Terms of reference to conduct a baseline and an end-line of the project on Reducing Iron Deficiency Anaemia in pregnant women and reducing mortality and morbidity in

children under five years of age in two provinces of East Java and East Nusa Tenggara in Indonesia

Background Micronutrient Initiative has been present in Indonesia for 10 years working closely with the Government of Indonesia (GoI) to advocate for both greater attention and resources for micronutrient programming, while providing funding and techno-management support to the GoI in designing and implementing such programs, seeking to make them more efficient, integrated within the health system, sustainable and have greater reach and impact. This proposed program seeks to expand this work with regard to four micronutrients – Vitamin A, Zinc, Iron and Folic Acid - with a focus on their key role in improving Maternal, Newborn and Child Health (MNCH). From 2011 – 2014, with financial support from the Government of Canada (DFATD) MI worked with the GoI at central, provincial and district levels to undertake pilot programs that aimed to increase the coverage and appropriate consumption of IFA supplementation by pregnant women and the coverage and appropriate consumption of zinc supplements with ORS, by children in the treatment of diarrhoea. Formative research was carried out and barriers identified and addressed with the result that the programs for these interventions showed significant improvement prompting the GoI to seek MI’s support in scaling them up in selected provinces where their impact on MNCH would be most felt. Three-year programs beginning in 2015 were designed in collaboration with provincial governments and funding made available from DFATD’s grant to MI. Similarly, MI has been supporting the GoI to scale up VAS in children aged 6-59 months for several years at the national level and in 6 high mortality provinces, in collaboration with UNICEF. MI is commissioning baseline and end line surveys with the key objective to establish baseline and end-line estimates of anaemia prevalence, in coverage and in adherence of key micronutrients of iron and folic acid supplementation, zinc and ORS and vitamin A. The study will be conducted in two program provinces (East Java and East Nusa Tenggara) and two comparison (non-intervention) provinces / districts. This ToR outlines the scope and activities to be carried out in this assessment. The tentative timeline for the baseline survey will be Q4 of 2015-16 and Q1 of 2016-17 and that for the end-line, it will be Q1 and Q2 of 2018-19. A separate contract will be signed with the agency for the end line survey on the basis of revised financial proposal submitted by the agency to the MI. Overall Objective The overall objective of the project evaluation, both baseline and end-line, will be to (a) assess any changes in anaemia prevalence as well as changes in coverage and in adherence of IFA, Zinc and ORS, and VAS; (b) evaluate the extent to which these changes are plausibly due to the program interventions, and (c) provide this information to the national and provincial governments to inform their further planning and scale-up of these programs. Specific Objectives The specific objectives of this baseline survey are as follows: Anaemia prevalence

• Estimate the anaemia prevalence among pregnant women IFA coverage and adherence

• Estimate the coverage and adherence of IFA supplementation among pregnant women • Assess the knowledge, attitude and practices among women and health workers about

causes and consequences of anaemia and the benefits of IFA supplementation • Identify knowledge, skill and behaviour levels of health workers related to services of anaemia

and IFA supplementation Vitamin A coverage

• To measure the coverage of the vitamin A supplementation in the last round • To assess the adherence of standard operating procedures (SoPs) during the round.

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• To assess the knowledge of service providers regarding benefits of Vitamin A and perceptions about safety of its administration.

• To assess availability of VAS supplies at national, provincial and frontline distribution points.

Zinc and ORS coverage • Measure coverage and adherence of Zinc and ORS during diarrhoea episodes of children 6-

59 months of age. • Measure knowledge, attitude and practices among caregivers of children 6-59 months of age

with diarrhoea in treatment of childhood diarrhoea • Assess the knowledge, skill and behaviour of health workers related to services and advice of

6-59 months old children suffering from diarrhoea Key Research questions The key research questions are as follows: IFA coverage and adherence

1. What is the coverage of IFA among pregnant women? 2. What is the adherence of IFA among pregnant women? 3. What are the reasons for non-adherence? 4. What is the knowledge level of women regarding IFA dosage, duration and its side effects

following consumption? 5. What is the knowledge level of Midwives and Kader Desa (community health volunteers)

regarding causes and consequences of Anaemia? 6. What is the level of knowledge of Midwives and Kader Desa regarding the benefits of IFA

supplementation? 7. Do Midwives and the Kader Desa counsel women regarding solutions to the side effects from

consumption of IFA? 8. Is there a stock out of supplies of IFA at the frontline distribution points?

Vitamin A coverage

9. What is the coverage of Vitamin A? 10. What are the reasons for children being missed out with Vitamin A during the rounds? 11. What is the awareness of care-givers of the benefits of Vitamin A and the recent round viz.,

dates, place of dosing? 12. What is the source of knowledge of care-givers related to Vitamin A supplementation rounds? 13. What is the knowledge of health workers regarding Vitamin A and the importance of

supplementation for children 6-59 months? 14. What is the adherence of health workers to standard operating procedures such as ---

monitoring the VA dose, storage of VAS, counseling of care-givers, precautions in administering VAS etc.

15. Are supplies adequate at the frontline distribution points? 16. Do the above issues vary across the different provinces?

Zinc and ORS coverage 17. What is the coverage of zinc and ORS in diarrhoea cases among care givers of children 6-59

months with an episode of diarrhoea in the two weeks preceding the survey? 18. What is the level of knowledge among care givers of children 6-59 months regarding

diarrhoea management? 19. What is the level of adherence of Zinc for 10 days? 20. What is the source of treatment for diarrhoea episodes? 21. What is the source of zinc and ORS? 22. What are the reasons for non-adherence of zinc and ORS? 23. What is the level of knowledge of health workers and Kader Desa regarding Diarrhoea

management with Zinc and ORS? 24. Whether involving the Kader Desa in zinc distribution associated with higher coverage and

utilization rates? 25. Are supplies of Zinc and ORS adequate at the frontline distribution points?

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Study Design The program will be evaluated using a quasi-experimental pre and post intervention survey design. The sample size will be powered to provide province level estimates for the two program provinces and two comparison provinces as separate domains. Cross-sectional surveys will be conducted prior to the program roll out (baseline) and at the end of the program exposure period (end-line) in the two program provinces and in similar comparison provinces among the following groups of respondents: • Recently delivered women (with an infant less than six months) to measure changes in coverage

and utilization of IFA supplements during their last pregnancy as well as knowledge and practices related to iron deficiency anaemia and IFA supplementation. Recently delivered women with an infant less than six months will be considered to allow for a period of complete exposure to the entire duration of the pregnancy to be able to effectively assess levels of complete coverage and utilization of IFA during the entire duration of the last pregnancy. In addition, knowledge about the causes, symptoms and consequences of anaemia, ways to prevent anaemia, the possible reasons for non-adherence of IFA, knowledge of IFA dose, duration and benefits, methods to overcome side effects of IFA consumption, counselling provided and use of behaviour change communication materials by health workers will also be assessed from the woman’s perspective.

• Pregnant women (pregnant at the time of survey), to measure the prevalence of any anaemia among pregnant women. Currently, anaemia prevalence among pregnant women has been estimated to be 37% as per the RISKESDAS 2013 in the Performance Measurement Framework. To measure change in haemoglobin levels more precisely, blood samples would be tested from currently pregnant women during the baseline and end line surveys. In these surveys, samples will be tested from pregnant women in all the three trimesters of pregnancy since the levels of anaemia may differ by gestational age, as reported in some studies. Further, during the end line survey, pregnant women who have been staying in the program area since the beginning of the program will be selected assuming that they have been exposed to the program interventions during the course of their pregnancy, and those who have migrated in and out of the program area during the program exposure period will be excluded. In addition, the coverage and adherence of IFA supplementation during the current and last pregnancy retrospectively as well as their knowledge and practices related to anaemia and IFA supplementation will be assessed through a questionnaire so that the association between the coverage and adherence of IFA and haemoglobin levels could be analyzed.

• Caregivers of children in the age group of 6-59 months with an episode of diarrhoea during the

two weeks preceding the survey to measure the knowledge of zinc and ORS and use of zinc and ORS for diarrhoea management. In addition, the source of diarrhoea treatment whether in the public or private sector, source of zinc and ORS, possible reasons for non-adherence of zinc, use of antibiotics will also be explored.

• Caregivers of children in the age group of 6-59 months to measure coverage of vitamin A

supplementation. In addition, the knowledge of benefits of VAS and the barriers and bottlenecks in achieving high coverage will also be assessed.

• Health worker (Mid-wives/ Nurses) and cadres knowledge and practices about causes, symptoms and consequences of anaemia, ways to prevent anaemia, IFA supplementation, dosage, duration and benefits of IFA utilization, supplies of IFA tablets, counselling provided and use of behaviour change communication materials by the health workers will also be assessed. Their knowledge about zinc and ORS for diarrhoea management, supplies of zinc and ORS at frontline distribution points and stock levels will also be assessed. Their knowledge of VAS, method of estimation of target group, forecasting of supplies of Vitamin A at the frontline distribution points and recording, reporting and compilation of VAS data will also be assessed.

• A sample of Health officials will be interviewed to understand their perspective about the project

strategies.

Study Area : The study will be conducted in the provinces of East Java and East Nusa Tenggara and two similar comparison provinces. The comparison provinces need to be selected after matching them with the

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program provinces on certain indicators. The provinces need to be matched using certain secondary variables like; 1. Literacy rate (Census 2010) 2. Population density (Census 2010) 3. Level of urbanisation (proxy for socio-economic development) (Census 2010) The best possible matches for intervention provinces should be derived based on the deviation across factors with respect to the intervention provinces. Out of the best possible options, the provinces with the minimum difference across indicators from the intervention provinces should be chosen as the matched comparison province ensuring a unique match for each intervention province. For the comparison areas, the provinces, where MI has presence with program activities will be excluded to avoid any program contamination. The survey will be carried out in the 20 program districts in the two program provinces and 20 comparison districts in two comparison provinces. Minimum Sample size: The sample size computations are based on a two-tailed hypothesis that there will be difference between the value at the baseline and expected value at the end-line with α=0.05 & β= 0.80 and an assumed design effect of 2.0 or 1.5* for multi-stage sample design and cluster selection incremented for 10% non-response. The total required sample for the province will be allocated on the basis of the rural and urban distribution of population in the provinces.

Table 1 : Minimum sample size required for individual province level estimate for anaemia

prevalence, coverage and adherence of the micronutrients (Zinc and ORS, IFA and Vitamin A) Baseline survey End-line survey

Outcome variable Prevalence of Anaemia among pregnant women

(%)

coverage of zinc and ORS (%)

Adherence of at least 90 IFA tablets

(%)**

Coverage of vitamin A supplementation

(%)

Prevalence of Anaemia

among pregnant

women (%)

coverage of zinc and ORS (%)

Adherence of at least 90 IFA tablets (%)**

Coverage of vitamin A

supplementation (%)

Respondent group

Currently pregnant

women at the time of the

survey for HB testing

caregivers of children in the age group of 6-59 months of age with an episode

of diarrhoea

Recently delivered women

caregivers of children in the age

group of 6-59 months of age

Currently pregnant women at the time of the

survey for HB testing

caregivers of children in the age group of 6-59 months of age with an episode of diarrhoea

Recently delivered women

caregivers of children in the age group of 6-59 months

of age

Baseline value as per Performance Measurement Framework (PMF)

37% 19% 48% 82% 37% 19% 48% 82%

Expected End-line value as per target set in PMF

30% 49% 68% 90% 30% 49% 68% 90%

Program area East Nusa Tenggara (10 program districts)***

1,635 80 200 528 1,635 80 200 528

East Java (10 program districts)

1,635 80 200 528 1,635 80 200 528

Comparison area

528

528

Province 1 (10 districts)

1,635 80 200 528 1,635 80 200 528

Province 2 (10 districts)

1,635 80 200 528 1,635 80 200 528

Total 6,540 320 800 2,112 6,540 320 800 2,112

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Total sample size

550 in each 1st, 2nd and 3rd

trimester s= 1,650*4

provinces =6,600

80*4 provinces=

320 200*4

provinces=800 528*4

provinces=2,112

550 in each 1st,

2nd and 3rd trimester

s= 1,650*4

provinces =6600

80*4 provinces=320

200*4 provinces=8

00

528*4 provinces=

2,112 Cluster size and no. of clusters per province 15 (5 from 1st ,

2nd and 3rd trimesters) women per cluster*110

clusters

10 caregivers

per cluster*8 clusters

10 recently delivered woman

per cluster*20 clusters

22 caregivers per cluster*24 clusters

15 (5 from 1st , 2nd and 3rd

trimester) women

per cluster*110 clusters

10 caregivers per cluster*8

clusters

10 recently delivered

woman per cluster*20 clusters

22 caregivers

per cluster*24 clusters

Total sample for Baseline 6,600 320 800 2,112 Total sample for End-line 6,600 320 800 2,112 Sample per district in a province 165 per district

32 per district 80 per district 211 per district

165 per district 32 per district

80 per district

211 per district

*For the computation of sample size for Anaemia prevalence, a design effect of 2.0 (based on the design effect for Birth with skilled attendant at delivery of 2.195 for Indonesia country sample in IDHS 2012) and for the other three sample sizes, a design effect of 1.5 has been considered [(coverage of zinc and ORS (based on the design effect of the indicator, had diarrhoea in the last 2 weeks of 1.505, for Indonesia country sample in IDHS 2012), Adherence of at least 90 IFA tablets (based on the design effect of the indicator of mothers received antenatal care for last birth of 1.678, for Indonesia country sample in IDHS, 2012), coverage of vitamin A supplementation (based on the design effect of the indicator of received all vaccinations of 1.510, for Indonesia country sample in IDHS, 2012)]. **For IFA utilization, the sample size has also been adjusted by 88% coverage of any IFA tablets as per the PMF. ***The survey will be conducted in the 20 MI supported program districts in the two program provinces (Among the remaining districts, some of the districts will be covered by other organizations) and 20 districts in two comparison provinces. Cluster and household selection: The total sample per province will be allocated equally between the 10 program districts in the province. The selection of the clusters in the program districts of provinces will be conducted using the probability proportionate to size (PPS) method. This means that each province is divided into geographical areas; the lowest level possible that has available population data. The names of all areas are then listed with their respective populations. The total population is divided by the number of clusters to obtain the sampling interval. A random number is selected using a random number table to determine the first cluster. In this case, as the sample size to measure anaemia prevalence is the highest, this has been considered for the computation of the required number of clusters. It is proposed to take 15 pregnant women per cluster and hence 110 clusters will be sampled by this method in a province to achieve the required sample size. These 110 clusters will be allocated in the ratio of the rural urban distribution of population of the ten districts in each of the province. Each subsequent cluster is determined based on the sampling interval. The sampling of households within clusters will be done by dividing the clusters into natural segments of approximately 150-200 households each. One segment from these segments will be selected randomly. The selected segment will be house-listed and households with a pregnant woman in the age group of 15-49 years of age, a recently delivered woman (15-49 years of age) delivered in the last six months with an infant less than six months of age, a caregiver of child of 6-59 months of age with diarrhoea in the two weeks preceding the survey and a caregiver of a child of 6-59 months of age without diarrhoea will be identified. In case, the sample size is not achieved, a neighbouring segment will be selected randomly and house listed to identify the required additional recently delivered women with an infant less than six months. In the selected segment, house listing exercise will be carried out to list all households in the selected cluster to prepare four sampling frames for eligible households with;

o pregnant women (15-49 years) in 1st, 2nd and 3rd trimesters o recently delivered women (15-49 years) in the last six months with an infant less than

six months of age o caregivers of children of 6-59 months of age without diarrhoea o caregivers of children of 6-59 months of age with diarrhoea in the two weeks

preceding the survey

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From these four sampling frames generated above, the following number of respondents will be selected

o 15 (efforts should be undertaken to recruit at least 5 pregnant women from each of the 1st, 2nd and 3rd trimesters) pregnant women (15-49 years)1 from each cluster in 110 clusters as it would be difficult to find women in their 1st trimester).

o 22 caregivers of children of 6-59 months of age without diarrhoea per cluster in 24 clusters

o 10 recently delivered women (15-49 years) delivered in the last six months with an infant less than six months of age per cluster in 20 clusters

o 10 caregivers of children of 6-59 months of age with diarrhoea in the two weeks preceding the survey per cluster in 8 clusters

In case of shortfall of any category of respondents in any cluster, an adjacent segment will be selected and houselisting conducted to cover for the shortfall. It is likely that additional segments will have to be houselisted to cover shortfall of the respondents identified. Haemoglobin testing The Hemocue system will be used for the testing the haemoglobin concentrations in the blood among the pregnant women. An ethical committee will approve the blood sample collection, testing and disposal procedures that will be undertaken in the survey, adhering to the international standards. Lancets and all blood-contaminated materials will be disposed of in a biohazard container according to an established protocol. Only paramedical or other personnel/ health investigator with specific training on the procedures and on universal precautions regarding blood-borne pathogens will be employed for conducting the haemoglobin tests. Prior to the questionnaire/collection of the blood samples, informed consent will be taken from the woman as per the International Ethical Guidelines for Biomedical Research Involving Human Subjects. Trained health investigators from the commissioned research agency/ institution/ organization will be employed to collect the blood samples for testing at the field level. The health investigator will read out a detailed informed consent statement to the woman informing her about anaemia, describing the procedure to be followed for the test and emphasizing the voluntary nature of the test. The health investigator will sign the questionnaire to indicate that the informed consent statement has been read to the woman and it will then be signed by her. If the test is performed, at the end of the test, the woman will be given a written record of the haemoglobin status. In addition, the health investigator will interpret the results to her and advise the woman regarding IFA supplementation. In cases of severe anaemia, an additional statement will be read to the woman to help her determine whether or not she would give permission to the research organization to inform a local health official about the problem so that appropriate medical treatment can be provided.

Knowledge, Attitude and Practices among Health Workers and Cadres: Qualitative study In addition to the quantitative survey, qualitative in depth interviews will be conducted among health workers and officials to understand the knowledge, attitude, practices, barriers and facilitators to increased coverage and adherence of IFA supplementation among women. The field teams will visit the related health facility of each cluster for interview with health workers and for collection of data about knowledge on Anaemia and IFA supplementation, zinc and ORS for diarrhoea management and regarding vitamin A supplementation. One mid-wife/ nurse and one Cadre (community health volunteer) personnel per cluster in 50 clusters per province will be interviewed. The following number of nurses/ mid-wives and Cadres are proposed to be interviewed:

Table 2 : Sample of Health Workers/ Cadres to be interviewed Health Workers Baseline End line

Mid-wife/ Nurse (50 clusters*4 provinces*1 mid wife/ Nurse per cluster)

200 200

Cadres (community health volunteer) (50 clusters*4 provinces*1 cadre per cluster)

200 200

1 It may be little difficult to get adequate women in the 1st trimester, as women may come to know about their pregnancy status little late and early registration is not so common. So, it would not be binding to have equal numbers from each trimester.

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In addition to the health workers, the following health officials will also be interviewed to understand their perspective about the project strategies. The list of health workers to be interviewed will be provided by MI.

Table 3 : Number of IDIs with Sample of Health Officials Health Officials Baseline End line

Nutrition programmer at Puskesmas (in the areas covered in the household survey)

5*4 provinces = 20 5*4 provinces = 20

Nutrition programmer at the district level 1*4 provinces=4 1*4 provinces=4 District Health Officer 1*4 provinces=4 1*4 provinces=4 Provincial Health Officer 1*4 provinces=4 1*4 provinces=4

Indicative information areas

This section presents illustrative information and questions which need to be answered as part of this baseline survey. The consultant will present the draft tools for review by MI and finalize after field testing and incorporating comments from MI. Information to be collected and questions to be asked for the baseline survey. Information areas for IFA coverage and adherence Pregnant women (currently pregnant at the time of survey) and Recently delivered woman 1. Consent • 2. Identifiers • District,

• Household number, • Hamlet • Village

3. Household and Respondent Characteristics

• Literacy of Respondent • Literacy of Husband; • Relation of respondent to head of household; • Highest class completed by respondent; • Highest class completed by husband; • Size, age and sex composition of household members; • Source(s) of household income; • Religion of respondent, • Smoking behaviour of the respondent • source of household drinking water; • kind of household toilet facilities; • Type of fuel used for cooking; • Assets owned by household (irrigation pumps, working

radios, cycles, rickshaws, almirahs/showcases, cot/bed, clocks, sewing machines, working televisions, motorcycles, mobile phones, tubewells, livestock);

• Construction material used for house (ground floor walls, roof, kitchen);

• Number of living rooms; • Presence of household electricity; • Exposure to mass-media • Use of social media • Questions on all the variables used in Demographic and

Health survey to compute wealth index to be included. 4. Ante-natal Care (ANC) and IFA supplementation Pregnancy

Registration • Last pregnancy registered; • Type of health worker who registered the pregnancy; where,

type of service , • Months running (i.e. gestational age) when pregnancy was

registered;

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Pregnant women (currently pregnant at the time of survey) and Recently delivered woman • Information given during pregnancy registration; only relevant

to anaemia identification prevention, treatment IFA ANC • Whether the woman received ANC

• How many ANC did she receive during the last pregnancy • What services were provided (iron tablets, blood-pressure,

weight, TT); • What advice was given (nutrition during pregnancy, anaemia,

IFA supplements, methods of overcoming side effects) • What gestational age did first ANC visit occur; • How many times was respondent visited by health worker to

check on her pregnancy; • How many times did the respondent visit any health worker? • Was PNC mentioned during ANC visits; • Was the timing of PNC mentioned during ANC visits.

IFA • Did respondent hear about iron tablets; • Knows about correct dosage of iron tablets • Aware about benefits of IFA • Did respondent take iron tablets during last pregnancy; • How many sachets (30 tablets per sachet) did she receive to

complete the full recommended dosage of IFA • How many sachets (30 tablets per sachet) did the

respondent consume; • For how many days did she consume IFA tablets during the

last pregnancy • At what gestational age did respondent started taking iron

tablets; • From where did respondent obtain iron tablets; private or

public • Number of tablets received from the Government source • Number of tablets received from the TTD Mandiri • Who gave the tablets • Did she have any side effects • Did she receive counseling on the benefits, dosage and side

effects of IFA and from whom and where (place of counselling)

• How did she manage the side effects (if she experienced one)? And did the side effects disrupt her routine / stopped her for taking the IFA tablet for a while?

• Reasons for non-adherence • Did the woman face any trouble with the resupply • Was the supply free or did the woman buy the tablets • If yes , what was the cost

Malaria and Parasitic infections

• History of Malaria and Parasitic infections

For Mid-wives/ Kader (community health volunteer), the illustrative information to be collected include;

Mid-wives/ Nurses/ Kader (community health volunteer) 1. Consent • 2. Identifiers • District, village, (and for cadres) hamlet / posyandu name.

• Number of households in workers catchment area, 3. Characteristics • Age of Mid-wife/ Kader;

• Highest class completed by Mid-wife/ Kader (community health volunteer);

• Duration of service as Mid-wife; Year Mid-wife received basic

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Mid-wives/ Nurses/ Kader (community health volunteer) Mid-wife training;

• Primary functions/activities performed; 4. Catchment area • Number of households,

• Reproductive aged women and total population in Mid-wife’s catchment area;

• Size of catchment area in square kilometres 5. Trainings • Has the health worker received any training/ meeting on

Anaemia and IFA supplementation for pregnant women • Has the health worker received training on strengthening the

IFA supplementation program for pregnant women? 6. Knowledge of

anaemia and IFA

• Does the worker understand and know the definition of Anaemia

• Does the worker know about the consequences of Anaemia • Is the worker able to state the correct dosage of IFA

supplements correctly ? • Is the health worker able to mention the prevention of side

effects correctly ? 7 Home visits • Does the health worker make home visits during the course

of pregnancy ? • Do the health workers check on IFA utilization? How?

8 Anaemia testing • Does the health worker conduct anaemia examination by Hb meter among pregnant women?

9 Supplies and stock

• Does the health worker have adequate stock of IFA supplements ? (Minimum 110 % of IFA supplements amount of stock)

• How many IFA supplements were received at the health facility for distribution in the previous month? (Check from stock registers and note the number)

• How many IFA supplements have been distributed in the previous month? (Check from stock registers and note the number)

• Were there any stock outs for IFA supplements at the health facility at any point in the previous month? (i.e. 0 stock anytime during the past calendar month)

• Were any damaged / expired IFA supplements reported at the health facility in the previous month ?

• Number of pregnant women enrolled for ANC at Posyandu in the previous month (Verify from the register and note the number)

• Number of pregnant women provided with IFA supplements in the previous month (Verify from the register and note the number)

10 Recording and reporting

• Whether stock registers and reporting form is available at the HF/CC?

• Whether the recording of information is correct and complete in the Register?(Assess from a sample of at least 5 entries in the Register)

• Whether monthly report is submitted timely (along with submission of HMIS Report)? (Verify from the last month’s report)

11 IEC • Are the IEC materials available with the health worker? What kinds of IEC materials are available?

• Are the health workers using the IEC materials for counseling pregnant women? When?

• What kind of IEC materials used? (Flip chart, cadre book or leaflet? (Number of copies received by the health worker, year of print)

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Information areas of Zinc and ORS coverage and adherence Caregivers of children 6-59 months of age 1. Consent • Agree/Disagree to participate in interview 2. Identifiers • Province

• District, • Cluster number, • Household number, • Hamlet • Village • Date of interview, Name of Interviewer,

3. Household and Respondent Characteristics

• Literacy of Respondent Mother; • Marital status; • Literacy of father of the child; • Relation of respondent to head of household; • Highest class completed by respondent; • Highest class completed by father of the child; • Size, age and sex composition of household; • Source(s) of household income; • Religion of respondent, source of household drinking water;

kind of household toilet facilities; • Type of fuel used for cooking; • Assets owned by household (irrigation pumps, working

radios, cycles, rickshaws, almirahs/showcases, cot/bed, clocks, sewing machines, working televisions, motorcycles, mobile phones, tubewells, livestock);

• Construction material used for house (ground floor walls, roof, kitchen);

• Number of living rooms; • Presence of household electricity; • Exposure to mass media • Use of social media • Questions on all the variables used in Demographic and

Health survey to compute wealth index to be included. 4. Health seeking behaviour Episode of

diarrhoea in the last one month

• Recent diarrhoea affected child; • Type of person who was contacted • Days (i.e. after diarrhoea affliction) when treatment was

sought; • Information given during treatment; • Prescription given • What type of health worker provided treatment; • What services were provided • What advice was given;

Diarrhoea management with Zinc and ORS

• Does the respondent have correct knowledge of dosage, preparation and administration of zinc tablets

• Is the respondent aware of any 2 benefits of administering zinc in diarrhoea

• Did respondent hear about ORS; where? • Did respondent hear about zinc tablets; where? • Whether ORS was given alone or with zinc? • How many were given both Zinc and ORS? • How many were given only ORS? • Did respondent give zinc tablets to her child during

diarrhoea? • How many zinc tablets did respondent give to her child? • What was the source of ORS and Zinc?

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Caregivers of children 6-59 months of age • What other treatment / medicine was given in addition to Zinc

and ORS? • How many packets of ORS was given by the health worker? • How many tablets of zinc was given?

Counselling • Who visited the care giver during the episode of diarrhoea? • Whether health worker / mid-wife/ Kader Desa visited the

care giver during the episode of diarrhoea? • Whether the health worker / mid-wife/ Kader Desa counseled

the respondent? For Mid-wives/ Kader (community health volunteer), the illustrative information to be collected include; Mid-wives/ Nurses/ Kader (community health volunteer) 1. Consent • Agree/Disagree to participate in interview 2. Identifiers • District, sub district/puskesmas

• Number of households in workers catchment area, 3. Characteristics • Highest class completed

• Duration of service • Primary functions/activities performed;

4. Catchment area • Number of households, Children <5 years and total population in the catchment area;

• Size of catchment area in square kilometres 5. Trainings • Training on Management of Childhood Diarrhoea

• Number, duration and dates of trainings attended on zinc for diarrhoea treatment

6 Knowledge • Understanding of the definition of diarrhoea • Understanding of the signs of mild to moderate dehydration • Awareness about the correct dosage of zinc tablets (20

mg/day for children 6-59 months) • Awareness about the correct duration for zinc tablets intake

(10 days) • Ability of workers to demonstrate preparation of ORS

correctly • Ability of workers to demonstrate use of dispersible zinc

tablets correctly • Awareness of benefits of giving zinc tablets in acute

diarrhoea • Awareness of the reason for intake of zinc tablet for 10 days

duration even if diarrhoea stops • Workers having latest edition of diarrhoea Disease Control

Program Guideline by Ministry of Health 7 Stock / Supply

Situation

• Workers with adequate stock of diarrhoea treatment courses -ORS (e.g. 20 courses i.e., 40 ORS packets & 200 zinc tablets / 20 zinc blisters)

• Workers with adequate stock of diarrhoea treatment courses -Zinc

• Number of zinc supplements were received at the health facility for distribution(check from stock registers and note the number)

• Number of ORS sachets were received at the health facility for distribution

• Number of zinc supplements have been distributed in the previous month(check from stock registers and note the number)

• Health facilities reporting no stock outs for zinc supplements/ORS in the previous month

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Mid-wives/ Nurses/ Kader (community health volunteer) 8 Recording and

Reporting

• Whether stock registers are available • Whether reporting forms are available

In the last month • Number of children of age 6-59 months with diarrhoea seen

during the last month • Number of children of age 6-59 months who have received

both zinc supplements and ORS sachets • Number of children of age 6-59 months treated with

antibiotics / anti-protozoal drugs/ anti-motility drugs • Number of children of age 6-59 months referred • Number of health facilities where recording of information is

correct and complete in the register • Number of health facilities where monthly report is submitted

in a timely manner (along with the submission of HMIS report)

9 IEC

• Number of health facilities displaying IEC materials related to project displayed at the centre

• Number of health workers reporting availability of Inter Personal Communication (IPC) tools

• type of tools available (flip chart, pocket book) • Number of service providers using IPC tools (in case the IPC

tools are available with her) • other- health promotion at posyandu, counselling at pustu,

poskesdes etc 10 Counselling and

home visits • health workers visiting homes of children suffering from

diarrhoea • health workers having the latest version of Diarrhoea

Disease Management Flowchart available • health workers who have received any IEC materials/IPC

tools related to this project Information areas of Vitamin A coverage Caregivers of children 6 – 59 months 1. Consent 2 Identifiers • District,

• Cluster number, • Household number, • Age of the child • Date of interview, Name of Interviewer,

3. Household and Respondent Characteristics

• Literacy of Respondent • Literacy of Husband; • Relation of respondent to head of household; • Highest class completed by respondent; • Highest class completed by husband; • Size, age and sex composition of household; • Nuclear family/ extended family • Source(s) of household income; • Religion of respondent, source of household drinking water; kind of

household toilet facilities; • Type of fuel used for cooking; • Construction material used for house (ground floor walls, roof,

kitchen); • Number of living rooms; • Presence of household electricity; • Exposure to mass media (TV, radio, newspaper) • Use of social media

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Caregivers of children 6 – 59 months • Questions on all the variables used in Demographic and Health

survey to compute wealth index to be included. 4. Knowledge of

Vitamin A, supplementation and recent round

• Benefits of Vitamin A for protecting children from morbidity and mortality

• Knowledge of recent Vitamin A round • Source of knowledge • Age and frequency at which child should be supplemented

5. Vitamin A dosing

• Received Vitamin A • Place of dosing • Person who dosed • Distance of dosing from residence • Waiting time for being dosed • Who accompanied the child to dosing center • Reasons for not dosing, if not dosed • Aware of recent round • Source of knowledge • Having vaccination card • VAS dose noted in MCH card or growth monitoring card • Awareness of next round/need for a second dose

Mid-wives/ Nurses / Cadres 1. Consent 2 Identifiers • District,

• Cluster number, • Designation of Health worker • Date of interview, Name of Interviewer,

3. Training and Knowledge of Health workers regarding Vitamin A supplementation

• Training received prior to round • Duration of training • Eligible age for dosing • Need for reaching all children 6-59 months with VAS • Frequency of dosing • Need for monitoring and follow-up for VAS • Storage of capsules • Precautions to be taken while administering dose

5. Vitamin A in round

• Micro-planning done for health worker’s catchment area • Who prepared the micro-plan • IEC for round • Social mobilization for round • Supplies of Vitamin A in booth for distribution days • Supplies at facility year-round • Constraints in supplies (at facility level as well as with the HW

themselves when conducting outreach • How was shortfall, if any, managed • Any problems with transport and storage of supplies • Reasons for children being missed out • Process of tracking missed children • Process of recording dosing, tallying and reporting upwards

Health Officials 1. Consent 2 Identifiers • District

• Name of Official • Designation • Date of interview, Name of Interviewer

3. Opinion of the • Adequacy of budget for procurement of supplies

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Health Officials Government officials at the province and district level

• Suggestions for improvement in coverage and adherence of IFA • Suggestions for improvement in coverage and adherence of zinc and

ORS for diarrhoea management • Suggestions for improvement in coverage of vitamin A

Qualifications of the Research Team: a) Nutrition epidemiologist with PhD level training and more than 5 years experience (or Masters

degree and 10 yrs experience) in designing and conducting epidemiological studies. A track record for publications in high impact peer reviewed journals is a plus. This individual will directly guide any adaptations of the baseline survey design for the end line survey, in collaboration with and approval from MI.

b) Maternal and child health expert with more than 5 years experience in conducting maternal and new-born health research and programs. A track record for publications in high impact peer reviewed journals is a plus. This individual will provide technical guidance on data collection related to the health facilities, Maternal and newborn health services and health posts.

c) Statistician with more than 5 years experience in data management and expertise in design and

analysis of quasi-experimental studies and/or program evaluations. The statistician will be responsible for quantitative data management and cleaning, basic data analysis and whether the data collection adhered to the approved collection methodologies. The survey team will be responsible for having the licences for both qualitative and quantitative data analysis softwares. The survey team’s up-to-date CVs with current level of time commitment and previous/current grants must be provided to MI as annex to the project proposal.

Deliverables The following deliverables are to be submitted in hard copy and electronic form by the firm as the implementation progresses to the Micronutrient Initiative:

• Timeline to complete the survey • Ethical clearance: Including certificates for all investigators confirming completion of

human subjects research training (NIH or other approved by MI); plan for how relevant training will be implemented for all coming into contact with participants or their data; procedures for ensuring the security of all electronic or hard copies of questionnaires; confidentiality agreements for all who come into contact with participants and data.

• Permit from the National Unity and Politic • Final English and Bahasa Indonesia questionnaires • Plan for training interviewers and supervisors • Field procedures manual in English and Bahasa Indonesia. • Detailed procedure used for multi-stage sampling including list of “clusters” and

respective population size. • Codebook including questions, variable names, value names • Analysis and Tabulation Plan • Cleaned and labeled datasets in SPSS format • Report of survey finalized after review by MI • Power point presentation summarizing the key findings in English and Bahasa

Report Outline The selected agency/ consultant will submit to MI a report which has the following sections / chapters:

1. Executive summary 2. Introduction 3. Study design 4. Methods 5. Key findings of anaemia prevalence among pregnant women 6. Key findings about IFA supplementation among women 7. Key findings about diarrhoea management among children 8. Key findings about vitamin A supplementation among children

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9. Key findings from interview of health officials and workers 10. Conclusion and Recommendations 11. Annexures: Questionnaires

The agency/ consultant will submit a draft report to MI for review and will be finalized after incorporating suggestions and comments from MI. Timeline The selected agency for this consultancy will adhere to the following timeline. The timeline is in reference to the time of signing the contract with MI. It is expected that period of consultancy will be 8 weeks for one round (baseline or end line) and the draft report will be finalized within this period.

Weeks

1 2 3 4 5 6 7 8 9 1

0 11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Translating and Pretesting data collection instruments and sampling plan

IRB clearance

Training of investigators

Data collection Data entry and analysis

Report writing and finalization

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