Nutrition Reference Guide

CORE Group’s Nutrition Working Group

xfff
Nutrition Reference Guide
CORE Group Nutrition Working Group
August 2017
Contents

INTRODUCTION

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Preface and Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Summary Reference Guide of Nutrition Tools and Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

REFERENCE GUIDE

Agriculture and Nutrition Context Assessment Tool Locator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Body Mass Index Wheel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Breastfeeding Counselling: A Training Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Community Management of Uncomplicated Acute Malnutrition in Infants Under Six Months . . . . . . . . . . . . . 10

Community-Based Infant and Young Child Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Community-Based Management of Acute Malnutrition Costing Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Community-Based Management of Acute Malnutrition Toolkit: Rapid Start-Up Resources

for Emergency Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Emergency Nutrition Assessment for SMART . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Engaging Grandmothers to Improve Nutrition: A Training Manual and Guide for Dialogue
Group Mentors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Essential Nutrition Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Essential Nutrition Actions and Essential Hygiene Actions Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Formative Research: A Guide to Support the Collection and Analysis of Qualitative Data for
Integrated Maternal and Child Nutrition Program Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Guidance for Formative Research on Maternal Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Guide to Anthropometry: A Practical Tool for Program Planners, Managers, and Implementers . . . . . . . . . . . 20

Infant and Young Child Feeding in Emergencies Orientation Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Length Mat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Title

Link Nutrition Causal Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Maternal Nutrition During Pregnancy and Lactation: A Dietary Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Minimum Dietary Diversity for Women: A Guide to Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Mobilizing Communities for Improved Nutrition: A Manual and Guide for Training Community Leaders . . . . 26

Mother-to-Mother Support Groups: Trainer’s Manual and Facilitator’s Manual with Discussion Guide . . . . . . 27

National and District Tools to Guide Anemia Programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Nutrition Assessment and Counseling Support Training Package for Facility-Based

Service Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Nutrition Assessment and Counseling and Support: A User’s Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Nutrition Impact and Positive Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Nutrition Program Design Assistant: A Tool for Program Planners, Version 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Optifood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Positive Deviance/Hearth: Resource Guide for Sustainably Rehabilitating Malnourished Children . . . . . . . . 34

ProPAN 2.0: Process for the Promotion of Child Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Setting Up and Running a School Garden: A Manual for Teachers, Parents, and Communities . . . . . . . . . . . 36

The Basics: Planning for Formative Research for Infant and Young Child Feeding Practices . . . . . . . . . . . . . 37

Tool for Rapid Evaluation of Facility-Level Nutrition Assessment and Counseling and Support:
A User’s Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Training Guide for Community-Based Management of Acute Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Training of Facilitators for Positive Deviance/Hearth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Trials of Improved Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

 Acronyms

BMI Body Mass Index

CMAM Community-Based Management of Acute Malnutrition
C-MAMI Community Management of Uncomplicated Acute Malnutrition in Infants Under Six Months
DATA District Assessment Tool for Anemia
ENA Essential Nutrition Actions
ENN Emergency Nutrition Network
FANTA Food and Nutrition Technical Assistance Project
FAO United Nations Food and Agriculture Organization
FHI 360 Family Health International 360
IFE Infant and Young Child Feeding in Emergencies
IMCI Integrated Management of Childhood Illness
IYCF Infant and Young Child Feeding
Link NCA Link Nutrition Causal Analysis
LSHTM London School of Hygiene and Tropical Medicine
MDD-W Minimum Dietary Diversity for Women
NACS Nutrition Assessment and Counseling and Support
NIPP Nutrition Impact and Positive Practice
NPDA Nutrition Program Design Assistant
PAHO Pan American Health Organization
SMART Standardized Monitoring and Assessment of Relief and Transitions
SPRING Strengthening Partnerships, Results, and Innovations in Nutrition Globally
TIPs Trials of Improved Practices
TOPS Technical and Operational Performance Support
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization

1
Preface and Acknowledgments

PREFACE
There are many tools and resources available for designing, implementing, and evaluating nutrition
programs. However, CORE Group Nutrition Working Group members did not have one place to go to
when determining which nutrition-specific tools and approaches to use for programming and research.

Consequently, members expressed an interest in developing a reference guide of nutrition-specific tools

and approaches, information on how and when to use them, and special considerations for their use.
This reference guide meets this need. It is targeted to program designers and technical staff among
CORE Group members, as well as others working in the area of nutrition globally. Its purpose is to guide
nutrition actors in selecting the most appropriate design, research, implementation, and evaluation tools,
based on their program objectives, context, and available resources.

ACKNOWLEDGMENTS
We are grateful for contributions and reviews from CORE Group Nutrition Working Group members and
representatives of organizations whose tools are included in this guide. This document would not have
been possible without the leadership and effort of Jennifer Burns (Catholic Relief Services), Mai-Anh
Hoang and Camilla Peterson (Chemonics), and Judiann McNulty (independent consultant).

PHOTO CREDITS
Cover Photo: © 2017 Riccardo Gangale, Courtesy of Photoshare. Nutrition program in Rwanda.

Back Cover Photo: © 2013 Krishnasis, Courtesy of Photoshare. Local vendor sells vegetables at an
outdoor market in Howrah, India.

PHOTO DISCLAIMER
Photographs used are for illustrative purposes only and do not necessarily represent the tools, resources,
or approaches documented in this guide or recommended by the CORE Group Nutrition Working Group.

GRAPHIC DESIGN
Holly Collins

2
 Title
Summary Reference Guide of Nutrition Tools and Approaches

REFERENCE GUIDE CATEGORIES: DESIGN FORMATIVE IMPLEMENTATION MONITORING &

RESEARCH SUPPORT EVALUATION

NAME DESIGN FORMATIVE IMPLEMENTATION MONITORING &

RESEARCH SUPPORT EVALUATION

Agriculture and Nutrition Context

Assessment Tool Locator
• •
Body Mass Index Wheel

•
Breastfeeding Counselling: A Training
Course
•
Community Management of
Uncomplicated Acute Malnutrition in
Infants Under Six Months •
Community-Based Infant and Young
Child Feeding
•
Community-Based Management of Acute
Malnutrition Costing Tool
•
Community-Based Management of
Acute Malnutrition Toolkit: Rapid Start-
Up Resources for Emergency Nutrition • •
Personnel
Emergency Nutrition Assessment for
SMART
• •

3
Title

NAME DESIGN FORMATIVE IMPLEMENTATION MONITORING &

RESEARCH SUPPORT EVALUATION

Engaging Grandmothers to Improve

Nutrition: A Training Manual and Guide
for Dialogue Group Mentors •
Essential Nutrition Actions

• •
Essential Nutrition Actions and Essential
Hygiene Actions Framework
•
Formative Research: A Guide to Support
the Collection and Analysis of Qualitative
Data for Integrated Maternal and Child • •
Nutrition Program Planning
Guidance for Formative Research on
Maternal Nutrition
• •
Guide to Anthropometry: A Practical Tool
for Program Planners, Managers, and
Implementers • •
Infant and Young Child Feeding in
Emergencies Orientation Package
•
Length Mat

•
Link Nutrition Causal Analysis

• •
Maternal Nutrition During Pregnancy and
Lactation: A Dietary Guide
•
Minimum Dietary Diversity for Women: A
Guide to Measurement
•

4
 Title
Summary Reference Guide of Nutrition Tools and Approaches

NAME DESIGN FORMATIVE IMPLEMENTATION MONITORING &

RESEARCH SUPPORT EVALUATION

Mobilizing Communities for Improved

Nutrition: A Manual and Guide for
Training Community Leaders •
Mother-to-Mother Support Groups:
Trainer’s Manual and Facilitator’s Manual
with Discussion Guide •
National and District Tools to Guide
Anemia Programming
• • •
Nutrition Assessment and Counseling
Support Training Package for Facility-
Based Service Providers •
Nutrition Assessment and Counseling
Support: A User’s Guide
•
Nutrition Impact and Positive Practice

• • •
Nutrition Program Design Assistant: A
Tool for Program Planners, Version 2
• •
Optifood

•
Positive Deviance/Hearth: Resource
Guide for Sustainably Rehabilitating
Malnourished Children • • • •
ProPAN 2.0: Process for the Promotion of
Child Feeding
• • •

5
Title

NAME DESIGN FORMATIVE IMPLEMENTATION MONITORING &

RESEARCH SUPPORT EVALUATION

Setting Up and Running a School

Garden: A Manual for Teachers, Parents,
and Communities • •
The Basics: Planning for Formative
Research for Infant and Young Child
Feeding Practices • •
Tool for Rapid Evaluation of Facility-Level
NACS: A User’s Guide
•
Training Guide for Community-Based
Management of Acute Malnutrition
•
Training of Facilitators for Positive
Deviance/Hearth
•
Trials of Improved Practices

• •

6
 Agriculture and Nutrition Context Assessment Tool Locator

DESCRIPTION, PURPOSE, AND AUDIENCE

The aim of this interactive tool and its associated user guide is to
support context assessment for project design — whether creating new
projects or amending existing ones. It intends to strengthen the link
between agricultural interventions and nutritional outcomes, focusing
on how to gather new information on the various components that
link agriculture and nutrition. The guide explains the basic steps of
context assessment and presents a variety of primary data collection
tools. While some parts of the guide are USAID-specific, it is also
intended for a broader audience, including local and international
NGOs, donors, and multinational organizations that are interested in
designing agriculture-nutrition projects.

SPECIFIC OBJECTIVES AND APPLICATIONS

The guide aims to support the process of choosing the most

appropriate tool for a given context and design purpose. It explains
the basic steps of context assessment and briefly summarizes each
featured tool, including content, application, and related resources.
Tool summaries are intended to facilitate an informed choice of which
tool is most appropriate based on assessment objectives, timing, and
available budget.

RESOURCES

The guide is available on the website: Part 1 outlines the basic steps
of context assessment and Part 2 focuses on how to gather new
information on the various components that link agriculture and
nutrition. The website also features an interactive conceptual pathway
that guides tool selection. All tools are provided in an online database
and downloadable format.

SPECIAL CONSIDERATIONS

The guide does not offer new tools for contextual assessment;
rather, it encourages use of existing manuals and handbooks to
provide practical guidance on assessing the various factors along the
agriculture-nutrition path.

This tool was developed under the SPRING project in 2015. More information can be found at: www.spring-
nutrition.org/publications/tools/context-assessment-tool-locator

7
Body Mass Index (BMI) Wheel

DESCRIPTION, PURPOSE, AND AUDIENCE

Determining BMI is a cheap, reliable way for health workers to

identify malnutrition in clients. The BMI wheel was created to make
calculating BMI and BMI-for-age quicker and easier for health workers
in developing countries. Using this time-saving tool, health workers
can quickly determine BMI and nutritional status without calculations.
Results can then be shown to clients and used for counseling.

SPECIFIC OBJECTIVES AND APPLICATIONS

All instructions are printed directly on the wheel. After a client’s height
and weight are taken, measurements are aligned on the wheel, which
displays the BMI (for adults aged 19 years or older) or BMI-for-age
(for boys and girls aged five to 18 years). BMI classifications are also
printed on the wheel, and are used to determine nutritional status
once BMI has been calculated.

RESOURCES

Design files for the BMI wheel are available in English, Spanish, and
Portuguese for organizations interested in printing the wheel for their
own use. Users can access the files through a sublicense agreement
with FHI 360. Interested organizations should review and sign the
sublicense agreement available on the website, and email a signed
copy to [email protected]. FHI 360 will then provide the design
files that can be given to a professional printer to print and assemble
the wheels. To ensure accuracy of the wheel, design files cannot be
modified other than for translation.

SPECIAL CONSIDERATIONS

This tool is not to be used for children under five years of age or for
pregnant or lactating women.

The wheel was developed by the USAID-funded FANTA project and the Boston Children’s Hospital. More
information about the BMI Wheel can be found at: www.fantaproject.org/tools/body-mass-index-bmi-wheel

8
 Breastfeeding Counselling: A Training Course

DESCRIPTION, PURPOSE, AND AUDIENCE

This course is designed to provide health workers with the skills

needed to support mothers and their children to breastfeed optimally.
The course is for health workers who care for mothers, infants, and
young children in maternity facilities, hospitals, and health centers.
This includes midwives, community health nurses, pediatric nurses,
and doctors — particularly those who are working at the first level of
health care.

SPECIFIC OBJECTIVES AND APPLICATIONS

The course aims to enable health workers to develop the clinical and
interpersonal skills needed to support optimal breastfeeding practices
and help mothers to overcome difficulties. It aims to address the urgent
need to train maternal and child health workers in all countries on
the skills needed to support and protect breastfeeding. The training
is for 24 participants and six trainers, and takes 40 hours. It can be
conducted intensively over five days or spread out over a longer
period. There are 33 sessions, which are structured around four two-
hour clinical practice sessions. Training is conducted partly with the
whole class together and partly in smaller groups. An additional 40
hours is necessary to prepare trainers; this usually takes place in the
week preceding the course for participants.

RESOURCES

The training package is available for download and includes guides

for the course director and trainers, a participants’ manual, a booklet
with overhead figures, a slide book, checklists, and other annexes.
Materials are available in English, French, Russian, and Spanish.

SPECIAL CONSIDERATIONS

Materials are designed to make it possible for all trainers, even those
with limited experience of teaching the subject to conduct up-to-date
and effective courses.

The course was developed in 1993 by WHO and UNICEF. Course materials are available at: www.who.int/
maternal_child_adolescent/documents/who_cdr_93_3/en/

9
Community Management of Uncomplicated Acute
Malnutrition in Infants Under Six Months (C-MAMI)

DESCRIPTION, PURPOSE, AND AUDIENCE

C-MAMI gives health workers a format to assess, identify/classify, and

manage uncomplicated acute malnutrition in infants under six months
of age in the community. Modeled on the Integrated Management
of Childhood Illness (IMCI) approach, C-MAMI helps apply the latest
World Health Organization (WHO) technical guidance complementary
to existing national and international guidance and protocols. C-MAMI
informs program design and resource needs, and is a key resource
for those designing, implementing, and resourcing care packages for
infants under six months in nutrition and health at the national and
international level.

SPECIFIC OBJECTIVES AND APPLICATIONS

C-MAMI is designed for managing uncomplicated cases of acute

malnutrition. (Complicated cases should be referred for inpatient care
per existing national protocols). C-MAMI incorporates assessment
and actions considering anthropometry, feeding, clinical factors, and
psychosocial factors affecting infants and mothers. The exact location
for delivery of C-MAMI services will vary by context and staff capacity.

RESOURCES

A detailed step-by-step C-MAMI tool, organized into assessment

and management sections, is available to download as a PDF. A
user-friendly checklist and feedback survey, as well as background
research, are also available on the website.

SPECIAL CONSIDERATIONS

This tool is a working document and a first step to filling a programming

gap in emergency and non-emergency contexts. Piloting and
evaluation of C-MAMI is underway. The developers recognize the
need for user-friendly program tools to support implementation
and map out capacity development and associated training needs.
Developers also recognize the need to develop meaningful data
collection and monitoring to inform programming and wider learning.

C-MAMI was developed by the Emergency Nutrition Network and the LSHTM, with expert input from
programmers funded by the Office of U.S. Foreign Disaster Assistance, Irish Aid, and Save the Children.
Access the website and related resources at: www.ennonline.net/c-mami

10
 Community-Based Infant and Young Child Feeding (IYCF)

DESCRIPTION, PURPOSE, AND AUDIENCE

This is a package of generic tools for programming and capacity

development on community-based IYCF counseling in diverse country
contexts. The package of tools guides local adaptation, design,
planning, and implementation of community-based IYCF counseling
and support services at scale. It also contains training tools to equip
community workers (via an interactive and experiential adult-learning
approach) with relevant knowledge and skills on recommended
breastfeeding and complementary feeding practices for children up
to 24 months; enhance their counseling, problem solving, negotiation,
and communication skills; and prepare them to effectively use
counseling tools and job aids.

SPECIFIC OBJECTIVES AND APPLICATIONS

The package aims to support community-level IYCF interventions to

improve survival, growth, and development of children with equity. It
provides information helpful for addressing suboptimal IYCF practices
and generating support, counseling, and accurate information for
caregivers in the poorest and most vulnerable communities.

RESOURCES

The package includes a planning guide, adaptation guide, and

facilitator guide; training aids; participant materials; counseling cards
for community workers; a key messages booklet; brochures on how to
breastfeed your baby, nutrition during pregnancy and breastfeeding,
and how to feed a baby after six months; and a supervision, mentoring,
and monitoring module. Materials are available in English and French.
Examples of materials and adaptations from selected countries and
partners are also available.

SPECIAL CONSIDERATIONS

Package components are living documents and are periodically

updated.

This package was developed by UNICEF. Tools are available to download at: www.unicef.org/nutrition/
index_58362.html

11
Community-Based Management of Acute Malnutrition
(CMAM) Costing Tool

DESCRIPTION, PURPOSE, AND AUDIENCE

This Microsoft Excel-based tool estimates the costs of establishing,

maintaining, and/or expanding services for CMAM at national,
subnational, and district levels. It helps program managers to
determine whether CMAM plans are financially feasible, to identify
necessary resources, and to formulate effective implementation plans.
The tool is geared toward individuals and organizations responsible
for designing and financing CMAM. However, any health and nutrition
agency considering starting or strengthening CMAM would benefit
from the tool.

SPECIFIC OBJECTIVES AND APPLICATIONS

The tool’s objective is to estimate the costs of establishing, maintaining,

and/or expanding services for CMAM at national, subnational, and
district levels. The tool is essentially a set of linked Excel spreadsheets.
Users enter key country-specific data, such as statistics on malnutrition,
distances between administration facilities, and prices of goods. The
tool automatically processes these (and other data fixed by the tool)
to calculate CMAM resource requirements and costs for a geographic
region and time defined by the user. Costs are calculated from the
quantity of resources (number of units) and the price per unit.

RESOURCES

Four documents comprise the complete package: the CMAM Costing

Tool, a user’s manual, a case study based on the tool’s application
in Ghana, and practical exercise answers. Materials are available in
English and French.

SPECIAL CONSIDERATIONS

The tool deals only with the management of severe acute malnutrition.
It is designed primarily for use at the central level, though it is possible
to focus on provinces, regions, districts, or CMAM sites.

CMAM Costing Tool resources were developed by FHI 360 under the FANTA project with funding from USAID. To
access the available resources, visit: www.fantaproject.org/tools/cmam-costing-tool

12
 Community-Based Management of Acute Malnutrition
(CMAM) Toolkit: Rapid Start-Up Resources for Emergency
Personnel

DESCRIPTION, PURPOSE, AND AUDIENCE

The CMAM Toolkit was designed as a collection of tools needed by

emergency nutrition program managers to begin implementation of
CMAM programs, either at the onset of a crisis or during a protracted
crisis. The toolkit was envisioned as an easy-to-use compilation of
existing tools and resources, thus allowing managers to rapidly
access needed inputs and begin implementation as soon as possible.

SPECIFIC OBJECTIVES AND APPLICATIONS

CMAM is a method for treating acute malnutrition in young children

using a case-finding and triage approach. Using the CMAM method,
malnourished children receive treatment suited to their nutritional
and medical needs. This toolkit intends to serve as a resource for
emergency nutrition personnel responsible for program design,
implementation, and management in an emergency context.

RESOURCES

The toolkit guides users through planning, implementation, and

assessment of community-based emergency nutrition programs.
It includes tools for caseload estimation, reporting form templates,
staffing descriptions, supervision checklists, and protocols.
Accompanying the CMAM Toolkit is an interactive 30-minute online
tutorial that provides a comprehensive introduction to the toolkit,
outlines programming tools, provides instructions on estimating
caseloads and supplies, and offers directions to tools needed for
rapid implementation.

SPECIAL CONSIDERATIONS

The toolkit is not meant to be used as a replacement of national

protocols. When starting up any emergency nutrition program, the
first resource for program managers is the Ministry of Health. The
toolkit was updated in April 2017.

This toolkit was developed by Save the Children, supported by The TOPS Program with USAID funding. Access
the toolkit at: https://sites.google.com/site/stcehn/documents/cmam-toolkit

13
Emergency Nutrition Assessment for SMART

DESCRIPTION, PURPOSE, AND AUDIENCE

Standardized Monitoring and Assessment of Relief and Transitions

(SMART) Methodology is a standardized survey method for measuring
mortality, nutritional status, and food security in humanitarian and
development contexts. SMART assists field workers to conduct
surveys, then analyze, interpret, and report on findings to support
decision-making. Emergency Nutrition Assessment software is a user-
friendly analytical program recommended by SMART. The tool helps
ensure SMART nutrition assessments and mortality rate calculations
are reliable, standardized, and simple to perform. It focuses on the
most important indicators (anthropometric and mortality data), checks
plausibility of entered data, and generates automatic reports. The tool
is continually updated based on user feedback and emerging best
practices.

SPECIFIC OBJECTIVES AND APPLICATIONS

The tool facilitates SMART survey planning, data collection, analysis,

and reporting. It has automated functions for sample size calculations,
sample selection, quality and plausibility checks, standardization for
anthropometric measurements, and report generation with automatic
analyses.

RESOURCES

Emergency Nutrition Assessment 2011 is available to download free

online, along with a software user manual. A SMART manual and
capacity building toolbox is also available. The toolbox includes an
e-learning series, as well as other training packages. A global pool of
SMART master trainers and emergency support is also available.

SPECIAL CONSIDERATIONS

Emergency Nutrition Assessment should be complemented with

qualitative information (e.g., discussions with key informants) to provide
contextual understanding. It also has limited capacity to analyze
additional variables collected and manage data from other programs.
A hybrid Emergency Nutrition Assessment/Epi Info software package
is available for expanded functionality.

SMART is an interagency initiative launched in 2002 by a network of organizations and humanitarian

practitioners. SMART materials were developed by ACF Canada, with financial support from USAID. For further
information on SMART, please visit: www.smartmethodology.org. Additional information on ENA software can
be found at: www.nutrisurvey.de/ena2011
14
 Engaging Grandmothers to Improve Nutrition: A Training
Manual and Guide for Dialogue Group Mentors

DESCRIPTION, PURPOSE, AND AUDIENCE

Mentor grandmothers facilitate discussions with their peers to

enhance maternal and child health practices. This manual and guide
are designed to train grandmothers to serve as dialogue group
mentors and to facilitate discussions on family care and maternal and
child nutrition.

SPECIFIC OBJECTIVES AND APPLICATIONS

The manual provides step-by-step guidance on facilitating a three-

day workshop to train grandmothers as dialogue group mentors.
Workshops use group activities, focused discussions, brainstorming,
and roleplaying to introduce issues like breastfeeding, complementary
feeding, and prevention of mother-to-child transmission of HIV, as well
as facilitation skills and practice. After training, grandmothers will be
more informed about best health practices and will be able to more
successfully engage mothers, children, and fathers toward better
feeding and care practices. The guide is designed to provide dialogue
group mentors (grandmothers) with key questions to encourage lively
discussions around the topics covered in workshops.

RESOURCES

The manual provides a training schedule, a list of necessary materials,

lesson plans, handouts, and test materials. The mentor guide covers
topics such as mentor responsibilities, preparing for meetings,
and setting ground rules, and outlines key discussion points. Both
resources are available in English and Portuguese.

These materials were developed under USAID’s Infant & Young Child Nutrition Project, which was implemented
by PATH in collaboration with CARE, The Manoff Group, and University Research Co., LLC. They can be
downloaded from: www.iycn.org/resource/engaging-grandmothers-to-improve-nutrition-a-training-manual-
and-guide-for-dialogue-group-mentors
15
Essential Nutrition Actions (ENA)

DESCRIPTION, PURPOSE, AND AUDIENCE

This document provides a consolidated package of 24 WHO

guidelines on nutrition interventions targeting the first 1,000 days of
life. Focusing on ENA can help policymakers to reduce infant and child
mortality, improve physical and mental growth and development, and
improve productivity. This approach looks at how to integrate ENA at
critical stages in the life cycle of women and children, within commonly
available facility and community contact points, to improve the quality
of nutrition services and to promote positive changes in family-based
feeding and caring behaviors. The document covers different aspects
of infant feeding in normal or exceptional circumstances, such as
emergencies, HIV infections, and diarrhea, as well as nutrition for
women.

SPECIFIC OBJECTIVES AND APPLICATIONS

Part 1 presents the interventions currently recommended by WHO,

summarizes the rationale and the evidence for each, and describes
the actions required to implement them. Part 2 analyzes community-
based interventions aimed at improving nutrition and discusses how
to deliver effective, integrated interventions. It also shows how the
actions described in Part 1 have been implemented in large-scale
programs in various settings and what the outcomes have been.

RESOURCES

The package is available to download in English and Farsi. To provide

real-time updates, WHO also launched the electronic Library of
Evidence on Nutrition Actions — a simple web-based tool for academics,
policymakers, health workers, and development partners containing
links to WHO evidence-informed nutrition recommendations.

SPECIAL CONSIDERATIONS

Dissemination of ENA and assistance for policymakers is needed to

adapt the guidance to country context. Additional operational tools
are often required, including analysis of cost-effectiveness.

This document was produced by WHO. It can be accessed at: www.who.int/nutrition/publications/

infantfeeding/essential_nutrition_actions/en

16
 Essential Nutrition Actions and Essential Hygiene Actions
Framework

DESCRIPTION, PURPOSE, AND AUDIENCE

This framework is a tool for advocacy, planning, training, and delivery

of an integrated package of interventions to reach the high coverage
(> 90 percent) needed to achieve public health impact. The materials
help strengthen the capacity of health workers, nutrition managers,
and community workers to deliver and promote evidence-based
essential nutrition and hygiene practices. Implementation emphasizes
a lifecycle approach, and includes nutrition-specific and nutrition-
sensitive platforms, as well as hygiene actions inextricably linked to
improved nutrition.

SPECIFIC OBJECTIVES AND APPLICATIONS

The training guide for health workers/nutrition managers introduces

key hygiene and nutrition information. The guide applies a participatory
approach, emphasizes exercises that improve counseling skills,
addresses nutrition for HIV, and links prevention of malnutrition with
treatment. It also trains nutrition managers to provide supportive
supervision to health and community workers. Its accompanying
reference manual provides supporting information that helps improve
delivery. The training guide for community workers builds capacity
to deliver and promote essential nutrition and hygiene actions.
It introduces technical content in hands-on sessions to practice
counseling and negotiation, and guides community workers in
understanding why and how to integrate messages on nutrition and
hygiene into programs. Its accompanying reference manual is a job
aid covering key concepts for each practice, as well as ideas on using
homestead food production to improve household diet.

RESOURCES

All resources are available online in English and French. Available

resources include the training guides and reference manuals for health
workers/nutrition managers and community workers; a framework
summary document; a flyer summarizing tools; and case studies.

SPECIAL CONSIDERATIONS

Materials were updated in 2014.

Multiple actors and programs contributed to updating these training materials, with funding provided by
USAID. For more information and to access the materials, please visit: www.coregroup.org/enaeha

17
Formative Research: A Guide to Support the Collection and
Analysis of Qualitative Data for Integrated Maternal and
Child Nutrition Program Planning

DESCRIPTION, PURPOSE, AND AUDIENCE

Formative research builds understanding on different

characteristics, interests, and needs in a target population. This
guide is primarily targeted to people who are planning programs to
improve maternal, infant, and young child nutrition and household
food security. It provides the basic information and tools needed
to conduct and analyze qualitative research to improve nutrition
programming through step-by-step instructions on using tools
such as key informant and focus group interviews, community
mapping, social network mapping, and food market analysis.

SPECIFIC OBJECTIVES AND APPLICATIONS

This guide focuses on promoting qualitative methods to develop

more effective nutrition programming. It aims to define key
problems in maternal and child nutrition and feeding practices
and local food insecurity; provide an introduction to conducting
formative research; familiarize users with qualitative methods;
and offer step-by step instructions on how to plan, conduct, and
analyze formative research. Activities in this guide are divided into
seven sections: barrier analysis, mapping, time analysis, linkages
and relationships, prioritization/quantification, action planning,
and experiential. Most activities are highly visual, allowing for
participation of people who are illiterate.

RESOURCES

The complete guide is available for download. Activities are

organized into modules, and each module contains an activity
overview, step-by-step instructions on data collection and using
the activity, and instructions on performing basic qualitative data
analysis.

SPECIAL CONSIDERATIONS

The guide may be combined with quantitative data collection

methods, such as baseline surveys, to provide additional details.
Although the methods reviewed in this guide are focused on infant
and young child feeding, maternal nutrition, and food security, they
can be applied to numerous topics. Research should be planned
carefully to ensure only essential data is collected.

This guide was developed by CARE and published in 2014. It can be downloaded from: http://fsnnetwork.org/
formative-research-guide-support-collection-and-analysis-qualitative-data-integrated-maternal-and

18
 Guidance for Formative Research on Maternal Nutrition

DESCRIPTION, PURPOSE, AND AUDIENCE

This document offers technical guidance for people working to

translate optimal practices into feasible actions and programs for a
given country or region. It is intended to increase awareness and
understanding of optimal maternal nutrition practices. The document
guides the development and design of a formative research process
for maternal nutrition programs or interventions.

SPECIFIC OBJECTIVES AND APPLICATIONS

The guidance presents different elements of creating and

implementing formative research for maternal nutrition including:
understanding the general nutrition context by using all readily
available data and information; choosing the best methods and
participants; and developing effective research guides and tools.

RESOURCES

The complete guide is available for download. It also includes examples

of formative research tools and plans, and offers suggestions for
analytical tools and formats.

SPECIAL CONSIDERATIONS

This guidance is not a “how-to” manual for planning and conducting

formative research; however, supplementary materials relating to
these topics are included in its annexes.

The guide was developed under USAID’s Infant & Young Child Nutrition Project, which was implemented by
PATH in collaboration with CARE, The Manoff Group, and University Research Co., LLC. It can be downloaded
from: www.iycn.org/resource/guidance-for-formative-research-on-maternal-nutrition

19
Guide to Anthropometry: A Practical Tool for Program
Planners, Managers, and Implementers

DESCRIPTION, PURPOSE, AND AUDIENCE

This user-friendly reference guide provides up-to-date information

on anthropometry and how to use it to assess and understand
the nutritional status of individuals and communities. It provides
comprehensive information on the importance of good nutrition,
common nutrition conditions, anthropometric measurements and
indices, and data interpretation, as well as measurement protocols
and information on equipment selection. The guide is intended to
help development practitioners (who implement or oversee food
security, nutrition, or heath programs) better collect, understand, and
use anthropometric data in their programs.

SPECIFIC OBJECTIVES AND APPLICATIONS

The tool offers guidance that can be used as part of providing regular
health services in a clinic or community setting, or for conducting
anthropometry as part of a population-based survey. It is also useful
for anyone who is engaged in improving or understanding food
security, nutrition, or health in developing countries, and wishes to
better understand the information provided through anthropometry.
The guide provides anthropometric guidance for all age groups from
birth to old age.

RESOURCES

The guide is available to download free online. It is organized into six

modules: anthropometry basics, children from birth to five years of
age, children and adolescents five to 19 years of age, pregnant and
postpartum women and girls, adults 18 years and older (non-pregnant,
non-postpartum), and measurement protocols and equipment.

SPECIAL CONSIDERATIONS

The guide focuses on anthropometric measurements commonly

used in low-resource settings that require affordable and accessible
equipment. It does not discuss measurements that require equipment
often unavailable in low-resource settings. The guide does not provide
information on planning surveys. The guide is not intended to serve
as a stand-alone training manual; however, its guidance and protocols
can be used as a resource to inform development of training materials.

The guide was developed by FHI 360 under the FANTA project with funding from USAID. The guide can be
downloaded at: www.fantaproject.org/tools/anthropometry-guide

20
 Infant and Young Child Feeding in Emergencies (IYCF-E)
Orientation Package

DESCRIPTION, PURPOSE, AND AUDIENCE

This package of resources helps orient emergency relief staff, program

managers, and technical staff involved in planning for and responding
to emergencies at the national and international level.

SPECIFIC OBJECTIVES AND APPLICATIONS

The package supports training and learning related to IYCF-E.

RESOURCES

All materials in the orientation package are available online. Resources

include self-paced e-learning lessons, preparation for face-to-face
training, or group exercises; training resources such as PowerPoint
presentations and practical training exercises; technical notes to
support online lesson content and training resources; a bank of other
key resources; and an evaluation guide with pre- and post-assessment
questions and an evaluation strategy.

This is an update of version 1.0 (2001). The updated content was developed by the Emergency Nutrition Network
(ENN) and IYCF-E Core Group members. Development of version 2.0 (2009) was funded by UNICEF’s IASC
Nutrition Cluster. Version 2.1 (2010) was updated by ENN to reflect Sphere 2011 and the latest WHO guidance
on infant feeding and HIV. Materials are available: www.ennonline.net/ourwork/capacitydevelopment/
iycfeorientation
21
Length Mat

DESCRIPTION, PURPOSE, AND AUDIENCE

The Length Mat was designed to raise community awareness of

stunting and to facilitate easy stunting detection at the community
level. It is a portable mat made from durable plastic that is marked with
measurements for boys and girls. Markings denote cutoff lengths for
children aged six, 12, and 18 months that indicate stunting (defined as <
-2SD of the current WHO standard). Pre-identified demarcations avoid
the need for looking up each child’s measurements on a growth table,
enabling the status of the child to be quickly and clearly known. The
six-month interval between cut-offs allows enough time for children’s
length to be affected by their diet or health status.

SPECIFIC OBJECTIVES AND APPLICATIONS

The mat provides a visual cue to determine if a child meets normal

height-for-age measurements. It aims to overcome difficulties
normally associated with collecting anthropometric measurements
to improve detection of stunting. By building awareness of stunting
at the community level, it enables community health workers and
parents to address health and nutrition practices that promote child
growth. It also helps identify children needing referrals for additional
services and counseling.

RESOURCES

Please contact The Manoff Group for more information.

SPECIAL CONSIDERATIONS

The length mat is a community (non-clinical) tool that requires country

adaptation.

The Length Mat was developed by The Manoff Group: www.manoffgroup.com

22
 Link Nutrition Causal Analysis (Link NCA)

DESCRIPTION, PURPOSE, AND AUDIENCE

Link NCA is a structured, participatory, and holistic study based on

the UNICEF causal framework that is designed to build evidence-
based consensus around the plausible causes of undernutrition in
local contexts. It uses a mixed-method approach to identify causes
of undernutrition and to support appropriate responses in various
environments. Through a sequential process, it collects and triangulates
information to determine undernutrition causality. While mostly used
by nutrition practitioners, it is available to all organizations involved
in the fight against undernutrition or other multisector responses. It
works best in local (typically district-level) and stable contexts, when
practitioners identify information gaps and situational understanding
needs before tailoring programs.

SPECIFIC OBJECTIVES AND APPLICATIONS

Link NCA has six analytical and operational objectives: determine

prevalence and severity of wasting and/or stunting; determine
prevalence of known risk factors; identify causal pathways of
undernutrition; assess changes to stunting and/or wasting and
their causes over time, seasonally, or due to recent shocks; identify
causal pathways that likely explain most cases of undernutrition; and
recommend programming improvements.

RESOURCES

The Link NCA Technical Unit at Action Against Hunger can offer
technical and training support to organizations wishing to undertake
Link NCA depending on the availability of trainers and funds. An
overview and set of guidelines for Link NCA is available in English,
French, and Spanish. An indicator guide and pathways module are
available on request.

SPECIAL CONSIDERATIONS

Quantitative data collection follows SMART guidance. All Link NCA

final reports should be validated by the Link NCA Technical Unit.
Link NCA implemented by partners should be conducted with the
Link NCA Unit to ensure correct application of the method and high-
quality results. The Link NCA process requires approximately four to
five months to complete.

Link NCA was developed by Action Against Hunger, with input from external technical experts. More
information is available at: www.linknca.org/index.htm

23
Maternal Nutrition During Pregnancy and Lactation: A
Dietary Guide

DESCRIPTION, PURPOSE, AND AUDIENCE

Health workers often lack information on how to counsel pregnant

and lactating women on increased nutrient requirements, and
on how to meet these through dietary and behavioral changes
and other health practices. Health workers also experience
uncertainty on how to translate general requirements into
individual recommendations. Maternal Nutrition During Pregnancy
and Lactation: A Dietary Guide attempts to fill this information gap.
The guide informs health workers on how to counsel pregnant
and lactating women to enable them to meet increased nutrient
requirements.

SPECIFIC OBJECTIVES AND APPLICATIONS

The guide is designed to help ensure women’s nutrient needs

are met during pregnancy and lactation. It fills health worker gaps
in information on nutrition in pregnancy and lactation, and helps
translate general requirements into individual recommendations.
It also helps programs develop appropriate protocols and
counseling materials on maternal nutrition.

RESOURCES

The guide includes nutrition recommendations and supporting

interventions; weight gain recommendations for pregnancy;
recommended micronutrient supplementation during pregnancy
and lactation; and a summary of increased nutritional needs during
pregnancy and lactation, with actionable advice on how to meet
them. Links to additional maternal nutrition resources are also
provided.

This guide is a joint publication of the LINKAGES Program and the CORE Group Nutrition Working Group.
Support for LINKAGES was provided to the Academy for Educational Development by USAID. Find more at:
www.coregroup.org/maternal-nutrition

24
 Minimum Dietary Diversity for Women (MDD-W): A Guide to
Measurement

DESCRIPTION, PURPOSE, AND AUDIENCE

MDD-W is a global dietary diversity population-level indicator for

assessing the quality of women’s diets. It reflects women’s consumption
of at least five of 10 food groups throughout the previous day and
night. Research has shown that women who consume at least five of
the 10 MDD-W food groups over a 24-hour period are more likely to
have a diet higher in micronutrient adequacy.

SPECIFIC OBJECTIVES AND APPLICATIONS

MDD-W is a dichotomous indicator of whether women 15 to 49 years

of age have consumed at least five out of 10 defined food groups
the previous day or night. The proportion of women 15 to 49 years of
age who reach this minimum in a population can be used as a proxy
indicator for higher micronutrient adequacy, which is one important
dimension of diet quality.

RESOURCES

A quick start guide, plus sampling guidelines, a model questionnaire

and suggested adaptations, open recall instructions, and guidance on
selection and training of enumerators is provided. Guidance is also
provided on tabulation, presentation, and interpretation of results.

SPECIAL CONSIDERATIONS

This is a population-level indicator, and should not be used to assess

individuals’ diets. The tool should not be used to develop dietary
guidance.

This resource was developed by FAO and FHI 360. It is available at: www.fantaproject.org/monitoring-and-
evaluation/minimum-dietary-diversity-women-indicator-mddw

25
Mobilizing Communities for Improved Nutrition: A Manual
and Guide for Training Community Leaders

DESCRIPTION, PURPOSE, AND AUDIENCE

These materials train community leaders — including religious leaders,

business leaders, and government officials — on topics related to infant
and young child feeding. The materials also guide leaders on sharing
learned information in their communities, increasing discussion and
reflection on nutrition-related topics, and supporting families to feed
their children well.

SPECIFIC OBJECTIVES AND APPLICATIONS

The manual provides instructions for facilitating a one-day workshop

to train community leaders on supporting and improving children’s
health and well-being through improved infant and young child
feeding and maternal dietary practices. The guide is a supplementary
resource for leaders, designed to support them in implementing their
training.

RESOURCES

The manual includes a training schedule, facilitation tips, background

notes, lesson plans, and handouts. The guide provides leaders with
supporting information on topics covered by the training course, and
includes resources such as work plan templates, strategic planning
tools, and reporting forms.

These materials were developed under USAID’s Infant & Young Child Nutrition Project, which was implemented
by PATH in collaboration with CARE, The Manoff Group, and University Research Co., LLC. They can be
downloaded from: www.iycn.org/resource/mobilizing-communities-for-improved-nutrition-a-training-
manual-and-participant-manual-for-community-leaders/
26
 Mother-to-Mother Support Groups: Trainer’s Manual and
Facilitator’s Manual with Discussion Guide

DESCRIPTION, PURPOSE, AND AUDIENCE

These manuals are designed for training mother-to-mother support

group facilitators to lead participatory discussions on maternal, infant,
and young child nutrition. The manuals provide detailed information
on potential support group topics and answers to questions that
may arise. Once trained, facilitators bring mothers together to learn
about and discuss issues relating to infant and young child nutrition;
participants also support each other as they care for children aged
under five years.

SPECIFIC OBJECTIVES AND APPLICATIONS

The trainer’s manual provides step-by-step guidance to facilitate

a four-day training workshop that uses group activities, focused
discussions, brainstorming, and role-playing to train women on
best practices in maternal, infant, and young child nutrition, as well
as facilitation techniques. The facilitator’s manual provides more
detailed background information on possible support group topics for
facilitators to use to prepare for meetings, or to do research if mothers
have questions that facilitators do not know the answer to.

RESOURCES

The trainer’s manual includes a training schedule, lesson plans,

handouts, and test materials. The facilitator’s manual includes general
tips on facilitating support groups, discussion guides, background
notes, and planning and reporting tools.

SPECIAL CONSIDERATIONS

There are three versions of the manuals. The first is a global version
designed to be adapted for an individual country context. There is also
a version in English adapted for Ethiopia and a version in Portuguese
adapted for Mozambique.

These materials were developed under USAID’s Infant & Young Child Nutrition Project, which was implemented
by PATH in collaboration with CARE, The Manoff Group, and University Research Co., LLC. They can be
downloaded from: www.iycn.org/resource/mother-to-mother-support-groups-trainer’s-manual-and-
facilitator’s-manual
27
National and District Tools to Guide Anemia Programming

DESCRIPTION, PURPOSE, AND AUDIENCE

These two tools support countries develop context-specific and

data-driven approaches to address anemia. The Landscape Analysis
Guidance Toolkit informs policymakers and program implementers on
gathering, interpreting, and using anemia-related data at the national
level. The District Assessment Tool for Anemia (DATA) helps districts
assess their current anemia situation. Both tools help stakeholders,
including governments, U.N. agencies, technical assistance providers,
and NGOs looking to better understand and address anemia. Due to
the multifactorial causes of anemia, multiple sectors are encouraged
to engage the tools.

SPECIFIC OBJECTIVES AND APPLICATIONS

The Landscape Analysis Guidance Toolkit guides assessment of the

national anemia situation, covering prevalence, programming, and
policies. Information inputted in the Microsoft Excel-based tool can
be used to generate awareness, develop partnerships, and design
effective interventions and strategies. DATA is a Microsoft Excel-based
tool to create dashboards that visualize the anemia situation based on
district-specific data. Used in district workshop settings, DATA helps
district managers to determine the factors that cause anemia, identify
enablers and barriers to addressing anemia, and identify/prioritize
interventions to strengthen anemia-related programming.

RESOURCES

Both toolkits are available in an interactive online format, with materials

that are downloadable from SPRING’s website. Each offers general
guidance, a user’s guide, and an Excel file. DATA also provides training-
of-trainers and facilitator guides, as well as scripted presentations.

SPECIAL CONSIDERATIONS

Use of these toolkits may require support from technical experts. The
tools are most effective when the availability of relevant data is high.
In cases where data is scarce, stakeholders can leverage qualitative
knowledge to identify data gaps and build capacity for the better
collection and use of data.

Both tools were developed by SPRING, with funding from USAID. Information on the tools can be found at:
www.spring-nutrition.org/publications/series/national-and-district-tools-guide-anemia-programming

28
 Nutrition Assessment and Counseling Support (NACS)
Training Package for Facility-Based Service Providers

DESCRIPTION, PURPOSE, AND AUDIENCE

NACS is a client-centered programmatic approach for integrating a set

of priority nutrition interventions into health services and strengthening
health systems. NACS covers prevention, detection, and treatment of
malnutrition, as well as maintenance of improved nutritional status.
This training package helps facilitators to train trainers or facility-based
health providers in NACS to strengthen integration of standardized
nutrition care and treatment into routine health services. Ultimately, it
equips health providers with the knowledge and skills to improve their
clients’ nutritional status and quality of life.

SPECIFIC OBJECTIVES AND APPLICATIONS

This training package supports facilitators to train participants

to advocate for and discuss the role of nutrition in routine health
services; assess clients’ nutritional status; design nutrition care
plans for clients; counsel clients on issues identified during nutrition
assessments; communicate critical nutrition actions for people with
chronic infections; prescribe and monitor specialized food products to
treat acute malnutrition; manage NACS services in the workplace; and
collect information to monitor and report on NACS services.

RESOURCES

Available materials include a facilitator’s guide, participant handouts,

and a PowerPoint presentation that can be customized for the local
context and for integration into a range of health services, including
maternal and child health and infectious disease care. The training
course is divided into 12 modules that can be taught separately
or combined into a five-day package as needed. The training
complements information in NACS: A User’s Guide, on the following
page. See also: REF-NACS.

SPECIAL CONSIDERATIONS

The training package was based on experiences in 10 countries in sub-

Saharan Africa. Materials should be customized for the local context.

This training package was developed by FHI 360 under the FANTA project, which is funded by USAID. The
training package is available at: www.fantaproject.org/tools/nutrition-assessment-counseling-and-support-
nacs-training-package-facility-based-service

29
Nutrition Assessment and Counseling and Support (NACS):
A User’s Guide

DESCRIPTION, PURPOSE, AND AUDIENCE

NACS is a client-centered programmatic approach for integrating a set

of priority nutrition interventions into health services and strengthening
health systems. NACS covers prevention, detection, and treatment of
malnutrition, as well as maintenance of improved nutritional status.
The NACS User’s Guide is a series of modules that provide program
managers and implementers with a package of essential information
and resources related to NACS.

SPECIFIC OBJECTIVES AND APPLICATIONS

Three current modules cover what NACS is, nutrition assessment

and classification, and nutrition education and counseling. Further
modules on nutrition support, monitoring and evaluation of NACS
services, and NACS planning are forthcoming.

RESOURCES

The NACS User’s Guide and its modules is available to download free
online. A glossary, crossword puzzle, and related resources are also
provided.

SPECIAL CONSIDERATIONS

NACS modules are living documents and will be updated as

appropriate when new evidence, guidelines, or field experience
emerges; the latest update was April 2016.

This guide was developed by FHI 360 under the FANTA project, which is fudned by USAID. To download
the modules, please visit: www.fantaproject.org/tools/NACS-users-guide-modules-nutrition-assessment-
counseling-support

30
 Nutrition Impact and Positive Practice (NIPP)

DESCRIPTION, PURPOSE, AND AUDIENCE

NIPP was designed as a preventive nutrition approach, but has

also proved to have significant impact on reducing rates of acute
malnutrition. NIPP comes with a comprehensive toolkit to support
the planning, implementation, and evaluation of multisectoral
programming (e.g., nutrition, health, WASH, and livelihoods) to
manage malnutrition by tackling contributory factors to poor
nutritional outcomes. The toolkit aims to meet the needs of
ministries of health and other organizations’ nutrition program
managers, coordinators, and advisors who wish to implement a
multisectoral nutrition approach to tackle malnutrition.

SPECIFIC OBJECTIVES AND APPLICATIONS

NIPP aims to reduce rates of malnutrition by triggering behavior

change and using locally available and sustainable multisectoral
solutions. The NIPP toolkit facilitates nutrition program planning,
rollout, implementation, monitoring and evaluation, and costing.
The approach and accompanying toolkit are agile, and can be
adapted to any setting with a basic level of food security and
access.

RESOURCES

A comprehensive guideline and toolkit is available to download

from the NIPP website. This includes planning tools, implementation
materials, monitoring and evaluation forms, guidance on cooking
demonstrations and micro-gardening, and methods for behavior
change counseling.

SPECIAL CONSIDERATIONS

In countries with existing national protocols for treating acute

malnutrition and preventing chronic malnutrition, this toolkit
should be adapted to align with and support existing policies. NIPP
is most suited to locations with basic food security.

NIPP was developed by GOAL in 2012, and to date has been tested in five countries in east and southern Africa.
Following extensive testing, in 2017 GOAL launched NIPP for use by other organizations. More information on
NIPP can be found at: www.goalglobal.org/nipp

31
Nutrition Program Design Assistant (NPDA): A Tool for
Program Planners, Version 2

DESCRIPTION, PURPOSE, AND AUDIENCE

NPDA helps program planners design or improve nutrition components

of community-based development programs and select appropriate
community-based nutrition approaches for target areas. It focuses
on preventive program design for areas with a high prevalence of
stunting or underweight in children. NPDA also provides guidance
on incorporating recuperative approaches in preventive programs in
areas with a high prevalence of acute malnutrition and a very high
prevalence of underweight in children. It is best used in collaboration
with ministry staff, community leaders, local organizations, and other
stakeholders.

SPECIFIC OBJECTIVES AND APPLICATIONS

NPDA provides a framework for analyzing the nutrition situation in

a target area and guides selection of the most appropriate nutrition
approaches based on context and need. Drawing on evidence and
expert guidance, NPDA supports development of nutrition programs
and Theory of Change. Focusing primarily on preventive programs
that address stunting and underweight, it applies a food utilization/
consumption lens to nutrition and health. NPDA emphasizes
community participation and ownership in program design, and
facilitates discussion, communication, and decision-making among
many stakeholders.

RESOURCES

The tool has two components: a reference guide for understanding the
nutrition situation and identifying and selecting program approaches,
and a workbook that helps users systematically record information,
make decisions, and think through decision-making rationale. The
workbook includes an Excel file with adaptable templates for data
collection and developing a logical framework.

SPECIAL CONSIDERATIONS

NPDA requires dedicated time and attention, and might take place in
a multiple-day program design workshop. It is helpful to have situation
analysis data available prior to use. It is intended for development
contexts and is not appropriate for emergency conditions.

NPDA creation was a highly collaborative effort coordinated by FANTA, Save the Children, and the CORE
Group’s Nutrition Working Group. Access resources at: www.coregroup.org/npda

32
 Optifood

DESCRIPTION, PURPOSE, AND AUDIENCE

Optifood provides scientific evidence on how to enrich people’s diets

with locally available foods at the lowest possible cost. It identifies
nutrient gaps, and recommends locally available foods to fill these.
It also helps identify options (e.g., fortified foods or micronutrient
powders) to plug any gaps that local foods cannot fill. Optifood uses
software based on linear programming analysis — a mathematical
optimization process that selects the best diets from among all
possible food combinations given model parameters. It is useful for
designing programs and informing policy decisions to improve the
diet of specific population groups. Key audiences include public
health professionals, governments, NGOs, academic institutions,
international organizations, program managers, and researchers.

SPECIFIC OBJECTIVES AND APPLICATIONS

Optifood provides low-cost, evidence-based dietary recommendations

for target groups in a specified area. Considering the local food supply
and dietary patterns, the software identifies diets that meet (or come
as close as possible to meeting) nutrient needs of target groups. It can
test and compare dietary recommendations based on nutrient level
and cost, identify nutrient requirements that are difficult or expensive
to meet, and determine the lowest and highest cost nutrients. For
example, it can assess if a food-based strategy alone can ensure
dietary adequacy; develop or evaluate food recommendations;
and inform nutrition-sensitive value chain initiatives, cash transfer
programs, and micronutrient interventions.

RESOURCES

Optifood software is available free of charge upon request. Please

contact: [email protected]

SPECIAL CONSIDERATIONS

Application of Optifood requires training.

Optifood was developed jointly by WHO, LSHTM, the FANTA project, and Blue-Infinity, with support from
USAID. For more information, please visit: www.fantaproject.org/tools/optifood

33
Positive Deviance/Hearth: Resource Guide for Sustainably
Rehabilitating Malnourished Children

DESCRIPTION, PURPOSE, AND AUDIENCE

Positive Deviance/Hearth is a home- and neighborhood-based

nutrition program for children at risk of malnutrition. Using a
strengths-based philosophy, the positive deviance approach
identifies beneficial practices used by caregivers of well-nourished
children from impoverished families. It then spreads these
practices and behaviors to their neighbors (who share the same
resources and face the same risks) via small group rehabilitation
sessions known as hearths. Participants bring locally available
nutritious foods to cook and feed their children during hearths, and
learn complementary health practices. This guide helps program
managers interested in mobilizing communities to sustainably
rehabilitate malnourished children.

SPECIFIC OBJECTIVES AND APPLICATIONS

The approach is designed for use in communities where moderate

or severe malnutrition affects 30 percent or more of the local
population. There are 14 key elements for implementing a positive
deviance program, which must be included to assure effectiveness.
It focuses on maximizing existing resources, skills, and strategies
to overcome a problem, and uses participatory methods and
processes. As such, it is important to have strong community buy-
in. As the approach requires availability of local and affordable
food, it is not recommended if the community is reliant on food aid.

RESOURCES

The guide explains step-by-step how to identify at-risk children;

conduct a positive deviance inquiry; conduct hearth sessions;
and set up a monitoring and evaluation system. Specific field
examples, case studies, and useful tools are provided. A detailed
training guide for facilitators of positive deviance programs is also
available (see Training of Facilitators for Positive Deviance/Hearth).

SPECIAL CONSIDERATIONS

There are several essential elements that must be included to

maintain the effectiveness of the approach. However, the approach
requires local adaptation, and many implementation steps are
flexible.

The resource guide was produced by CORE Group, with support from USAID. For further information, visit:
www.coregroup.org/positive-deviance-hearth-resource-guide

34
 ProPAN 2.0: Process for the Promotion of Child Feeding

DESCRIPTION, PURPOSE, AND AUDIENCE

ProPAN was developed to provide ministries of health, NGOs,

researchers, and international organizations a tool to develop,
implement, and evaluate interventions and programs to improve infant
and young child feeding and diet. It outlines a process for identifying
specific breastfeeding and complementary feeding problems and
defining the context in which these problems occur.

SPECIFIC OBJECTIVES AND APPLICATIONS

ProPAN provides a process for identifying and contextualizing specific

breastfeeding and complementary feeding problems based on 12 ideal
practices; quantitative and qualitative research techniques for joint
analysis of these practices; software for standardized input/output of
anthropometric, diet, and feeding information; a method for formulating,
ranking, and selecting dietary and feeding recommendations that are
practical, feasible, and acceptable to caregivers and health providers;
and guidance on how to use the resulting information in programming
and for monitoring and evaluation.

RESOURCES

ProPAN includes a field manual with step-by-step guidelines on

how to apply quantitative and qualitative research methods. It has
four modules: assessment, testing recommendations and recipes,
developing the intervention plan, and designing a monitoring and
evaluation system. Each module has two components: an overview
of purpose, products, steps, and concepts and research techniques,
and an annex of custom tools and instructions for analysis of dietary
and feeding problems. ProPAN also offers an Epi Info-based software
program for data entry and analysis, and a software user guide.
ProPAN is available at no cost in English, Spanish, and French. Online
video training tools are also available.

SPECIAL CONSIDERATIONS

ProPAN modules can be used individually or as a comprehensive

exercise, depending on users’ needs. Modules I and II can also be
used to train nutritionists in quantitative and qualitative research
methods.

ProPAN was developed jointly by PAHO and UNICEF. The U.S. Centers for Disease Control and Prevention,
Emory University, and the FANTA project also contributed to the effort. The updated version of this tool was
funded in part by the Global Alliance for Improved Nutrition. To access the tool, visit: www.paho.org/propan

35
Setting Up and Running a School Garden: A Manual for
Teachers, Parents, and Communities

DESCRIPTION, PURPOSE, AND AUDIENCE

The School Garden Manual is based on experiences and best practices

from setting up and running school gardens worldwide. It details
each step of planning a garden project: deciding what your garden
is for, planning how to get help, and learning how to prepare the site.
Classroom lessons link to practical learning in the garden about the
environment, food production and marketing, food processing and
preparation, and healthy food choices. The manual is for anyone who
is interested in starting or improving a school garden — especially
for growing good food or learning how to market garden products.
This includes teachers, garden managers, parents, and community
members from one or multiple schools

SPECIFIC OBJECTIVES AND APPLICATIONS

The manual aims to improve the nutrition and education of children

and their families in rural and urban areas. It provides a platform
for learning about nutrition and food production. It promotes the
environmental, social, and physical well-being of the school community,
while fostering a better understanding of the natural world. Schools
are encouraged to create learning gardens of moderate size, which
can be easily managed by students, teachers, and parents. Gardens
include a variety of nutritious vegetables and fruits, and occasionally
small-scale livestock such as chickens or rabbits.

RESOURCES

The manual provides a step-by-step guide for creating and maintaining

a school garden. It includes sections on organizing and implementing
the work, lesson plans, nutrition factsheets, and horticultural notes.

This manual was developed by FAO. For more information, visit: www.fao.org/docrep/009/a0218e/A0218E00.
htm

36
 The Basics: Planning for Formative Research for Infant and
Young Child Feeding Practices

DESCRIPTION, PURPOSE, AND AUDIENCE

This guide is intended to assist researchers, who are familiar with

formative research methods, in conducting formative assessments
for infant and young child feeding programs. It aims to address the
challenge of choosing from the multiple methods and approaches
to conducting formative research for infant and young child feeding.
It also aims to complete knowledge gaps for people contracted to
conduct formative research; as often they are either not subject matter
experts in infant and young child feeding or have limited formative
research experience.

SPECIFIC OBJECTIVES AND APPLICATIONS

The guide orients users to infant and young child feeding; describes
major formative research methods and techniques that can be
applied to nutrition; outlines a process for determining the appropriate
formative research approach; and provides guidance for analyzing
the information collected.

RESOURCES

The complete guide is available to download. It also includes examples

of formative research tools and plans, and offers suggestions for
analytical tools and formats.

SPECIAL CONSIDERATIONS

The guide is intended to fill knowledge gaps for those who have
some of the knowledge and skills, but lack the specific experience in
formative research for infant and young child feeding.

This guide was developed under USAID’s Infant & Young Child Nutrition Project, which was implemented by
PATH in collaboration with CARE, The Manoff Group, and University Reserach Co., LLC. It can be downloaded
from: www.iycn.org/resource/the-basics-planning-for-formative-research-for-infant-and-young-child-feeding-
practices
37
Tool for Rapid Evaluation of Facility-Level Nutrition
Assessment and Counseling and Support (REF-NACS): A
User’s Guide

DESCRIPTION, PURPOSE, AND AUDIENCE

REF-NACS is a generic tool that helps gather information on the

capacity of health facilities to implement NACS for pregnant women,
children, and people with HIV. It is designed to help countries plan
for integration of NACS through a method that stimulates discussion,
facilitates an analytic process, and helps plan for strengthening and
integrating NACS services. REF-NACS can determine whether the
minimum elements required to implement the NACS approach are in
place, help identify gaps in service delivery, and highlight priorities for
integrating and improving NACS services. It can be used prior to or
during program implementation, and can be implemented in a sample
of health facilities or in all facilities where a program is intending to
work.

SPECIFIC OBJECTIVES AND APPLICATIONS

REF-NACS results will help government policymakers, donors,

program managers, service providers, and even clients to understand
current services provided and human resource capacity to implement
high-quality NACS services; identify gaps in services provided; identify
weaknesses in the health system for implementing a continuum of
comprehensive NACS services; and prioritize interventions and
identify actions to strengthen NACS-related programming.

RESOURCES

PDF and Microsoft Word versions of REF-NACS are available to

download from the website. The guide includes a background section
describing the NACS approach; indicators measured by the tool; steps
for using the tool; and the tool itself. See also: NACS: A User’s Guide
and NACS Training Package for Facility-Based Service Providers.

SPECIAL CONSIDERATIONS

In addition to planning for NACS integration into a health system,

the tool can be used for regular assessment of the quality of
implementation of NACS services.

The USAID-funded SPRING project developed this guide in collaboration with other USAID-funded projects. To
access this resource, please visit: www.spring-nutrition.org/publications/tools/tool-rapid-evaluation-facility-
level-nutrition-assessment-counseling-and-support

38
 Training Guide for Community-Based Management of
Acute Malnutrition (CMAM)

DESCRIPTION, PURPOSE, AND AUDIENCE

This training guide is designed for health care managers and health
care providers who manage, supervise, and implement CMAM
programs in emergency and non-emergency contexts. This includes
health providers who are involved in health outreach activities;
ministry of health officials at the national, regional, and district levels;
and health and nutrition program managers for NGOs.

SPECIFIC OBJECTIVES AND APPLICATIONS

This training guide focuses on the community-based management of

severe acute malnutrition in children under 5 years old. It is designed
to increase participants’ knowledge of and build practical skills to
implement CMAM. The guide complements WHO protocols for the
management of SAM and the WHO training modules for inpatient
management of severely malnourished children. The full course takes
about 10.5 days.

RESOURCES

Trainer guidance and information are provided. The training package

includes eight modules, with objectives, handouts, a list of necessary
materials, and suggested activities provided for each. A packet for
participants with handouts for each module is also provided.

SPECIAL CONSIDERATIONS

The developer recommends consulting the latest WHO guidelines,

and adapting these materials to take latest WHO guidance, as well as
national guidelines and local considerations, into account.

The CMAM training guide was produced in 2008 by the FANTA project in collaboration with Concern
Worldwide, Valid International, and UNICEF, with technical input and review from USAID, WHO, and numerous
NGOs working to reduce the impact of severe acute malnutrition on children. F or more information, visit:
www.fantaproject.org/focus-areas/nutrition-emergencies-mam/cmam-training
39
Training of Facilitators for Positive Deviance/Hearth

DESCRIPTION, PURPOSE, AND AUDIENCE

Orientation and training for the design and implementation of a positive

deviance/hearth program is a 2.5 day workshop to enable managers
to better design, implement, and support sustainable community-
based nutrition initiatives. Program managers include headquarters,
regional, and country-level staff of NGOs; ministry and district health
officials; and others who manage nutrition programs. It is designed to
complement the CORE Group’s Positive Deviance/Hearth: Resource
Guide for Sustainably Rehabilitating Malnourished Children.

SPECIFIC OBJECTIVES AND APPLICATIONS

This workshop is designed to provide program managers with a

solid understanding of the principles of and criteria for a successful
positive deviance/hearth program, as laid out in the resource guide.
It may help programmers to determine whether to pursue a positive
deviance/hearth approach and clarify essential considerations for
successful programming.

RESOURCES

The 2.5 day workshop consists of 25 sessions, which follow the nine-
step process outlined in the resource guide. A detailed workshop
session and materials guide is provided, along with individual session
plans. For each session, objectives, timing, exercises, handouts, and
other resources are outlined.

SPECIAL CONSIDERATIONS

Lesson plans and materials in this manual are designed to be used

in conjunction with Positive Deviance/Hearth: A Resource Guide for
Sustainably Rehabilitating Malnourished Children.

This guide was produced by CORE Group, with support from USAID. Find more information at: www.coregroup.
org/positive-deviance-hearth-training

40
 Trials of Improved Practices (TIPs)

DESCRIPTION, PURPOSE, AND AUDIENCE

TIPs is a human-centered, client-driven, qualitative formative research

and design technique for behavior-centered programming. It focuses
on what people do, rather than what people know or believe, and uses
trials to gauge acceptability of a practice or product and to identify
the best ways of promoting it. The method combines the advertising-
design idea of concept testing with product testing to modify a practice
or product before it is introduced into the market. Thus, TIPs allows
program planners to pre-test the actual practices or products a program
will promote. A small sample of target beneficiaries are engaged
to try out proposed practices or products, and their experiences
and opinions are used to inform programming. TIPs gives program
planners an in-depth understanding of participants’ preferences and
capabilities, the obstacles they face in improving their health, and their
motivations in trying new behaviors and practices. Key audiences for
this tool include ministries of health, NGOs, program managers, and
researchers.

SPECIFIC OBJECTIVES AND APPLICATIONS

Although first used to improve nutrition programming, TIPs has been

applied to many other public health issues. It aims to test families’
response to recommendations for improving infant and child feeding,
WASH, or other desired practices, and to determine which are the
most feasible and acceptable. It also investigates constraints on
families’ willingness to change feeding patterns or other routines, and
their motivations for trying and sustaining new practices or products.

RESOURCES

The resource page includes an overview of the method and a bank

of TIPs studies.

SPECIAL CONSIDERATIONS

Some behaviors are difficult or impossible to test with TIPs, including

behaviors that stretch over long time periods, unpredictable or rare
behaviors, behaviors with major external barriers, and behaviors
requiring approval of many peers, colleagues, or supervisors.

TIPs was developed by The Manoff Group, and was first used in the 1970s. To learn more, visit: www.
manoffgroup.com/approach_developing.html

41
Access more resources at www.coregroup.org/resources