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LESSON 5 HOW TO USE THE “GOOD FOOD TOOLKIT” (Facilitator EN)

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Learning objectives

At the end of this session, participants will be able to:

  1. perform the five steps for nutrition counselling
  2. able to complete the Toolkit monitoring forms

Duration: 5 hours 35 minutes

Methods

  • Review
  • Participatory Lecture
  • Demonstration
  • Practice

Materials

  • Nutrition Counselling Monitoring Forms (3 per participant)
  • Lesson 5 Learning Objectives written on large paper or white board
  • Monitoring Forms written on 2 large pieces of paper, white board or on LCD projector
  • Good Food Toolkit (1 per participant)
  • Steps to Nutrition Counselling written on large paper or white board
  • Star cut-out
  • Markers
  • Tape

Introduction

  • Note to facilitator

    Since Lesson 5 is approximately 6 hours long we suggest giving the participants a break in the morning and in the afternoon. It is also helpful to include energizers!

So far in this training we’ve gained basic knowledge and skills related to nutrition for PLHIV. In this lesson we will learn about and practice how to use the “Good Food Toolkit”. This is a very practical lesson, so we will take the counseling process one step at a time.

Presentation of learning objective

The facilitator shows the learning objective written on the large paper and asks one participant to read the objective aloud to the group.

Learning objective:

Participants will be able to perform the five steps for nutrition counseling and will be able to complete the toolkit monitoring form.

Methodology: Review, Lecture, Demonstration, Practice

  • Step 1: Review

Ask participants to refer back to Lesson 1 (in the participant manual) and their copy of the toolkit. Review the contents of the Toolkit:

  1. “Small food cards” with photos of many foods – these cards help you and the PLHIV decide what foods are available and affordable for the PLHIV, including children so that you can help them plan good meals realistically.
  2. “Large food cards” – photos of plates and bowls of rice, soup, desserts, etc. – these cards help you advise the PLHIV and their care givers about the amount and quality of foods they should be eating.
  3. “Positive Living” counseling cards – these illustrations, along with the questions and information on the back of the cards, will help you and the PLHIV and their care givers have a two-way conversation about different ways to stay healthy and manage symptoms of illness with the right kinds of foods, healthy behaviors, and prompt care seeking.
  4. “Drinking Cups” – pictures of three different size drinking cups to help estimate the amount of water the PLHIV normally drinks each day and how much he or she should drink each day.
  5. Assessment tools:
    1. BMI table for adults (both gender and over 6 months post-partum women) – a tool to help estimate BMI in a simple way without having to compute using the formula
    2. WHO BMI-for-age chart for children (boys and girls) – a tool to assess nutritional status of children aged 5-19 years
    3. FANTA BMI-for-age look up tables for children and adolescent 5-18years – these tables are a quick reference to work out a child or adolescent BMI (weight for height) without having to compute using the formula
    4. MUAC child and adult tapes – a tool to measure nutritional status in children (aged 6-59 months), pregnant and post-partum within 6 months after delivery
  6. Monitoring Forms – counselors will keep a record of the PLHIV’s status, and key suggestions provided during nutrition counseling (what they talked about and agreed upon). This will help you track changes in the PLHIV’s weight and BMI and follow-up on the improved behaviors with the PLHIV from one visit to the next. There are three different monitoring forms to record nutritional related changes for:
    • Adults (both gender) and over 6 months post-partum women;
    • Adults pregnant and post-partum within 6 months after delivery; and
    • Children and adolescents aged 0-19 years
  7. Cooking Demonstration Manual—This guide is designed to assist those who provide cooking demonstration activities for PLHIV.
  • Note to Facilitator

    This Training Manual teaches the recommended standard method of nutrition counseling using the Good Food Toolkit however there will be opportunities for trained HBCT, health centre, OI/ART and NGO staff to use the Toolkit in other creative ways. See Annex 11 for other ideas for using the Good Food Toolkit.

Explain to participants, We will now learn and practice, step by step, the procedure for counseling PLHIV with the Toolkit on what to eat and how to eat in a way that will help to keep him or her healthy.

Show the following information on the big paper or white board and review the steps to Nutrition Counseling – keep the written steps in front of the group throughout the lesson so it can be referred to as each of the steps are being discussed. Make a star out of colored paper and move the star down the page or board to indicate which step is being discussed.

Remember that there are THREE different monitoring forms (adults, pregnant women and within 6 months after delivery, and children), and also different forms for health facility assessments and community based assessments (Annex 12 and 13). Hand out the correct monitoring forms. Participants who work at a HC or OI/ART clinic should use the monitoring forms for health facility assessment however HBCT or Self Help Group (SHG) members should use the monitoring forms for community based assessments.

Steps to Nutrition Counseling

  1. Assess – review the health of the client and their dietary habits
  2. Analyse – based on the assessment, determine the problem areas and appropriate solutions (e.g. behaviour change or referral)
  3. Suggest – provide a few solutions to the client
  4. Negotiate – negotiate ways for the client to overcome barriers to adopt the selected solutions and make a plan of action
  5. Follow-up – revisit the client to determine if the behaviour was adopted and further assist the client in maintaining the solutions

Filling out the monitoring form – General Information

Ask participants to look at the top page of the form. Explain to participants, The first box contains information that you should try to prepare before the visit, if possible. Look at the Lesson 5 (participant manual).

Explain each piece of information recorded on the monitoring form as participants follow along with the items as indicated below.

1. Date of visit: The date that the counseling is conducted.

2. Name of client: The name of the PLHIV being visited.

3. Age:The age of the PLHIV being visited in years

4. Gender:Record the PLHIV’s sex by ticking the appropriate box. If a female, please indicate if the PLHIV being pregnant or breastfeeding

5. Address: Address of the client.

  • Counseling Step 1: Assess

1.1 Assess – health/nutritional status of the client (question 6-8)

Refer to the Steps to Nutrition Counseling and put the star next to

Step 1. Assess.

Explain to participants, For the first step we will assess the health/nutritional status of the client which will guide the rest of the counseling session. Given that the Toolkit has three key target groups, we will start with assessing health/nutritional status of an adult PLHIV, this also includes a pregnant or breastfeeding woman. Later in this lesson, we will also learn how to fill out the monitoring form for children.

Counseling Steps

* 1. Assess

2. Analyse

3. Suggest

4. Negotiate

5. Follow-up

Tape the large page of the Adult Monitoring Form on the wall where all participants can see. Give a Counselor’s Monitoring Form for adult to each participant (or ask them to remove one of the Forms from their Toolkit).

Explain, The Monitoring Form will guide your nutrition counseling sessions and provide some prompts on what advice and activities to conduct at certain times in the session. We are going to learn to complete the form one box at a time. You will need your assessment tools and equipment to fill out the monitoring form. We are then going to learn how to fill out the monitoring form.

For an adult (man or non-pregnant woman), you will need a BMI table, a tape measure to measure height and a scale. If your client is a woman who is pregnant or up to 6 months post-partum, we need another assessment tool called a MUAC tape. We learnt earlier that BMI cannot be used for pregnant women so we will use MUAC to analyse their nutritional status.

For a child aged 6-59 months, you will need a MUAC tape for a child. If your client is a child over 5 years of age, you will need a BMI look-up table and BMI-for-age for children and adolescents 5-19 years of age. There is a different one for boys and a different one for girls.

Explain that, The health and nutrition assessment begins with question numbered 6-9 and is based on information that can be obtained from various client records at the HC and/or OI/ART clinic or direct measurement before filling out the form. Explain items 6-8 as indicated below.

6. Problem told by client: This is an open ended question. Ask the client if they are having problems. Record the types of problems, side-effects, or symptoms the client is experiencing.

7. ARV and OI medication (a, b, c): Tick yes or no. For completion of this question, the counselor does not need to see or record the type of medication that the person is taking. However, the HBCT members should record if they saw the type of medication as part of the Home Visit documenting this on the other records they use to document ART Adherence.

Is the client an adult male or a non-pregnant female or over 6 months post-delivery? Use BMI to determine nutritional status (question 8 a, b, c).

8. a. Client’s most recent weight: Insert the client’s weight in kilograms.

b. Client’s height: Insert the height of the client in centimeters. Insert height in meters if you calculate BMI using the formula.

c. Client’s BMI found: The BMI of the PLHIV can be calculated if both height and weight are available. BMI can be calculated by using the formula (kg/m2) or by using the BMI table. We learned to calculate BMI in Lesson 4.
Only NGO staff and/or HCstaff calculate BMI using the formula. Trained HBCT are recommended to use BMI table.

Is the client is a pregnant woman or up to 6 months post partum? Measure MUAC using a MUAC tape measure for adult (question 8).

8. Client’s MUAC: Read the MUAC in cm and document in the space provided.

For Children and adolescents aged 0-19 years (question 8)

8.     For children aged 0-6 months of age:

Tick yes or no for the presence of edema. If there is a presence of bilateral pitting edema then the child is severely malnourished and should be referred to the health centre.

For children aged 6-59 months: Measure the MUAC which is taken on the left arm using a MUAC tape measure. Read the MUAC in cm.

For children and adolescents aged 5-19 years: Calculate the child’s BMI using the FANTA BMI Look-up Table for Children (This table is different than the BMI table for adults) and determine the child’s BMI-for-age using the WHO BMI-for-Age Chart.

Ask participants, Does anyone have questions about how to complete the boxes of the Monitoring Form for health and anthropometry (body measurements)?

1.2 Analyse – the client’s dietary frequency and quality (question 10)

Explain: We will continue the assessment step by asking the client some questions regarding the frequency and quality of the client’s diet. Not eating and drinking enough times during the day and not eating enough nutritious foods at each meal are some of the main causes in Cambodia for poor nutritional standing that are very easy to solve. This is why the toolkit is focusing on these two areas for counseling.

Ask participants to look at the box labelled Dietary Intake on the Monitoring Form. Explain the following information in the table and use the cards from the toolkit to demonstrate the exercises conducted with the client to gather the information.

Frequency of Meals, Snacks, and Drinks – Adults, pregnant women and within 6 months after delivery (question 10)

10.  a. What does the client eat typically each day? Put a tick in the appropriate box to indicate which foods the client eats at breakfast, lunch, dinner and dessert/snacks/drinks

  b. Number of meals consumed per day: Ask the client to describe what he/she typically eats in a normal day, “How many meals do you usually eat?” Put tick in the appropriate box.

 c. Number of snacks consumed per day: Ask the client “How many times do you usually eat a snack/desert per day?” Put tick in the appropriate box.

 d. Number of liquids drank per day: Ask the client “How many glasses of water or other fluids do you usually drink a day?” Show the client the photo of the drinking glasses and ask the client which glass is the same size as the one that they drink from. Ask the client how many glasses he/she usually drinks including medicinal teas, any time of day, with or without meals and medicine. Put a tick in the appropriate box. So if the client drinks a blue glass of water eight times during the day, then tick the ≥ 2 litters box.

Record also numbers of cups of water drank per day.

Frequency of Meals, Snacks, and Drinks – Children and adolescents aged 0-19 years (question 10)

10. What does the child eat/drink typically each day? Put a tick in the appropriate box.

For children aged 0-6 months of age
Exclusively breastfed or replacement feeding? If the child is cup fed, is the formula prepared correctly? Hygienically? In this box tick yes or no for each question, based on the feeding being provided to the child aged under 6 months.

For children aged 6-59 months or children and adolescents aged 5-19 years

What does the child eat typically each day? Put a tick in the appropriate box to indicate which foods the child eats at breakfast, lunch, dinner and snacks/drinks.

Number of meals consumed per day: Ask the parent/carer to describe what the child typically eats in a normal day. Put tick in the appropriate box.

Number of snacks consumed per day: Record how many snacks consumed per day. Put tick in the appropriate box.

Number of liquids (other than water) and cups of water drank per day:  Ask the parent/carer “How many glasses of liquids other than water does the child usually drink a day?” Show the parent/carer the photo of the drinking glasses and ask which glass is the same size as the one that the child drinks from. Put tick in the appropriate box. So if the child drinks a blue glass of water four times during the day, then tick the 1 liter box.

Record also numbers of cups of water drank per day.

If the child is aged 6-59 months: specify the liquid (milk, infant formula) and quantity in cups.

Now ask participants to remove the “small cards” from the Toolkit and look at them. The cards are different colors. What do you think the colors mean?

After getting their answers, explain that the colors represent the food groups that we learned in Lesson 2: Body Building, Protective, and Energy.

Colored Groups in Toolkit:

  • RED – Body Building Foods
  • GREEN – Vegetables, which are Protective Foods
  • YELLOW – Fruits, which are also Protective Foods
  • WHITE – Energy Foods
  • PURPLE – Purple cards are not a food group; they include “enhancer” foods that can increase the calories and/or the nutritional value of soups and other foods. “Enhancers” are coconut, coconut milk, oil, nuts, condensed milk, fermented soy beans and beans.
  • BLUE – Examples of nutritious fluids that PLHIV can be encouraged to drink so that they consume 2 liters of fluids every day.

Explain to participants, A well balanced meal of all food groups being eaten is one indicator of a good quality diet. Other indicators we will explore further in the nutrition counseling session. We will use only the Red, Green, Yellow, and White small food cards in the next exercise to assess if the client is eating a balanced diet. We want to make sure all three colors are consumed in one day and even in each meal.

Refer participants to the monitoring form and review information in question 10e and 10f.

10.  e. Are all three food groups (energy, protective and body building) eaten with each meal? In this box, assess which of food groups the client typically eats in a normal day.

For this question, the counselor puts the small food cards on the table. Either by individual color or by looking through all of the cards mixed together on the table, ask the client to pull out the cards of foods that they usually eat. Some prompts might be required such as – What is in your soup? What kinds of vegetables? Is there any kind of fish or shell fish or meat in your soup? Do you cook with oil? Herbs? Spices?

If all food groups are consumed, tick “Yes”.

f. Does the client eat iron rich foods (e.g. red meat, chicken, fish, egg, beans, green leafy vegetables)? In this box, assess which of iron rich foods the client typically eats in a normal day. For this question, the counselor can use the small food cards on the table of the iron rich foods.

Example of Ms Peng

Ask for one volunteer from the group to pretend to be Ms Peng and to answer the questions based on what she usually eats. Interview the volunteer and have the participants complete their form based on the results of the interview. Another facilitator records the information on the Big Monitoring Form at the front of the room. Check the results of the participants against this form.

Give the participants a chance to fill in the information on their monitoring form. Ask the participants to tell you how to complete the dietary intake box (using the large white paper or white board). Make any necessary corrections on the Ms Peng example and explain the correct way to fill out the form.

  • Counseling Step 2: Analyze

Explain to participants, Now we will learn how to analyze the information from the boxes of the assessment and to identify the correct behaviors to promote with the clients.

Move the star on the Steps to Nutrition Counseling big paper or white board in the front of the room down to “Step 2: Analyze” to show participants where they are at in the overall process of the nutrition counseling session.

Counseling Steps

1. Assess

* 2. Analyse

3. Suggest

4. Negotiate

5. Follow-up

2.1 Analysis of body measurements (question 9)

Explain to the participants: We will use previous information we gathered for analysis. Take a look at the monitoring form. First look at question 9 and 11 – these questions will help analyze the health and nutritional status of the client.

Have one of the participants read the box out loud and point it out on the Monitoring Form on big paper or the white board at the front of the room.

Is the client an adult male or non-pregnant female or over 6 months post-delivery? Use BMI to determine nutritional status (question 9).

9. Nutritional status:

Underweight/malnourished, BMI <18.50
Normal, BMI 18.50 – 24.99
Overweight, BMI ≥25.00
This step helps the counselor to analyze the situation and to determine the problem areas. There are two indicators used to assess the client’s nutritional status. Use the information from Question number 8 to tick the appropriate box.

Is the BMI less than 18.5? If so, this is the first sign that the person needs to gain weight. The client is considered malnourished. Besides providing nutrition counseling, this client needs to be referred to the HC and/or OI/ART clinic.

Is the client is a pregnant woman or within 6 months post-partum? Measure MUAC using a MUAC tape measure for adult (question 9).

9. Nutritional status:

Underweight/malnourished, MUAC ≥ 23 cm
Normal, MUAC < 23 cm

BMI cannot be used for a pregnant woman because a pregnant woman’s weight will be related to the growth of the baby and changes in the body related to pregnancy. MUAC is recommended for pregnant women and up to 6 months post-partum. Use the information from Question number 8 to tick the appropriate box.

Is the MUAC less than 23cm? If so, the client is considered malnourished. Besides providing nutrition counseling, this client needs to be referred to the Health Centre.

For children and adolescents aged 0-19 years, explain the following information.

Nutritional status

Physical assessment (less than 6 months)

MUAC (6-59 months)

BMI for age (5-19 years)

Normal

No edema

More than 12.5 cm

Equal or more than -2 SD

Moderately malnourished

No edema

Equal or more than 11.5 – to equal to or less than 12.5 cm

Between -3 and -2 SD

Severely malnourished

Bilateral pitting edema

Bilateral pitting edema OR Less than 11.5cm

Equal or less than -3 SD

8.    For children aged 0-6 months of age:

Tick yes or no for the presence of edema. If there is a presence of bilateral pitting edema then the child is severely malnourished and should be referred to the health centre.

For children aged 6-59 months:
Measure the MUAC which is taken on the left arm using a MUAC tape measure. Read the MUAC in cm.

Is the MUAC less than 11.5cm? If so, the client is at risk of malnutrition or malnourished.

Classification

MUAC

Normal/growing well

>12.5

Moderately malnourished

≤12.5 – ≥11.5cm

Severely malnourished

< 11.5cm

For children and adolescents aged 5-19 years
Calculate the child’s BMI using the FANTA BMI Look-up Table for Children and calculate the child’s BMI-for-age using the WHO BMI for Age Table. This table is different than the BMI table for adults.

Classification

BMI-for-age

Normal/growing well

≥ -2SD

Moderately malnourished

Between -3 and -2SD

Severely malnourished

≤ -3SD

2.1 Analysis of Analysis of Frequency and Quality of Diet (question 11)

Let’s continue with the Ms. Peng example by looking now at the analysis of frequency and quality of the client’s diet. Using the information from the box 10 that we just completed, we will use this information to determine if Ms Peng’s diet is poor, fair or good.

Remind them, This is all information you just learned in previous lessons. We want our clients to eat at least 3 meals and 2 snacks a day, plus drink two liters of water. The photo of the glasses will guide you on how many glasses equal 2 liters. If the client drinks less than the designated number of cups on the photo, then the client did not drink 2 liters. For example, if the client’s cup is most like the blue cup, the client should say they drank 8 cups in order to have consumed 2 liters.

For quality, we looked at balanced diet –in other words, if all colored food groups RED, GREEN, YELLOW, WHITE are usually consumed. If only one or two is not consumed then the client’s diet is poor.

For all adults and pregnant woman or within 6 months post-partum

11.  Diet is:         Poor     Fair     Good

This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from Question number 10 to complete this box. There are two indicators to assess the client’s dietary frequency and quality (i.e. the number of meals and snacks consumed per day and food diversity).

Tick “Poor” if the client usually eats 1 meal or less, no snacks and less than 1 liter of liquids per day and/or they only eat foods from one or two food groups each day.

Tick “Fair” if the client usually eats 2 meals, 1 snack and 1 liter of liquid each day, and eats from the 3 food groups each day.

Tick “Good” if the client usually eats at least 3 meals with two snacks every day, drinks at least 2 liters of liquid and they consume a variety of foods from the three food groups – Energy group (white), Body building group (red), and Protective group (yellow/green).

For the children aged 0 – 19 years, the questions are slightly different to reflect the amounts and type of food eaten for this age group.

11. Dietary intake analysis

Diet of child aged 0-6 months of age:         Poor         Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from the Dietary intake questions to complete this box.

Tick “Poor” if the client is not being exclusively breastfed or the replacement feeding is deemed unsafe.

Tick “Good” if the client is exclusively breastfed or has safe replacement feeding.

Diet of child aged 6-59 months:        Poor        Fair        Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from the Dietary intake questions to complete this box. There are two indicators to assess the client’s dietary frequency and quality (i.e. the number of meals and snacks consumed per day and food diversity)

Tick “Poor” if the client usually eats less than 2 meals and snacks per day and/or they only have one food group and 0-1 cups of milk per day and no breastfeeding.

Tick “Fair” if the client usually eats 2 meals, 1-2 snacks and 1-2 cups of liquid, and eats from 1-2 food groups each day.

Tick “Good” if the client usually eats at least 3 meals with two snacks every day and consumes a variety of foods from the three food groups, and at least 2 cups of milk per day if no breastfeeding.

Diet of child or adolescent aged 5-19 years:        Poor        Fair        Good
This step helps the counselor to analyze the situation and to determine the problem areas. Use the information from the Dietary intake questions to complete this box. There are two indicators to assess the client’s dietary frequency and quality (i.e. the number of meals and snacks consumed per day and food diversity)

Tick “Poor” if the client usually eats 1 meal or less and no snack, and less than one liter of liquid per day, and eats from 1-2 food groups per day.

Tick “Fair” if the client usually eats 2 meals, 1 snack and 1 liter of liquid each day, and eats from 3 food groups each day.

Tick “Good” if the client usually eats at least 3 meals with two snacks and consumes a variety of foods from the three food groups, and 2 liters of milk per day

Activity: Ms. Peng Example

Use the Ms. Peng Example and look at the questions in the box at the left column of the form and tick appropriate box based on information from the Dietary Intake box.

  • Counseling Step 3: Suggest

In the first two steps we assessed and determined the nutritional and feeding problems of our client. Now we will proceed to Step 3: Suggest – selecting some options for the client to change their feeding practices and health seeking behavior that address the problem to improve their nutritional status.

Move the star on the Steps to Nutrition Counseling big paper in the front of the room down to Step 3: Suggest to show participants where they are at in the overall process of the nutrition counseling session.

Counseling Steps

1. Assess

2. Analyse

* 3. Suggest

4. Negotiate

5. Follow-up

Now that we know the problem – we can suggest some solutions to the client and negotiate ways for the client to overcome the barriers to adopt the selected solutions.

However before we go into details, we will spend some time to learn about communication skills. It is important for us, as counselors, to learn counseling skills in order to

  • effectively communicate behaviors to improve nutrition;
  • help the client try small do-able actions; and
  • to judge when it is necessary to refer clients to a more experienced counselor/health staff.

Some key points in nutrition counseling

  • Conduct counseling in a nonjudgmental manner in which the client is respected. Develop a trusting relationship. This is crucial in the face of stigma and discrimination.
  • Individualize nutritional counseling and involve PLHIV in the decision-making process.
  • If there are signs for behavior change, suggest one change at a time and ensure goals are realistic
  • Work with PLHIV to identify potential barriers due to cultural traditions, linguistic preference, distrust, cognitive dysfunction, or limited literary skills, and discuss possible solutions.
  • Provide practical suggestions and recommendations. Dietary strategies should be adapted to the local context, taking into consideration a client’s medical history, available foods and other household conditions, culture, finances, and individual beliefs about food and diet.
  • Organize follow-up visits or establish links with the multidisciplinary team for PLHIV facing special challenges.

Rollnick and Masson (1995) identified some false assumptions that health, welfare and other workers can make when working with clients. The following ‘dangerous’ assumptions are not wrong but can reduce the effectiveness of nutrition education and counseling:

  • This client SHOULD change
  • This client WANTS to change
  • Personal health is a priority for this client
  • If he or she does not change then the intervention has failed
  • A client either wants to change or doesn’t
  • Now is the right time for this client to change
  • I’m an expert, so he or she must follow my advice

Remember: it is very important to practice good communication skills when we suggest some behavior change to the client. Good communication is not telling or advising a person what they should do. It is a way of working together with people to help them decide for themselves what they think is best to do in their situation. The discussion may include other family members or care givers but it is the decision of the client as to whom to include in the discussion. We will practice these skills later when we do an activity to conduct a full counseling session.

Activity: Ms. Peng Example

  • Note to Facilitator

    The analysis for frequency and quality of the Ms. Peng example will depend on the answers the volunteer initially provided in the role play in the previous Ms. Peng exercise and should reflect in the rest of the examples provided at the training. In the manual, the Ms. Peng exercise will be based on the information above, but for your training – please use the information from the role play.

Ask Participants, Based on the Analysis what are the problem areas regarding the health/nutritional status and frequency and quality of Ms. Peng’s Diet?

Answer: Ms. Peng has poor nutritional status (low BMI) and has signs of infection (white patches in her mouth making it difficult for her to eat). She also has poor frequency and quality of diet since she usually eat less than 3 meals and drinks less than 2 liters of fluid a day, and lacks variety in her diet.

Ask participants: Based on this information, let’s do an analysis of the situation…what do you think will be the focus of the counseling session with Ms. Peng?

Answer: To make a plan whereby she can eat more food to gain weight. Why? She is underweight (BMI 17.5) and she has lost 2 kg weight in the previous month (47kg to 45kg). This weight loss could be due to the sores in her mouth causing her to eat less, so advice should be given on how to care for them.

Ask participants, With the example of Ms. Peng, should we refer her to a health facility?

Answer: Because her BMI is low, she is losing weight, and had signs of infection from mouth soars, Ms. Peng should be advised to seek care as soon as possible from the HC and/or the OI/ART clinic.

Refer the participants to the lesson 5 (participant manual), question 12. Following the instructions in the table, demonstrate how to negotiate seeking appropriate care with a volunteer in the audience. The following script can be used to help guide the session.

If your client advised you that they were experiencing an illness or infection recently the proper care needs to be given. For minor situations, the messages in some of the positive living cards like on fever, diarrhea, and thrush can be reviewed. If the situation persists for a long time or is more severe, the client needs to be referred to the HC immediately. If your client has lost weight recently, this could also be a sign of an infection and should always be referred to the HC or OI/ART clinic. Besides advising the client to seek care immediately, you could assist the client to make a plan to get to a facility immediately (e.g. identify transport options). If it’s a minor illness make a plan to treat the situation at home using the positive living cards, and always include in the plan continuous food intake during illness – ask the client to identify some foods on the small food cards that make them feel good when they are ill and review the positive living card on increasing their appetite. Lastly, during the recovery period it is very important that we negotiate with the clients to increase their food intake until the weight that they loss during illness is regained and then maintained. This can be done by negotiating any of the behaviors under frequency and quality.

Does everyone understand how to negotiate Improvement on Seeking Appropriate Care for Infections or Illness?

Explain to and show participants (using the large paper example of the Monitoring Form) that they should record which Positive Living cards were used in the counseling by ticking the appropriate box. For example, if client Ms. Peng agrees that she will rinse her mouth out with warm salt water every day for a week, then tick “Seek immediate care for infections”.

Record the plan to seek care in the space provided on the monitoring form:

Ms. Peng will go to the HC on Tuesday of this week. She will ask her brother to take her on the moto. She will also rinse her mouth out with warm salt water every day for a week.

Demonstration

Seek appropriate care for infections or illness: Ms. Peng Example

Ask for a volunteer to be the counselor for the “seek appropriate care for infection or illness” behavior and another volunteer to be the client. Have the counselor negotiate this behavior in accordance with the steps. Have the volunteer show the participants where to record the agreed plan for the behavior on the monitoring form.

From our previous examples we’ve identified several problems. It’s important to realize that we will not be able to solve all of the problems in one nutrition counseling session. You must select a maximum of 3 behaviors to focus on with each session. If the client is having problems with their health/nutritional status, then one of the behaviors must be to seek proper care. Depending on the situation, you should also select one behavior from the frequency category and one from the quality catgory. Tick the box corresponding to the behavior you want to focus on in the session.

Write the following on flipchart paper to help review the information:

If the client has a problem with weight loss, low BMI, or sign of illness / infection – always select “seek proper medical care” as a behavior to be suggested and negotiated.

With each suggestion it is important to ask the client:

How do you feel about this suggestion?

Is it something feasible that you are willing to try?

Focus on one or two practices that are feasible for their situation that they agree to practice in a session.

Ms Peng Example continued:

Now let’s look at Ms. Peng again…based on the analysis we conducted for Ms. Peng – which behaviors would you suggest to Ms. Peng to work on changing? Make a tick.

Note: these answers reflect the example in the training manual – again, it will be dependent on the initial role play.

Analysis

Suggested Behavior Change

Ms Peng lost weight and had sign of infection

Seek appropriate care

Ms. Peng ate less than 3 meals the day before

Eat 3 meals a day

Ms. Peng drank less than 2 liters the day before

Drink 2 liters of fluid everyday

Ms. Peng lost weight / sign of infection

Eat additional rice and/or quality soup or add enhancers

Ms. Peng did not eat from the Red Group

Eat foods from the Red group each meal

Ms. Peng did not eat a thick quality soup

Add other foods to thicken the soup

Explain to participants, Ms. Peng has many behaviors she needs to work on, but it is not likely that she can change all of them at one time – so it is best to select a maximum of 3. Because she had signs of weight loss and an infection, seeking appropriate care needs to be promoted. If she does not like the one you selected – you can offer a different choice to her. As a group select 3 behaviors that will be suggested to Ms. Peng. One behavior must be to seek appropriate care!

Demonstration:

Demonstrate with a volunteer how to make the 3 suggestions to Ms. Peng. Be sure to ask the two questions:

  1. How do you feel about this suggestion?
  2. Is it something feasible that you are willing to try?
  • Counseling Step 4: Negotiate

Explain to participants, Now that the client’s situation has been analyzed and appropriate behavior change identified and suggested, it is now time for Step 4: Negotiate. This is where we will use the tools in the kit to help the client identify options and overcome barriers so that he/she can change the behavior. This is probably one of the most important steps.

Move the star on the Steps to Nutrition Counseling big paper in the front of the room down to Step 4: Negotiate to show participants where they are at in the overall process of the nutrition counseling session.

Counseling Steps

1. Assess

2. Analyse

3. Suggest

* 4. Negotiate

5. Follow-up

Demonstration: Frequency and Quality

Explain to participants, We will continue learning the negotiation activities for each of the behaviors under frequency and quality. To break things up a bit we will divide into groups.

Facilitator Instructions:

Divide the participants into two groups. Have one group go to one end of the room with a facilitator and the other group goes to another part of the room with a different facilitator. One of the facilitators demonstrates the negotiation activities with the toolkit as outlined in lesson 5 (participant manual) for each of the suggested behaviors number 1-3 (see Table 4). The other facilitator demonstrates the negotiation activities for each of the suggested behaviors numbered 4-7 with his or her group. Conclude each behavior with showing the participants where to record the agreed plan between the counselor and the client on the monitoring form.

In between reviewing the behaviors let the participants practice each behavior in pairs using a new, blank monitoring form. Make sure they are recording the plans and key suggestions provided in the appropriate place on the monitoring

Suggesting and Negotiating Behavior Change Based on Assessment and Analysis

Analysis

No 

Suggested behavior change

If the client ate less than 3 meals yesterday

1

Eat an extra meal (3 or more meals) every day.

Use positive living card # 13 and the small cards to identify available/affordable foods and plan an additional meal.

If the client ate less than 2 snacks or desserts yesterday

2

Eat an extra snack or dessert (2 or more snacks or desserts) every day.

Use positive living card # 13, the small food cards, and the large food card to identify what foods are available / affordable and plan an additional snack or dessert of the correct amount.

If the client drank less than 2 liters yesterday

3

Drink at least 2 liters of water or fluid every day (4-8 glasses).

Use positive living card #12, the picture of drinking cups, and the blue cards to identify water and other drinks and the number and size of drinks for each day.

If the client is losing weight, has a BMI < 18.5, or symptoms of illness

4

Eat a larger amount of rice and soup at each meal.

Use positive living card #11

Show the large food card. How much rice do you normally eat at a meal? Negotiate a larger amount (if needed).

Review the kind of soup the client normally eats. Use small food cards for the client to choose available/affordable foods that he/she will add to the soup.

5

Add enhancers (coconut milk, oil, beans, nuts, etc) to soups or other dishes.

Use positive living card #11. Let the client choose the available/affordable enhancers (purple cards) and negotiate adding the selected enhancers.

If the client did not eat from all three food groups yesterday.

6

Eat from all food groups at every meal (every meal includes food from the white, red, green and/or yellow groups).

Using the soup cards and small food cards let the client choose available/affordable foods to add color to the soup or other meal.

If the client consumed watery or medium thick soup

7

Eat a highly nutritious soup or meal

Using the soup cards and red, green and purple small food cards let the client choose available/affordable foods to increase the quality of the soup.

form. The facilitator should walk around the room observing all pairs and providing guidance and clarification as needed.

Observation guidelines for facilitators

As you are walking around observing the counseling sessions between the pairs take note of the following:

  • Do participants use the cards to negotiate improvements?
  • Do the participants get agreement or just tell people what to do?
  • Do participants document the key suggestions for improvement on the Monitoring Form?

Facilitators should provide guidance and correction for any incorrect or incomplete information on this section of the Form. Praise participants when they do a good job. Gently correct and encourage participants if they make mistakes while learning the correct procedure.

After the groups have finished observing the demonstrations from the facilitators – have the groups switch sides of the room so they can learn the negotiation activities for the other behaviors.

The following script can help with demonstrating the negotiation activities for the behaviors.

Group 1:

1. If a client ate less than three meals yesterday, or if the client needs to gain weight, they should try to eat an extra meal. What if a client ate three meals yesterday, but still needs to gain weight? You can encourage them to eat 4 meals a day or skip down to number 4 and increase snacks throughout the day! But you must make sure they are willing to try that. Ask the person how they would plan to eat 3 or more meals per day. Demonstrate an example following the steps in the lesson.

Does everyone understand how to negotiate this behavior?

2. If a client ate less than 2 snacks and desserts yesterday, or if the client needs to gain weight, they should try to eat at least 2 snacks or desserts every day. What if a client ate 2 snacks yesterday, but still needs to gain weight? You can encourage them to eat 3 or more snacks or desserts each day! It is good for PLHIV to eat smaller amounts like snacks but more frequently. Ask the person what they could eat and how they would plan to eat 2 or more snacks per day. Use the small food cards to identify which snacks are available to the client. Examples of simple snacks that are easy to prepare are various types of fruits. Inexpensive snacks that can be purchased from the vendor include grilled banana or steamed banana and sticky rice. Use the large food card (picture of bobor in chan chang koeh) to show what amount of snack/dessert to eat. What are some inexpensive snacks you could negotiate with the clients in your area? Demonstrate an example following the steps in the lesson.

Does everyone understand how to negotiate this behavior?

3. If a client drank less than 2 liters of water in the previous day, they should try to drink more. Explain to the client that drinking more will help the body to fight illness, and help medicines to work better. Show the A4 card with pictures of common drinking cups. Ask the client what size drinking cup they normally use. How many cups should he/she drink to total 2 liters? Help the client plan what they would drink and how they would remember to drink that many cups throughout the day. Emphasize that the water / drink should be boiled and cooled and stored safely. You can use the blue cards to help the client identify other types of fluids besides water and tea that they can consume. Demonstrate an example following the steps in the lesson.

Does everyone understand how to negotiate this behavior?

Group 2: Quality

4. If a client needs to gain weight, another thing they can try is to eat a larger amount of rice and soup at each meal. Please look at the large food card pictures of rice and soup. If you choose to negotiate this change with your client, encourage them to eat a larger amount of rice than they normally eat. Show the client the size of the larger portion using the large food cards (rice plates). Point out on their own dishes a line to increase the rice size to for each meal so it is easier for them to remember. For example the client will try to eat 250gm portion of rice at each meal instead of 200gm.

Also encourage them to eat a full bowl of soup at every meal. The soup should be thick with many vegetables (green group) and fish, chicken, or meat from the body-building (red) group. Many of these foods can be gathered such as trachoun, small fish and snails from the rice fields, etc. Show the client the thick soup using the large food cards (soup bowls). Soup can also be “thickened” with enhancers – the purple cards can be used here as well. Demonstrate an example following the steps in the lesson.

Does everyone understand how to negotiate this behavior?

5. If a client needs to gain weight, one thing they can try is to add enhancers to their soups or dishes. Please look at the small food cards that are PURPLE in color. If you choose to negotiate this change with your client, find out exactly what enhancer they would like and will be able to use and how. Demonstrate an example following the steps in the lesson.

Does everyone understand how to negotiate this behavior?

6. How would you know if a client did not eat from all three food groups -Energy (White), Body-building (Red), Protective (Green and Yellow)- at every meal? You can refer to the cards the PLHIV has selected from the small food cards of the foods they ate the previous day. Remind them that it’s important to eat a balance diet. The colors represent the food groups: White for Energy, Red for Body-Building, and Green or Yellow for Protective. They should eat from all the colors in every meal. If a color is missing in their diet – have the client go through that missing color of cards and select foods that are available and affordable and brainstorm with them ways to introduce that food into their meals and snacks. Demonstrate an example following the steps in the lesson.

Does everyone understand how to negotiate this behavior?

7. How would you know if a client did not eat a highly nutritious meal or soup? You can refer to the soup card the PLHIV selected as the one that is most like the soup or meal he/she ate yesterday. Using the large soup cards and white, red, green and purple small food cards let the client choose available/affordable foods to increase the quality of the soup.

Does everyone understand how to negotiate this behavior?

Tell participants: There are many possible Improvements your client can do. Your job is to discuss with the client which Improvements are appropriate and feasible. In addition to counseling the client to seek appropriate care, if necessary, only negotiate one or two Improvements in a single visit. More than three improvements, including seeking appropriate care, at one visit are too much for PLHIV to remember! Save additional improvements for the next visit.

  • Counseling Step 5: Follow-up

Explain to participants, You now have a record of the negotiated new behaviors that the client agreed to try. At subsequent visits, the counselors can review these agreements, see if the clients were able to do the new behavior as discussed, and negotiate additional changes as needed or introduce new improvements. Now is your job to determine when the next visit is planned. This is step 5: Follow-up.

Move the star on the Steps to Nutrition Counseling big paper in the front of the room down to Step 5: Follow-Up to show participants where they are at in the overall process of the nutrition counseling session.

Counseling Steps

1. Assess

2. Analyse

3. Suggest

4. Negotiate

* 5. Follow-up

Explain to participants the information from the following box (question 13).

13. Monitoring and Follow Up

Every month         Every 3 month         Every 6 months
Determine the frequency of the monitoring and follow up.

Key times that an adult PLHIV should have a nutrition assessment and counseling:

  • Initial visit
  • Depending on stage of HIV infection:
    • Asymptomatic (without any symptoms): every 6 months
    • Symptomatic: every month or 3 months
  • When initiating or changing ART

Make an appointment to follow up with the client on agreed actions.

Explain to participants the additional considerations in nutrition assessment for children:

Nutrition assessment assists in the monitoring of disease progression in children. Children with HIV infection are frequently only identified when they present with more serious signs and symptoms. HIV positive children should be referred to other care facilities when specific needs are identified or health workers with other skills or other resources are required. All infants should have their weight monitored monthly in the first year of life and at least every three months in the second and third years of life; this is especially important for non-breastfed children. After this time, growth should continue to be monitored until adulthood.

When to Review:

Condition

Review interval

Comment

The child who is well and growing appropriately

2-3 months

Unless needing to attend to receive ART or routine medication/vitamin supplement

The child on ART

3 months

If gaining weight and no other problems

2-4 weeks

If failing to gain weight

The child is unwell and/or showing signs of growth faltering or has had recent diarrheal illness

2-4 weeks

May require more frequent visits depending on clinical status and support offered or being provided

Source: Guidelines for an Integrated approach to the nutritional care of HIV-Infected Children (6 months -14years), WHO 2009

An important element associated with nutrition counseling is to plan any ongoing monitoring and follow up. Few nutrition problems are solved immediately. A complex nutrition problem will often require ongoing nutrition counseling, over a matter of weeks or months. Nutrition monitoring and follow up will enable the counselor and the client to know when the goal (i.e. the negotiated behavior change) has been reached, and identify new issues as they arise. A client’s situation is likely to change over any given period of time and they may face new barriers to adopt new behavior change. By monitoring a client these changes can be identified and integrated into the action plan.

Activity:

Allow 15 minutes for role plays and 20 minutes for discussion, refer to Role play scenario, Annex 14.

Have the participants break into groups of 3 people. They will play a client, an observer and a counselor. Give the participant who is playing “the client” 5 minutes to read the scenario. Ask the participant to role play according to the information provided in the scenario. The participant who is playing “the counselor” will practice conducting the full counseling session including: taking a height and weight measurement and calculating BMI (with a calculator or using the BMI table). The client should respond to any questions and information provided by the counselor, as needed. “The observer” (i.e. the other participant) will use a one page checklist (Annex 14) to review the role play and provide feedback to the counselor and the client. Observe the participants to make sure they complete all five counseling steps using a new revised monitoring form. Suggested behaviors should be ticked on the form (Box 13) – a maximum of 2 behaviors should be selected in addition to seeking appropriate care, if applicable. Make sure the counselors ask their clients these two questions:

  1. How do you feel about this suggestion?
  2. Is it something feasible that you are willing to try?

If time permits give each participant a chance to be a counselor, a client and an observer.

Summary

Review the nutrition counseling steps with the participants on the big paper and also on the monitoring form.

Steps to Nutrition Counseling:

  1. Assess – review the health of the client and their dietary habits.
  2. Analyze – based on the assessment, determine the problem areas and appropriate solutions (e.g. behavior change or referral).
  3. Suggest – provide a few solutions to the client.
  4. Negotiate – negotiate ways for the client to overcome barriers to adopt the chosen solutions and make a plan of action.
  5. Follow-up – revisit the client to determine if the behavior was adopted and further assist the client in maintaining the solutions.

Ask participants to look at Lesson 5 (in the participant manual). Ask participants to study this lesson and the procedures learned today as their homework for the field practice that will take place later in the training. Invite any questions from participants and answer/discuss/clarify as needed.

Pass out the test questions to the participants. Have the participants spend no more than 10 minutes answering the questions. Each person should work by himself/herself. Go over the answers as a group. Answer any questions the participants have at this time.

CONGRATULATE all participants for learning how to use the Good Food Toolkit for nutrition counseling!

Tell participants: We will learn about one more step in the counseling process in the next Lesson (Lesson 6) which deals with positive living messages for our clients.

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