Improving Nutritional Counseling in Hyderabad, India: A Pilot Study

BACKGROUND: If not addressed before the age of five, pediatric undernutrition can lead to irreversible long term health effects, including death. Mild to moderate pediatric undernutrition specifically contributes to 83% of malnutrition-related deaths in children. India has one of the world's largest prevalence rates for mild to moderate pediatric undernutrition. In India, improving nutritional counseling for caregivers of undernourished children is the most effective and sustainable way to reduce the prevalence of pediatric undernutrition. LOCAL PROBLEM: Staff at the Niloufer Hospital nutritional counseling center in Hyderabad, India were concerned that their counseling sessions were not aligned with international guidelines for these sessions and consistent between patients. It was unknown how reliable these sessions were. Therefore, the aim of this study was to increase the reliability of the evidence-based practice for nutritional counseling given at a nutritional center in Hyderabad, India by 25% by March 2017. Reliability was defined as how often counseling sessions followed 100% of international guidelines appropriate for a given patient. METHODS: The quality improvement methodologies of DMAIC (Define-Measure-Analyze-Improve-Control) and PDSA (Plan-Do-Study-Act) were used. The design and improvement of the interventions was carried out with PDSA cycles within the larger DMAIC methodology. During the define phase, a project charter was established and it was found that locally adapted WHO-UNICEF counseling guidelines were the best practice for this setting. During the measure phase, observation of counseling sessions showed that the sessions were given orally by nurses, without visual aids, and were inconsistent from patient to patient. A study to measure reliability and compliance of current practices and future intervention was created. Compliance is the percentage of topics covered out of the total topics listed in the age-appropriate guidelines for a given session. Guidelines were grouped into three age groups: under six months, six months to 35 months and three years to five years. Baseline reliability and compliance scores were collected in the analyze phase. During the improve phase, checklists and subsequently, flipcharts, were created as interventions to improve counseling using multiple PDSA cycles for each intervention. Reliability and compliance scores were collected for sessions using each intervention. INTERVENTIONS: The first intervention created was a checklist, a low-cost tool shown to improve long-term compliance with standardized medical processes. The content of the final checklists was adopted from the WHO-UNIFEF guidelines that served as a standard for this setting. A checklist was made for each of the three age groups. The second intervention created was a flipchart, which is a booklet with illustrations and corresponding talking points on opposite pages. It is the most common visual aid used in nutritional counseling worldwide. The final version of the flipcharts was created by using infographics adopted from a UNICEF nutritional counseling flipchart for India and supplemental images created by the local staff. The talking points of the flipchart were based on the checklists created earlier in the study. A flipchart was created for each of the three age groups. RESULTS: Counseling reliability did not increase with either intervention and was 0% for all age groups during all phases. However, counseling compliance increased with both. All results are reported for the age groups in the following order: under six months, six months to 35 months, and three years to five years. The average counseling compliance during the baseline phase were 20.6% (SD=4.1), 24.2% (SD= 8.2), and 28.9% (SD = 5.2). The average counseling compliance during the checklist phase were 56.8% (SD = 7.8), 57.8% (SD = 13.8), and 57.7% (SD = 10.5). The average counseling compliance during the flipchart phase were 64.6% (SD= 7.3), 57.8% (SD = 10.3), and 70.8% (SD = 7.8).The largest increase in average compliance was between the baseline and flipchart phase and was 44.0%, 33.9%, and 41.9%. A one-way ANOVA with post-hoc comparisons compared the effect of the interventions on compliance during each phase. For the youngest and oldest group, the mean compliance during the checklist and flipchart phase was found to be significantly different than for the baseline phase and from each other. For the middle group, the mean compliance during the checklist and flipchart phase was found to be significantly different than for the baseline phase but not from each other. CONCLUSION: This pilot study showed that both checklists and flipcharts can improve compliance in this setting though neither helped achieve the target reliability. Flipcharts were a more successful and advantageous intervention than the checklists for increasing compliance. Additionally, this study demonstrated that quality improvement framework used was an effective model to develop sustainable interventions in low resource settings. Further studies are needed to determine if these interventions can be improved and expanded to wider use.