrated services, supported them in using data recording tools, and addressed their concerns;
• Supported the monitoring of integrated services using adapted data recording tools;
• Encouraged existing QI teams, which typically focused on problem-solving for immunisation service delivery, to expand their focus to include nutrition services; and
• Provided guidance around HW roles and responsibilities during the provision of integrated outreach and mobile services (e.g., engaging and mobilising communities to attend outreach).

From December 2020 to January 2021, the research team conducted 43 key informant interviews (KIIs), observed 4 integrated sessions, and completed document reviews at 17 HFs. Overall, findings  indicate that planning for and delivering IYCF counseling and IFA supplementation with immunisation services was feasible. Integrating these services provided opportunities for collaborative planning: Key informants noted that microplans were developed by the woreda health office, HFs, community members, and immunisation and nutrition partners using a participatory approach, which resulted in the incorporation of diverse views in planning and provided an opportunity to discuss adjustments needed for service delivery mechanisms, workflows, community engagement, and resourcing. Although integration enabled providing multiple services to clients through a single interaction, HWs felt that additional human resources were needed, especially regarding integrated outreach and mobile service delivery.

HWs indicated during KIIs that the community response to integrated services was mixed. Community members said they preferred integrated services, which enabled them to access multiple services in a single visit. HWs also perceived an overall increase in community awareness about immunisation and nutrition services because each service reinforced the other. HWs stressed that the engagement of community members was essential for integrated service uptake. QI teams composed of HWs and community members supported integration by communicating the time and location of integrated outreach sessions. HWs reported they received several complaints about integrated sessions taking too long and that some communities felt that IYCF counseling was not critical.

The researchers call for additional studies to advance understanding of how best to co-deliver integrated interventions in different contexts using varied strategies (i.e., via static, outreach, and mobile service delivery). In addition, since this study assessed the quality of service delivery through informal observation of a limited number of integrated sessions, systematic research could help clarify the extent to which quality is maintained when services are codelivered.

"In summary, integrated microplanning is an essential step that requires the broad engagement of all stakeholders, including HWs, community members, and partners. Careful monitoring of implementation, and - for HWs - ongoing support from supervisors, are critical for reinforcing new practices and troubleshooting challenges that may arise, such as when using data recording tools. Sufficient human resources for health are critical for offering integrated services, particularly outreach and mobile services. Finally, community engagement strategies will be important to ensure community acceptance of and utilization of services."