Translating the strategy of integrating comprehensive nutrition assessment, counselling, and support into action using a grounded theory approach in Tororo district, Uganda

Abstract

Background

Integrating comprehensive nutrition assessment, counselling, and support into the health system is crucial for providing preventive, holistic care and managing chronic conditions. While Uganda adopted this strategy over the past decade, tailored to clients’ needs, evidence of health workers’ understanding of the integration concept remains limited. The study explored how health workers interpret the integration of nutrition assessment, counselling and support in health service delivery and how this interpretation translates into their day-to-day practices.

Methods

The study utilised grounded theory to interrogate health workers’ interpretation of the integration of comprehensive nutrition assessment, counselling and support into health service delivery. Observations were conducted to examine whether their interpretation is reflected in daily practices. The study was conducted in Tororo district, Eastern Uganda, among district-level policymakers, implementing partners, and health workers. The study participants were aged between 22 and 60 years, with work experience ranging from 5months to 35 years. Using purposive and theoretical sampling, data were gathered across 17 health facilities through four focus group discussions, 24 key informant interviews, 22 in-depth interviews and 17 observations.

Results

The findings confirm that health and nutrition education sessions, nutrition assessment and categorisation, and active follow-up are essential components of daily routines in 17 health facilities. However, food demonstrations, growth monitoring, community linkages, and nutrition-focused quality improvement activities require strengthening. A model for integrating nutrition assessment, counselling, and support was developed based on health workers’ interpretations and experiences. This model demonstrates the multidimensional nature of integration, involving health worker-client factors, nutrition assessment, counselling, and support characteristics, as well as external environmental factors that interact to facilitate effective nutrition service delivery.

Conclusions

The study shows that although some aspects of nutrition are included in routine service delivery, the level of this integration varies across health facilities. The multidimensional model highlights the importance of health workers’ cognitive attributes, client factors, interpersonal dynamics, service features, and external environmental influences in improving health service delivery. The study identifies key areas for enhancing daily nutrition services that could guide interventions to improve the overall effectiveness of nutrition service provision.

Background

Integrating nutrition interventions into the health system is a vital strategy for addressing the global, regional and national burden of malnutrition and diet-related diseases.

The 2020 Global Nutrition Report emphasises the significance of incorporating nutrition into healthcare systems to tackle malnutrition challenges effectively. This report highlights that integrating nutrition interventions within health systems is crucial for improving service access, enhancing care quality, and aligning with global health goals [1]. Adequate nutrition is central to achieving all the Sustainable Development Goals (SDGs) [2, 3]. The National Development Plan of Uganda recognises the vital link between nutrition and overall health, emphasising the need for a well-coordinated approach to tackle malnutrition and its related health issues [4]. Additionally, Uganda’s Nutrition Action Plans provide a strategic framework for coordinated efforts in enhancing nutrition outcomes, ensuring that nutrition is seamlessly embedded within the broader health system [5]. Such integration is crucial for enhancing the health and well-being of the population, promoting sustainable development, and breaking the cycle of poverty and malnutrition.

To integrate nutrition into the health system, Uganda adopted the Nutrition Assessment Counselling and Support (NACS) strategy in the past decade, offering a package of nutrition services tailored to clients’ needs [6, 7]. The success of this integration depends on how service providers interpret and implement the program.

Integrating nutrition into healthcare systems is an essential and strategic move that requires a robust theoretical foundation to navigate its complexities effectively. Establishing this groundwork is crucial for shaping impactful policies and successful program implementation. Over the years, researchers and practitioners have increasingly relied on the Grounded Theory Methodology, recognizing its power to unravel and comprehend the intricate nature of such phenomena. Embracing this approach not only enhances understanding but also paves the way for more effective and sustainable integration efforts.

The Grounded theory, developed by Glaser and Strauss in 1967, was used to interrogate the integration of comprehensive NACS in health service delivery and to develop a conceptual understanding from the data obtained from this social research [8–10]. This methodology, which simultaneously integrates data collection, enables theories to emerge organically until theoretical saturation is reached [11–13]. It is an inductive approach grounded in the study phenomenon, with an iterative literature review [8, 9, 14]. The key principles of grounded theory include: openness, simultaneous data collection and analysis, coding and comparative analysis, memo writing, theoretical sampling and coding, theoretical saturation, and generation of substantive theory [15–17]. The method is valued for its creativity and conceptual depth [9, 18], though it faces criticism for a lack of assumption development during review of literature, diverse methodological approaches, and limited generalizability. These insights informed this study’s understanding of the applicability, strengths, and limitations of grounded theory.

The choice of Grounded Theory for this study was based on its appropriateness for exploring how health workers interpret the integration of comprehensive NACS within the complex environment of health service delivery, particularly in the face of limited existing evidence. Prior research has contributed valuable insights into the integration of nutrition services within health systems, focusing on various aspects, including counselling approaches and service delivery. For instance, Deconinck et al. [19] examined integration efforts of acute malnutrition interventions into the health system, while Alehegn et al. [20] applied grounded theory to study maternal counselling. Similarly, Murray-Davis et al. [21, 22] focused on gestational weight gain counselling and nutrition, as well as exercise post-delivery. Although informative, these studies highlight the need for further exploration of how health workers interpret and implement NACS integration in their daily practice.

Observation studies have also provided insights into the delivery and quality of nutrition services. In Ghana, Agbozo et al. [23] found that while community child growth promoters provided individualised counselling following UNICEF recommendations, nurses primarily offered didactic group sessions without educational materials or documentation. Nsiah-Asimoah et al. [24] highlighted gaps in nutritional counselling for caregivers of children under two years, emphasising the need for improved strategies. Similarly, Billah et al. [25] identified disparities in service quality and training in Bangladesh, indicating suboptimal nutrition service delivery. The findings emphasise the importance of considering contextual and systemic factors for a comprehensive understanding of NACS integration.

This study aimed to explore how health workers interpret NACS integration into health service delivery and how these interpretations influence their daily practices. Additionally, the study sought to develop a conceptual understanding of NACS integration within the health system by identifying key themes emerging from the data. Addressing the limited knowledge of how health workers perceive and implement NACS is essential for informing effective programme design and implementation, ultimately supporting positive behavioural changes and improved health.

Methods

Study setting and population

The study was conducted in Tororo district, Eastern Uganda, to understand the concept of NACS integration from the perspective of district-level policymakers, implementing partners, and health service providers. The Assistant District Health Officer, District Health Education and Promotion Officer, and Medical Superintendent were interviewed as key informants. Health facility in-charges, heads of the maternal and child health, outpatient department, nutrition, and HIV clinics were purposively selected from each of the three levels of health facilities for focus group discussions (FGDs), namely: Tororo hospital, Mukujhu Health Centre IV (HCIV), Malaba Health Centre III (HCIII), and Kwapa HCIII. Experienced nurses, midwives, clinical officers, and linkage facilitators involved in NACS services were purposively chosen for in-depth interviews (IDIs). Participants were purposively selected based on their roles and active involvement in NACS service delivery within Tororo district. There was no requirement for a minimum duration of residence in the study area; inclusion was determined by professional role and engagement in NACS service provision at the time of the study.

The principal investigator and research assistants conducted the observations. The validation process was strengthened through regular debriefings, discussions with research assistants, and consultations with team members.

Sampling

Purposive or strategic sampling was used for observations, key informant interviews (KII), FGDs, and IDIs. The researcher employed theoretical sampling for the key informants and in-depth interviews. The selection of new data, as well as decisions on whom and where to collect it, was guided by emerging theory from ongoing data collection and analysis. Continuous comparison of categories and further theoretical sampling were conducted until saturation was achieved. We determined that theoretical saturation had been reached when no new information, codes, or themes emerged during the simultaneous process of data collection and analysis. This was confirmed through ongoing memo writing, constant code comparison, and team discussions, which revealed redundancy and repetition of ideas in later interviews.

Saturation was reached after the fourth FGD and approximately 18 in-depth or key informant interviews, although a few additional interviews (bringing the total to 24 KIIs and 22 IDIs) were carried out to ensure representation across the various levels of health facilities.

Sample size

Altogether, 17 observations, 24 KIIs, 4 FGDs, and 22 IDIs were conducted. The sample size for the interviews was determined by theoretical saturation. District-level key informants initially included the District Health Officer, the Assistant District Health Officer for Tororo, the Medical Superintendent of Tororo Hospital, the Director of The AIDS Support (TASO) Tororo Branch, and the District Nutritionist. We adapted the key informant interview guide to address emerging gaps in our understanding. The FGDs were conducted at the Hospital, HCIV, and HCIII levels with 6–12 health workers. A review of literature related to the concept of integration and NACS was carried out throughout the research process.

Data collection instruments and procedures

Observations were conducted on key nutrition services before the interviews and discussions, using an observation checklist. The areas covered included health and nutrition education, nutrition assessment and categorisation, counselling on maternal, infant, and young child nutrition, active client follow-up, support for malnourished individuals, community linkages, and quality improvement and monitoring activities.

Data from the FGDs, KIIs, and IDIs were collected using guides after obtaining consent from the study participants. The guides were designed in accordance with the study objective, research question, and data collection requirements. A wide range of questions was assembled and organised by themes. The first section included rapport-building questions, followed by open-ended questions to encourage participants to share their detailed perceptions and experiences. Follow-up questions were incorporated to explore the responses further. The guides were pretested at Mulago National Referral Hospital with Nutritionists, and any comments were integrated into the final interview guides.

The duration of the FGDs ranged from 60 to 120 min, while the KII and IDI lasted between 30 and 60 min. All interviews and discussions were conducted in quiet, private spaces within the participating health facilities, away from patient care areas, to ensure confidentiality and comfort. Participants did not have to choose their own venues, but rooms were arranged in consultation with facility managers to provide privacy. Only the interviewer(s) and the participants were present during each session. To further maintain confidentiality, responses were anonymised during transcription, and no personal identifiers were recorded.

The study participants were asked to share their views on their understanding of the concept of integration, the meaning of NACS, and the circumstances under which integration occurs. Additionally, participants were asked about the reasons and individuals responsible for integrating nutrition services. All interviews were conducted in English. The FGD, IDIs, and KII were audio-recorded, transcribed, and the transcripts were cross-checked with the recordings.

Data analysis

The principal investigator and research assistants at each health centre observed the delivery of essential nutrition services. The performance of nutrition service delivery was summarised across the 17 health centres as a percentage.

Data from the FGDs, KIIs, and IDIs were collected and analysed simultaneously during theoretical sampling. The confidentiality of study participants was upheld by ensuring all responses remained anonymous. Audio-recorded interviews were transcribed, and analysis sheets were prepared. We used ATLAS.ti 22 software for data analysis.

Codes were developed inductively through a comprehensive review of the transcribed materials. Codes were categorised, with coding and note-taking occurring concurrently. The researcher consistently compared data to identify patterns. Memo writing was an ongoing process that provided insights into the context and substantive theory. Sorting and theoretical outlining involved conceptualising the emerging theory and organising memos to reveal relationships and concepts.

The final stage involved documenting the findings and developing a substantive theory, with input from the research team and using quotes to highlight key points based on the Standards for Reporting Qualitative Research (SRQR) [26]. Based on data gaps identified during initial data collection and analysis, theoretical sampling was employed to choose the next participants to interview and the questions to ask. Theoretical coding was then applied, continuing until theoretical saturation was achieved. For validity, we sought clarifications from the study participants after the interviews, and some other health workers from the same facilities were asked to comment on the findings. The developed theory was also presented to nutrition stakeholders and other researchers for their feedback. The final theoretical model for NACS integration involved open coding of data, axial coding, and the generation and comparison of themes.

Researcher characteristics and reflexivity

The principal investigator, SN, a nutritionist with extensive experience in policy and nutrition programmes, drafted questions for three types of interviews and the observation checklist. SN has expertise in practical approaches to qualitative research, research methodology, and Atlas. ti 22 through short courses, she completed. She understands the cultural contexts of the study participants and possesses the analytical skills to draw meaningful inferences from the observed data. The research assistants responsible for conducting the interviews had prior experience in qualitative research, with specific expertise in providing nutrition services within the study area. The research team, led by SN, ensured reflexivity by acknowledging their backgrounds and skills, remaining patient and open-minded, and not imposing their own beliefs and ideas on the respondents. Before data collection, the principal investigator trained the research assistants on conducting the three types of interviews, making observations, and writing memos for data triangulation. The research assistants transcribed the interviews while the principal investigator carried out the coding and analysis. The research team members subsequently validated the findings: SNK, GWM, and FEM. The preliminary findings and emerging theory were shared with the two research assistants who conducted the interviews, as well as three researchers from the School of Public Health at Makerere University, for transparency and validity, during a meeting in Kampala following the initial data analysis. All participants were in one room, and the process was participatory. The feedback provided was used to enhance the theoretical model and was thereafter shared with SNK, GWM, and FEM for their final input.

Results

Evidence of integration of NACS in routine activities

Observations across the 17 health facilities (2 hospitals, 4 HC IVs and 11 HC IIIS) revealed notable patterns and gaps in the delivery of nutrition services, and the results are summarised in Table 1.

Table 1.

Percentage of health facilities providing nutrition services observed

1. Health and nutritional education	Facilities observed integrating/17 (%)
Health and nutrition education conducted	12 (70.6)
Is there a health and nutrition education schedule	10 (58.8)
Does the schedule cover nutrition topics	11 (64.7)
Does the facility conduct food demonstrations	2 (11.8)
Are the health and Nutrition education talks documented	6 (35.3)
2. Nutrition assessment and categorisation for the mothers and infants
Taking mid upper arm circumference (MUAC)	17 (100)
Age of the client recorded	17 (100)
Taking height/length	15 (88.2)
Taking weight	17 (100)
Plotting of the Child Health Card	16 (94.1)
Interpretation of growth curves to the mother	10 (58.8)
Checking for Oedema	16 (94.1)
Checking for pallor (i.e pale palms and inner eyelids)	17 (100)
Haemoglobin estimation	0 (0)
Taking dietary history	8 (47.1)
Categorisation of nutrition status	17 (100)
3. Active follow-up of mother, mother-baby pairs
How counselling is done (Group/individual)	17 (100)
Infant and young child feeding and support focusing on IYCF key messages	16 (94.1)
Maternal nutrition counselling focusing on key maternal messages	17 (100)
Counselling for malnourished clients	14 (82.4)
Use of counselling skills (Listening and learning skills, Building confidence and support skills)	14 (82.4)
Vitamin A supplementation according to the national schedule, dewormers	15 (88.2)
Iron-folic acid supplementation for the mother	17 (100)
Whether the mother, mother-baby pairs are given return dates	17 (100)
Facility mechanisms for the loss to follow-up	11 (64.7)
4. Provision of support to malnourished mothers and infants
Whether the facility provides Ready to Use Therapeutic Foods or supplementary foods to mothers and infants	3 (17.6)
Follow-up mechanism for malnourished mothers and infants	3 (17.6)
5. Linkage of the mother-infant pairs to the community for a continuum of healthcare
Whether the facility links mothers, mother-baby pairs to the community for a continuum of care	Not observed
Which community structures
6. Use of quality improvement approach in delivering the NACS services
Whether the health facility has a QI work plan and budget, including nutrition	13 (76.5)
Does the facility have a nutrition work improvement team?	11 (64.7)
Functionality of the nutrition work improvement team	5 (29.4)
Availability of documentation, journal, and nutrition QI projects	10 (58.8)
Does the facility have a Quality Improvement and mentorship schedule?	9 (52.9)
Is nutrition included in the mentorship schedule?	7 (41.2)
7. Monitoring and reporting the NACS performance
Does the health facility have a designated person for HMIS data?	16 (94.1)
Does it register and report clients receiving nutrition support?	14 (82.4)
Integrated Nutrition Register available?	15 (88.2)
Nutrition quarterly report form available?	16 (94.1)
Whether referral forms available?	13 (76.5)
Is nutrition data analysed and displayed on notice boards?	6 (35.3)
Whether nutrition data generated by your health facility is used for quantification of therapeutic and/or supplementary food requirements, planning and decision making?	4 (23.5)
8. Availability of guidelines, policies, job aids, and equipment
Infant and Young Child Feeding (IYCF) Policy Guidelines	10 (58.8)
National Guidelines for the Integrated Management of Acute Malnutrition (IMAM)	9 (52.9)
NACS facilitators and participants guide	6 (35.3)
Maternal nutrition guidelines	4 (23.5)
The Integrated National Guidelines on Antiretroviral Therapy, Prevention of Mother-to-Child Transmission of HIV and Infant & Young Child Feeding	16 (94.1)
Nutrition care and support for PLHIV: Health facility Job Aides	10 (58.8)
MUAC tapes	17 (100)
Weighing scales	17 (100)
Height meter	15 (88.2)

Health and nutrition education

The integration of health and nutrition education sessions was observed in 70.6% of health facilities, lasting between 10 and 45 min. These sessions were mainly conducted at the Maternal and Child Health, Outpatient, and HIV clinics by midwives, linkage facilitators, and nurses. Only 58.8% had a structured schedule for health and nutrition education, with just 64.7% explicitly covering nutrition topics. Food demonstrations were observed in only 11.8% of the health facilities.

During the health and nutrition education sessions, climate-setting measures such as prayer and introductions, as well as the clarity of the health educator, encouragement of participation, focus on the topic, and effective use of job aids were observed.

Following the education sessions, feedback from participants about the session and their intentions to apply the information were recorded. However, documentation of these discussions was only found in 35.3% of health facilities.

Nutrition assessment and categorisation of the mother and infant

Most health facilities carried out essential nutrition assessment activities. All health facilities (100%) measured Mid Upper Arm Circumference (MUAC), recorded client age, weighed individuals, checked for signs of pallor, and categorised nutritional status, demonstrating adherence to standard procedures. Over 94% plotted child health cards, while only 58.8% interpreted growth curves for mothers. Dietary history taking was observed in just 47.1% of facilities. None (0%) of the patients were tested for haemoglobin during antenatal care.

Active follow-up of mothers and mother-baby pairs, as well as support for malnourished cases, was provided through group counselling (100%) across all health facilities, focusing on maternal nutrition (100%), infant feeding (94.1%), and malnutrition (82.4%). HIV-infected mothers received individual counselling. Iron/folic acid supplementation was available in all (100%) of the facilities, while vitamin A and deworming were provided in 88.2%. All (100%) of the health facilities scheduled return dates for the mother-baby pairs. However, only 64.7% had systems in place for loss to follow-up.

Only 17.6% of health facilities providing support and follow-up for malnourished individuals offered therapeutic or supplementary foods. Facilities below Health Centre IV level referred malnourished cases to higher-level care for further treatment.

Linkage to the community for a continuum of health care

This would have been best observed during community outreaches or health worker home-to-home visits, rather than at the health facility. Besides Village Health Team members and linkage facilitators, there was no clear evidence of community structures, such as mother care groups, community-based organisations, or livelihood programmes, to support and link mothers and mother-baby pairs.

Quality improvement approach in NACS services

While 76.5% of health facilities had Quality Improvement (QI) work plans and budgets that included nutrition, only 64.7% had a nutrition work improvement team, with just 29.4% of these teams being functional. Documentation journals and QI projects were observed in 58.8% of health facilities, while only 41.2% included nutrition in the mentorship schedules.

Monitoring and reporting of NACS services

A strong monitoring and reporting system exists, with 94.1% of health facilities having a designated person responsible for the Health Management Information System (HMIS) and nutrition reporting forms. Over 75% of facilities have integrated nutrition registers and referral forms. Only 35.3% of health facilities analysed and displayed nutrition data, and 23.5% used it for quantification or decision-making.

Availability of guidelines, policies, job aids, and equipment

The availability of essential tools and guidelines varied across facilities. While 94.1% of the health facilities had HIV-related guidelines, just over half had nutrition guidelines (IMAM, IYCF), and fewer had NACS (35.3%) or maternal nutrition guidelines (23.5%). All (100%) health facilities possessed MUAC tapes and weighing scales, whereas 88.2% had height meters.

Health workers’ understanding of the integration of NACS into health service delivery

The age of participants interviewed ranged from 22 to 60 years, while their work experience varied from 5 months to 35 years. Most respondents were female, and the overall gender distribution of participants is summarised in Table 2.

Table 2.

Types and number of interviews by gender distribution

Type of interview	No.1 of interviews per service delivery level				Total no of interviews/ observations	No. of participants by gender		Total participants/ health facilities
	District	Hospital	HCIV	HCIII		Male	Female
Focus group discussions	0	1	1	2	4	13	20	33
In-depth interviews	0	2	4	16	22	4	18	22
Key informant interviews	3	4	6	11	24	14	10	24
Observations	0	2	4	11	17	-	-	17

¹ No number

The open codes were categorised into axial codes and later into themes as shown in Table 3.

Table 3.

Codes and themes generated on the interpretation of the concept of NACS integration by health workers

Concept	Open coding	Axial coding	Theme
NACS actions	History taking, taking MUAC 1, height, measuring BMI 2, categorise the nutrition status, assess health conditions, physical examination, testing haemoglobin, status assessment of socioeconomic status, assessment of feeding practices, analysis of root causes of illness, counsel based on the nutrition status, counsel on locally available foods, glow/go/grow foods, diversified diets, eating habits, food preparation, provide support, prevent malnutrition, health education, nutrition education, nutritional management of patients, bridging nutrition gaps, appointment dates, refer for further management, follow nutrition standards	Characteristics of Nutrition Assessment, Counselling and Support	NACS 3 characteristics
NACS integration in health service delivery	One Stop Centre, simultaneous Services such as EPI 4, HIV 5, and Nutrition, several services at the same time, bring together different services, holistic approach, a requirement in health service delivery, several services in one place, problem analysis, different services at the same point and time, include other activities in the existing ones, addition of services to existing ones, nutrition support to prevent malnutrition, multiple services at same place same time with same resources	NACS integration understanding	Interpretation of NACS integration
	Appreciative since no missed nutrition opportunity, happy since nutrition assessment and counselling conducted in every department, happy for provision of a complete package to clients, not easy due to inadequate human resources, cumbersome with an overwhelming number of clients, possible in clinics with a stable number of clients, NACS mandatory for MCH clinics, majority of clients come late when education is over, divided attention between the visitors and the clients, clients feel the delay, suitable for nutrition reduces medical costs, feel happy to see clients improve	Feeling about NACS integration
	Helped the community, a disservice if NACS is not done, children should not die of malnutrition, communities are capable of producing enough food, malnutrition is due to inadequate knowledge on balancing meals, NACS prevents malnutrition, demonstration gardens can be done on small land, small land can improve one’s nutritional status, nutrition is marginalised	Beliefs about NACS integration
	Better health outcomes with NACS integration means supporting clients with food, adherence to medications requires good food like meat, clients expect monetary support from health workers, health workers confident with nutrition service delivery, good nutrition yields better health and nutrition outcomes, early antenatal care yield better health outcomes, clients anticipate guidance on nutrition, malnutrition is a reason for health care seeking, malnourished cases require home visits, NACS integration hectic but useful, more deaths due to malnutrition if no intervention, NACS integration requires commitment and sacrifice, clients empowerment to manage malnutrition, small bodied people may not necessarily be malnourished, integration process time-consuming, clients provided with a package of care, Better health outcomes, NACS integration important for HIV clients	Perceptions on NACS integration
	Positive given the ability to refer clients for further management, additional workload but necessary, additional workload but welcomed it, initially unhappy due to increased workload but later appreciated, increased workload but mandatory for the benefit of the community and patient, health workers positive since they are beneficiaries of demonstration gardens, nutrition important component of health service delivery, tagging work trained, competency in interpretation on nutrition assessment results, clients happy and appreciative, health workers positive and confident with nutrition service delivery	Health workers’ attitudes towards NACS integration
Why integrate	Boost the immunity of mothers and babies, mothers and babies are vulnerable, brain development of babies, support mothers have enough breastmilk for babies, prioritize mother and babies for proper growth and development of the foetus, Promote the health of mother and baby, prevent malnutrition and medical complications	Integrate to improve maternal and child health	Improved maternal and child health
Where to integrate	Laboratory, all Service Delivery Points, ART 6, Young Child Clinic, every department, OPD 7, MCH 8, and the community.	Integrate at all health contact points, the community	Health and community systems
Who does NACS integration?	Linkage facilitators, midwives, nurses, district midwives, nutritionists, TASO 9, RHITES E 10, everybody, clinicians, counsellors, Uganda Cares, Partners, Ministry of Health, Assistant Medical Superintendent, NACS trainees, PLAN International	Integration by Health workers, Ministry of Health, Partners	Stakeholders in the Internal and external environment

¹ MUAC mid upper arm circumference,

² BMI body mass index

³ NACS Nutrition assessment counselling and support

⁴ EPI expanded program for immunisation

⁵ HIV Human immunodeficiency virus

⁶ ART Antiretroviral Therapy,

⁷ OPD Out patient department

⁸ MCH Maternal and child health

⁹ TASO The AIDS support organisation

¹⁰RHITES E Regional health integration to enhance services

Health workers’ interpretation of the integration of NACS varies in its effect on health service delivery. The model demonstrates the multidimensional nature of NACS integration, including internal environmental factors such as health workers’ cognitive attributes, which are shaped by client attitudes, as well as interpersonal dynamics. These elements interact with NACS charac480teristics as perceived by health workers and external environmental factors in the provision and access to nutrition services, ultimately contributing to improved health service delivery, as shown in Fig. 1.

Fig. 1.

Derived Theoretical model on NACS integration for improved health service delivery. NACS, Nutrition Assessment Counselling and Support; MUAC, Mid Upper Arm Circumference; BMI, Body Mass Index, Hb, Haemoglobin

Internal environment: health workers’ cognitive attributes

Health workers’ interpretation of NACS integration was categorised into the following themes: understanding, feelings, beliefs, perceptions, attitudes towards NACS integration, and characteristics of NACS.

Understanding the concept of NACS integration

Participants recognised the importance of integrating NACS into the health system through the concept of a one-stop centre. They understood integration as a crucial requirement in health service delivery, enabling comprehensive problem analysis and the provision of different services at the same point and time, as illustrated in the following quote.

“…when a client visits the health facility, regardless of the services they seek, we should not remain silent or neglect to discuss nutrition or assess their nutritional status. … when a client arrives, we should recognise that nutrition has the greatest impact on their health; therefore, we must ensure that clients receive nutrition services, no matter which services they are there for.” FGD_Health worker_ Malaba HCIII.

To the administrators, integration was seen as maximising existing resources by adding extra activities within current services, ensuring nutritional support to prevent malnutrition. Overall, combining multiple services in one location with the same resources improved the efficiency and effectiveness of healthcare delivery. This is illustrated by the following quote;

“Integration means having multiple services or activities that can be carried out simultaneously, in the same area, using minimal resources to provide these various services,” KII_ District administrator_Tororo district.

Whenever a client visits a health facility for one issue, they should also access other services at the same time and place. When they come for other services, nutrition services should be provided.

Reflection PI

Feelings about NACS integration in the health system

Participants expressed mixed feelings about the integration of Nutrition Assessment and Counselling Services (NACS). A participant from one FGD appreciated the initiative because it eliminates missed nutrition opportunities, and enhances the provision of a complete service package to clients, resulting in client satisfaction as illustrated below,

“To a large extent, it was so good because different patients come with different problems.

in different departments, so if we only look at them in one department, we shall miss out on.

Those in other departments. the NACS package needed to be implemented in every

department. The clients also appreciated and demanded these services whenever they came.

but the challenge was manpower to provide the service,” FGD_Health worker_Kwapa HCIII.

Conversely, a participant from another FGD, felt NACS integration was cumbersome due to the overwhelming numbers of clients, and split attention between visitors and clients, especially when the majority of clients arrive late after educational sessions are completed.

“In OPD, it becomes challenging because of the high turn-up of clients. When the number is overwhelming, especially since the services have just been introduced, providing them to each person and documenting everything may not be feasible. For the rest of the clinics, such as ART, the numbers are stable and are controlled. Also, the visitors come and they all want us, so it confuses the entire facility as you have to attend to both the visitors and the clients,” FGD_Health workers_Malaba HCIII.

Despite these difficulties, the hospital administrators felt NACS integration was mandatory, especially for Maternal and Child Health (MCH) clinics due to health and nutrition benefits and reduced medical costs, as illustrated in the following quote;

“Integration is effective because most of the diseases we encounter involve some degree of malnutrition. If you have malaria without anaemia, you might not be admitted because you have blood and are strong enough to fight malaria.… you may not be admitted, but if you are anaemic, indicating malnutrition, you should be admitted. And if you are generally healthy, the cost of illness will decrease. We will not spend much on medication; instead, we will focus on managing non-communicable diseases, accidents, and trauma,” KII_Hospital administrator_Tororo hospital.

Beliefs about NACS integration in the health system

Participants believed that child deaths due to malnutrition could be prevented through government and organisational support. They linked malnutrition to a lack of knowledge about balanced meals, highlighting inadequate community awareness of proper nutrition practices. As a result, they considered Nutrition Assessment Counselling and Support (NACS) a health-promoting strategy for child survival if properly implemented. The creation of demonstration gardens, even on small plots of land, was seen as a practical intervention to improve nutrition education. They felt that nutrition is marginalised, which they believe is the reason for ongoing malnutrition. This is illustrated in the following quotes;

“I believe that malnutrition is mainly due to a lack of knowledge because, in most cases, the food is locally available in our community. It is simply that people do not know how to combine those foods. I believe this is something that even the government does not need to support, apart from providing information on what to do instead of giving physical food. Children should not die of malnutrition when these foods are available in the community. We educate the mothers about these foods whenever they visit the hospital for services,” FGD_Health worker_Tororo Hospital.

One district health administrator added, “You know, first of all, nutrition is an area which has been marginalised… and the reason for this persistent malnutrition,” KII_District administrator_Tororo district.

Perceptions of NACS integration in the health system

Participants regarded the integration of NACS into the health system as vital for achieving better health outcomes. They emphasised the importance of supporting clients with food, recognising that proper nutrition is key to adherence, especially for HIV patients. While clients often expected financial assistance, participants felt confident in the delivery of nutrition services. They advocated for early antenatal care and highlighted the role of NACS in tackling malnutrition, a common reason for seeking healthcare. Although time-consuming, integration was seen as essential in preventing deaths related to malnutrition. Health workers stressed the need for dedication and sacrifice to offer clients a comprehensive care package, as illustrated in the following quote;

“Yes, because they feel that when they come around you, you just prescribe for them, get medicine, and then they leave. This process is seen as a delay by them. It requires sacrifice and commitment to educate clients to take care of themselves and to offer them a comprehensive package of services,” KII_Health worker_Kiyeyi HCIII.

Another participant from the IDIs added, “. when you come for one service, you get more than one service….now we are able to do it and the mother goes with a full package of services home,” IDI_Health worker, Nagongera HCIV.

Attitude towards the integration of NACS

Participants showed mixed attitudes towards integrating NACS into the health system, with concerns about increased workload. However, most acknowledged its importance for both patients and the community. They emphasised the role of demonstration gardens in highlighting the significance of nutrition and noted that positive feedback from clients boosted health workers’ motivation. The following quotes demonstrate this;

“When that NACS system was integrated, it increased the workload, and at first, the attitude was not very good, but as we continued, we got used to it,… all this is our work; we have no choice but to carry on,” FGD_Health worker__Kwapa HCIII.

A linkage facilitator added, “I love providing nutrition services. I was trained as a VHT to help the community,” IDI_Linkage facilitator_Iyolwa HCIII.

A key challenge remained in assigning responsibilities, as only a few trained staff were left to handle all the nutrition services, as illustrated by the following quote;

“Especially at our level, you find that two or three staff may be taken for the training. When she returns, she may share the information with the staff, but they still believe it was you who attended the training. …so whoever comes in need of that service, they will say, … is not around. Then, if there is a bad attitude, some staff leave for you because you are the one who went for the training,” KII_ Health worker_Mella HCIII.

NACS characteristics

Participants viewed NACS as an approach to ensuring comprehensive patient well-being, involving detailed processes such as history taking and nutritional assessment. Initial data collection, which included measuring Mid-Upper Arm Circumference (MUAC), height, and Body Mass Index (BMI), was essential in categorising individuals’ nutritional status. This was followed by a thorough evaluation, examining health conditions, haemoglobin testing, analysing socio-economic factors, feeding practices, and the root causes of illnesses. After determining nutritional status, individual or group counselling was provided, focusing on nutritional guidance supported by food demonstrations of local food choices, proper food preparation methods, and a balanced diet including glow, grow, and go foods. Support was extended to prevent malnutrition, emphasising health and nutrition education. This holistic approach continued into nutritional management, following existing policies and guidelines. Referrals for specialised management were made when necessary, particularly to higher-level health centres IV and above. This is illustrated in the following quotes;

“I will need to introduce myself to you first, then review the MUAC results and the information provided by the clinician. I would advise her to feed the child at least five times daily, with these feeds not always being the same. For example, if the baby had milk tea in the morning, I would counsel her to have “matooke” (sweet potatoes) with greens in the afternoon, and “omena” (silverfish) with millet bread in the evening, so she can also get some iron and other nutrients. After that, we will, of course, set an appointment day to review whether the child’s condition is improving or worsening. If it worsens, we shall take her back to the clinician so she can be referred to the main hospital, where they can provide foodstuffs such as RUTF to manage malnutrition,” FGD_Health worker_Kwapa HCIII.

Similarly, a frontline health worker added,

“I will use the acronym ‘NACS’, which stands for Nutrition Assessment, Counselling, and Support. The first thing I will discuss with you is about your nutrition, whether you are in good health or experiencing malnutrition. I will then proceed to the assessment to determine how well you are doing. After the assessment, I will counsel you based on the findings. If you are doing well, I will encourage you to maintain your progress. If the findings are not favourable, I will advise you accordingly. I aim to find ways to support you, either through counselling or by referring you to the appropriate services. I do my best to help you,” FGD_Health worker_Malaba HCIII.

Stakeholders in the internal and external environment

The successful integration of NACS into the health system was driven by a collaborative effort involving various stakeholders in both the internal and external environments. External stakeholders included partners such as TASO, RHITES East, Uganda Cares, PLAN International, the Ministry of Health, and the community. Internal stakeholders comprised health workers, including the NACS trainees. The Ministry of Health played a vital role in providing policies, guidelines, and supporting capacity-building initiatives. Community engagement was primarily aimed at promoting uptake and ownership of interventions. This comprehensive involvement of a diverse range of internal and external actors, particularly partner funding, was crucial for the effective integration of NACS within the broader health system. The following quote exemplifies this;

“It is the government because even when the implementing partner arrives, they perform the work on behalf of the government. The implementation of NACS was carried out by TASO, which was the partner identified by the district and, therefore, by the government. Partners initially supported demonstration gardens by providing seeds, but community members later supplied these to foster ownership. The community members also demanded nutrition services,” KII_Health worker_Merikiti HCIII.

Discussion

The study aimed at developing a conceptual understanding of how health workers interpreted NACS integration in health service delivery and how this interpretation manifested in daily nutrition services. From the observations, the findings confirm that some nutrition services are an essential part of the daily routines in 17 health facilities. A model was developed that viewed NACS integration as multi-dimensional, influenced by the interconnectedness of health workers’ cognitive attributes, client factors, interpersonal dynamics, NACS characteristics, and external environmental factors in providing nutrition services, ultimately leading to improved health service delivery.

Integration of nutrition in health service delivery

Health and nutrition education sessions are embedded into service delivery with varying duration and structure across health facilities. This demonstrates some commitment to public health awareness. The flexibility in session length and timing indicates an adaptable approach to the diverse educational needs of communities. The study highlights room for enhancement in creating a conducive learning environment through measures such as climate control and improving educator effectiveness. The lack of food demonstrations in most health facilities suggests a gap in practical learning opportunities. Limited evaluation of education talks indicates a need for a robust feedback mechanism to assess the effectiveness and redesign the education strategies, as echoed in several studies [27, 28]. This implies the need to address these recurring limitations to improve the effectiveness of health and nutrition education efforts within service delivery.

Regarding nutrition assessment and categorisation, the study found consistent implementation of comprehensive measurements such as MUAC, age recording, and anthropometric data across all facilities. However, challenges in interpreting growth curves for mothers reveal a potential gap in holistic healthcare delivery. Several studies have demonstrated low coverage of growth promotion and monitoring for children under five years [29–31]. Notably, one study showed that Growth Promotion Monitoring (GPM) programmes in low and middle-income countries relied on criteria that poorly predict or diagnose inadequate growth in children [32, 33]. This emphasises the need to improve caregivers’ understanding of growth curves and redesign GPM strategies for adequate nutrition and health outcomes.

The study highlights a well-organised and supportive health system through active follow-up of mother-baby pairs, group counselling, individual counselling for HIV-infected mothers, and a referral system for malnourished cases. However, the lack of a list of community structures and livelihood programmes to connect mothers and mother-baby pairs reveals potential barriers in maintaining care continuity, emphasising the need for targeted interventions to strengthen community linkages for sustained health outcomes.

The study highlights a commitment to continuous improvement through the presence of Quality Improvement (QI) work plans and budgets in most facilities. However, the limited existence of nutrition quality improvement teams indicates a potential area for enhancing focus on nutrition service enhancement. Several studies have revealed shortcomings in the quality of nutrition services delivered [25, 34–38]. This suggests that strengthening nutrition-focused quality improvement teams could help tackle these deficiencies, resulting in better healthcare delivery and improved nutritional outcomes.

Designated individuals for HMIS data demonstrate a focus on data management, and standard registration and reporting practices ensure accurate record-keeping. However, the limited display of nutrition data in facilities suggests a gap in utilising data for informed decision-making action.

Health workers’ interpretation of NACS integration

The derived model clarifies the multi-dimensional aspects of NACS integration, including internal factors like health workers, client characteristics, and interpersonal relationships, as well as external environmental influences, all of which interact during the delivery of nutrition services.

This model aligns with theoretical frameworks reviewed by Piquer-Martinez et al. [39], Atun et al. [40], and Tsasis et al. [41], which highlight stakeholder and community engagement, adequate funding, intervention characteristics, governance, technology, and communication as key components of successful integrated healthcare. Similarly, Noor et al. [42] proposed a synthesised model that emphasises understanding the specific needs of the target population by adopting a social determinants approach, prioritising individual and community empowerment, enhancing health literacy, and reorienting services to align with the specific needs voiced by the population. This implies that a multi-dimensional approach, considering social determinants, stakeholder engagement, and adequate resources, is essential for effective and efficient health service delivery. Anchoring the NACS integration model within these existing frameworks improves its validity and scalability.

Health workers held mixed views on NACS integration into health service delivery, noting both advantages and challenges of implementation. They regarded NACS as a comprehensive approach to patient well-being, involving detailed data collection, individual or group counselling, and nutritional management. This approach aims to fill gaps in nutrition and emphasises education, prevention, and the treatment of malnutrition, as well as preventing malnutrition-related deaths, lowering medical costs, and enhancing health for patients and communities. They recognised NACS integration into the health system as a one-stop centre, combining various health services simultaneously for increased efficiency and effectiveness. Successful integration was seen as a collaboration with multiple stakeholders, including partners, health workers, and the Ministry of Health, through the provision of policies, guidelines, and capacity-building initiatives. Their views are in alignment with the international definitions and the role of NACS [43–45]. The implication is that health workers’ perspectives are based on established standards, guidelines, and best practices, and that there is a need to adhere to these standards when tackling malnutrition.

However, concerns were expressed about increased workload, limited human and financial resources, assigning nutrition services to NACS trainees, challenges in managing high client turnover, and the time-consuming nature of the integration process. These issues reflect common difficulties faced by frontline service providers dealing with resource limitations while trying to meet the diverse needs of clients [46–48]. This indicates a compromised quality of service delivery, highlighting the urgency of addressing resource limitations and workload challenges, as well as ensuring proper support and training for the nutrition workforce to integrate nutrition services effectively [49]. This integration is essential for Uganda to achieve the Sustainable Development Goals.

The study highlights the complexity of NACS integration, providing insights into how service providers interpret the concept of integration and translate it into practice, as well as the strengths and gaps in health service delivery.

Study strengths and limitations

The study goes beyond theoretical discussions to offer practical insights into daily nutrition services, highlighting both strengths and areas for improvement within health facilities. However, it was confined to a single geographical area (Tororo district) and healthcare setting. This narrow scope may restrict the broader applicability of the findings to other regions with different contexts. Additionally, participants in the FGDs were not grouped by cadre, and the self-reported information from health workers might have introduced response bias and social desirability bias. These issues were addressed through in-depth probing by trained research assistants.

Conclusion

The study shows that while some parts of NACS are integrated into regular health services, the extent of this integration varies across different health facilities. The multi-dimensional model emphasises the importance of health worker cognitive attributes, client factors, interpersonal interactions, NACS features, and external environmental factors in improving health service delivery. The study points out key areas where daily nutrition services can be improved, helping to guide interventions that aim to increase the overall effectiveness of nutrition service delivery.

Recommendations

Based on the findings, we propose the following recommendations to enhance practices, policies, and future research in NACS integration:

The government should allocate adequate human and financial resources to support NACS integration, including staff training and skill development in nutrition assessment, counselling, and service delivery. Stakeholder engagement is essential in fostering collaboration among health workers, partners, policymakers, and community members to address challenges and enhance nutrition services through integrated healthcare delivery.

The Ministry of Health should strengthen nutrition-focused quality improvement teams within health facilities to monitor and enhance the quality of nutrition services over time. It should also address the gap in interpreting growth curves for mothers and improve coverage for growth promotion and monitoring among young children to achieve better health and nutritional outcomes. Health facilities should include practical food demonstrations and return demonstrations to improve learning outcomes. They should also enhance the utilisation of health management information system (HMIS) data for informed decision-making, including the display of nutrition-related data.

Future research could explore community perspectives on NACS integration to understand its impact on patient engagement, health-seeking behaviours, and overall health outcomes.

Author contributions

SN, SNK, GWM, and FEM contributed to the conception and design of the study. SN contributed to data acquisition. SN, SNK, GWM, and FEM were involved in data processing, analysis, and interpretation of the findings. SN drafted the initial manuscript, while all authors contributed to subsequent revisions and approved the final version.

Funding

The authors received no specific funding for this work.

Data availability

The ATLAS.ti 22 datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study received approval from the Uganda National Council of Science and Technology (SS 4251) and the Office of the President in Uganda (ADM/194/212/01). Permission to conduct the study was obtained from the Tororo District Health Officer and the Ministry of Health. The Principal Investigator briefed both the Tororo District Health Officer and the District Resident Commissioner on the study plan before it began. Informed consent was obtained from all participants after clearly explaining the purpose and objectives of the study. The study was conducted in accordance with the WMA Declaration of Helsinki on research involving human subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.