Terms of Reference (ToR) for a formative qualitative research and quantitative baseline survey for an improved IFA supplementation program for school going adolescent girls in selected districts of West

Java province in Indonesia

STATEMENT OF SERVICES AND DELIVERABLES Background and rationale: The prevalence of anaemia among adolescent girls and women of reproductive age (15-24 years) at national level is 18.4% (RISKESDAS, Basic Health Research, 2014). However, the data from screening of junior-high school children in Cimahi and Bandung districts in 2013 revealed the prevalence of anaemia among adolescents in the range of 40-50% (DHO, Cimahi, 2013). Based on national guidelines (MoH, 1998), it was recommended to give one IFA tablet weekly for 16 weeks consecutively, plus one IFA tablet daily during menstruation for 10 days to adolescent girls. However, the program was not implemented as envisaged. Some of the reasons for this are:

non-availability of IFA tablets, limited promotion of the intervention and no clear channel for distribution.

Estimation for IFA supplements by government is calculated based on expected population of pregnant and postpartum women only, and supplies IFA supplements for the adolescent girls is very limited. The District Health Office (DHO) advocates to other sectors such as education/school to provide IFA tablets for adolescent girls at school, while the health sector only promotes the benefits of consumption of IFA supplementation and risk of anaemia, however the provision of IFA tablet is still not available for all schools.

Therefore, MI Indonesia proposes a trial on Weekly Iron and Folic Acid (WIFA) supplementation for school-going adolescent girls to reduce the prevalence of anaemia among them and reinstate the focus of district and national government on the IFA supplementation program for adolescent girls for improved health outcomes. In this regard, MI proposes two activities: a qualitative formative research study and a quantitative baseline survey. Both activities will inform the design of a Behavior Change Communications (BCC) strategy to improve awareness regarding dosing, adherence, and benefits of IFA supplements and estimating the coverage of weekly IFA supplementation among school-going girls. The qualitative study will be conducted in the two program districts of Cimahi and Purwakarta. The quantitative study will be conducted in two program districts of Cimahi and Purwakarta and one comparison district of West Java province. The quantitative baseline survey will be carried out with the key objective of estimating the anaemia prevalence, coverage and adherence of weekly IFA supplementation among school going adolescent girls. This ToR outlines the scope and activities to be carried out in this survey. Overall objective: The purpose of the consultancy is to provide MI with information to formulate a BCC strategy to improve awareness regarding dosing, adherence and benefits of IFA supplements and estimate prevalence of anaemia, coverage and adherence of weekly IFA supplementation among school going adolescent girls in selected districts of West Java.

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Specific objectives of the quantitative survey : To achieve the purpose the following specific objectives should be met:

1. Estimate the prevalence of anaemia among school going adolescents girls 2. Estimate the coverage and adherence of IFA supplementation among school going adolescents girls 3. Assess the knowledge, attitude and practices among school going adolescents girls about causes and

consequences of anaemia and the benefits of IFA supplementation

Specific objectives of the qualitative survey : Specific objectives for school-going adolescent girls include the following:

1. Identify the local terms girls use for listlessness, fatigue, and lack of energy. Determine what causes these symptoms and (broadly) what girls do to address these conditions.

2. Name the foods girls eat and determine reasons for consuming (or failure to consume) these foods (with a particular focus on foods that are rich in iron and folic acid such as ASFs).

3. Determine whether girls take any micronutrient supplement or (separately) medicine to address the symptoms described above.

4. Identify the following for consumption of IFA tablets: a. Perceived advantages and disadvantages of consumption of IFA tablets. b. Facilitators and barriers to regular consumption (what might encourage/discourage

adolescent girls from taking tablets?) c. Adolescents' self-efficacy with respect to taking tablets. d. Social norms regarding consumption of IFA tablets specifically and micronutrient

supplements generally. e. Individuals who might influence (one way or another) adolescents' uptake of IFA tablets

(including girls' perceptions about teachers themselves with respect to encouraging IFA consumption and the practice of nutritious behaviors).

f. Perceptions about IFA tablets and how they might impact the body and girls' health. g. Concerns about the tablets (for example, the long-term consequences of taking tablets

regularly) as well as potential side effects. 5. Identify perceived advantages/disadvantages, facilitators/barriers, self-efficacy, influential

individuals, perceptions, and concerns with respect to consumption of a diverse, iron-rich diet. This should take the form of asking girls what they think about consuming specific meats, etc. The use of the term "iron-rich" should be avoided in all conversations with girls so as not to bias their responses.

Specific objectives for school teachers include the following:

1. Determine the extent to which adolescent girls in their classrooms suffer from listlessness, fatigue, and lack of energy. From teachers' perspectives, identify what causes these symptoms and (broadly) what girls have done or can do to address these conditions.

2. Have teachers name things that they think can be done to mitigate listlessness, fatigue, and lack of energy in the classroom.

3. For each of the following: 1) promoting the use of IFA tablets 2) promoting a diverse, iron-rich diet 3) dispensing IFA tablets, and 3) ensuring that adolescent girls take them, gauge:

a. Facilitators and barriers

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b. Teachers' self-efficacy with respect to nutrition education and promoting IFA supplements

c. Social norms surrounding teachers with respect to these promotion of these actions d. Perceptions about IFA tablets themselves, and e. Concerns about the tablets (including potential side effects)

4. Probe teachers' understanding of the causes and consequences of anemia. The following questions layout the types of information that will be required to meet the specific information these questions should be interpreted as a minimum requirement for the information to be obtained in this consultancy but consultants should feel free to propose the collection and utilization of any additional information that may strengthen their ability to respond to the specific objectives. Key research questions for the quantitative survey The key research questions are as follows:

1. What is the regimen that is given for IFA supplementation among school going adolescent girls? 2. What is the coverage of weekly IFA supplementation among school going adolescent girls? 3. What is the adherence of weekly IFA supplementation among school going adolescent girls? 4. What are the reasons for non-adherence, if any? 5. What is the knowledge level of school going adolescent girls regarding IFA dosage, duration and

its side effects following consumption? 6. Do teachers counsel the school going adolescents regarding solutions to the side effects from

consumption of IFA? 7. Do health workers counsel the school going adolescents regarding solutions to the side effects

from consumption of IFA? 8. Who supplies the IFA supplements among the school going adolescent girls? 9. Is there a stock out of supplies of IFA in the schools?

Key research questions for the qualitative formative research

1. What media do girls pay attention to most (radio, TV, social media, etc.)? 2. What other sources of support might be helpful (e.g., in school peer support)? 3. What specific messages might appeal to adolescent girls the most? Which ones might be most likely

to encourage girls to take IFA tablets and consume ASFs? 4. What support from teachers and others would help girls not only adopt practices related to

consumption of IFA tablets and ASFs but maintain those practices? 5. What pedagogical methods do teachers currently use to promote health? What facilitators and

barriers might teachers face when implementing hands-on, participatory learning? 6. Which training design and content for teachers will be most appropriate and effective in delivering

the program (knowledge of dosing and benefits of IFA, counseling, adherence, and monitoring)? 7. What other constraints might teachers face in promoting consumption of IFA tablets and ASFs (e.g.,

lack of supervisor's support, negative reaction from parents, girls' disinterest in the topic, etc.)? Based on results, the consultant(s) will recommend actions to inform MI's program design which is meant to improve the uptake of IFA tablets as well as healthier diets. This should include 1) impactful messages based on responses from adolescent girls and teachers 2) individuals who might be especially good at encouraging girls to consume IFA tablets and eat healthier diets 3) actions teachers can take to improve girls' consumption of IFAs, and 4) suggestions for teacher training (and in particular, content of that training based on results from this study and the BEHAVE framework or similar).

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Design and method: A pre and post intervention cross-sectional survey design with comparison group will be adopted for this study. The study will involve the use of both quantitative and qualitative methods of data collection. The quantitative surveys will be conducted at two time points the two program districts and one comparison district of West Java. The qualitative formative research is a one-time, cross-sectional, guided by health behavior theory. This qualitative study relies upon focus groups with in-school adolescent girls and teachers as well as in-depth interviews with teachers and other influencers and structured observations of classrooms to assess pedagogical methods. Please note that if there are not enough health instructors to form a focus group in a particular school, teachers who instruct on similar topics should be included in FGDs. Target respondents: School going adolescent girls in the age group of 12-19 years will be the respondents of the quantitative survey. In the formative qualitative research, focus group discussions and in-depth interviews will be conducted among school teachers, principals, religion officers, health workers like; midwives, cadres, other potential influences like; parents of unmarried adolescents and husbands and in-law of married adolescents. Sample size for the quantitative baseline survey The target respondents for the study will be school going adolescent girls in the age group of 12-191 years from randomly selected households. In the absence of any reliable data on the prevalence of anaemia among adolescent girls (10-19 years), the sample size is powered to detect a difference between 18.4%2 (assumed for the school going adolescent girls at baseline and an anticipated 3% at endline (based on the end line target mentioned in the Innovation agenda proposal), with 95% confidence, a power of 80% adjusted for a design effect of 2 and incremented by a probable non-response rate of 10%. The sample size is powered to provide combined project area level estimates for the two program districts. The sample is not powered to provide individual district level estimates3.

Table 1 : Sample size for the quantitative survey

Outcome variable: prevalence of anaemia Required sample of households =0.05 and & = 0.80 and an assumed design effect of 2.04

Program areas (two program districts of Cimahi and Purwakarta of West Java province)

170

Comparison areas (a district in West Java with similar socio-economic, demographic and health characteristics to the two program districts)

170

Total 340 Sample selection for the quantitative survey The sample of households will be selected in a two stage sampling design. In the first stage, all the villages in the two program districts as per census 2010 will be listed and 17 villages will be selected by probability proportional to size (PPS) method. Similarly, 17 villages will be selected in the selected comparison district by PPS method. At the second stage, all households in the selected cluster will be

1 12-19 years is being taken considering those who are in junior/ senior secondary high school students would have had menarche. 2 adolescent girls and women of reproductive age (15-24 years) at national level is 18.4% (RISKESDAS, Basic Health Research, 2014) 3 For separate district level estimates, we need a higher sample size, which will have higher cost implications. 4 The sample size has been computed using Stata 12.0 Statistical Software for two sample tests with standard statistical assumptions (two-sided test; alpha= 0.05; 0.8 power, and non-continuity) and have been increased to account for design effect and assumed non-response rate and rounded off.

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listed to prepare a sampling frame for households with a school going adolescent girl in the age group of 12-19 years. The required number of respondents (10 in each cluster) will be selected by a systematic sampling method from the sampling frame of households. A cluster/ village with more than 200 households will be divided into two equal segments, with each segment of about 100 households. Then, one segment will be randomly selected for the preparation of the sampling frame. In case, the desired number of households is not available in the selected segment, then the nearby segment will be covered to get the required number of respondents. In addition to canvassing of a structured questionnaire with the 340 school going adolescent girls in the age group of 12-19 years regarding coverage and adherence of IFA and their knowledge, attitude and practices related to anaemia and IFA supplementation, haemoglobin tests will be conducted among them by drawing blood samples from them during the baseline and end line surveys to measure anaemia prevalence. An Ethical Committee will guide the blood sample collection, testing device, method of testing and disposal procedures that will be undertaken in the survey, adhering to the international standards. Prior to collection of the blood samples, informed consent will be obtained from the adolescents. 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 adolescent girl 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 adolescent girl and it will then be signed by her. If the test is performed, at the end of the test, the adolescent girl will be given a written record of the haemoglobin status. In addition, the health investigator will interpret the results to her and advise the adolescent girl regarding IFA supplementation. In cases of severe anaemia, an additional statement will be read to the adolescent 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.

Sample size for the qualitative survey The optimal behavior MI's programs seek to improve upon is consumption (according to national guidelines) of one IFA tablet weekly by adolescent girls for 16 weeks consecutively plus one IFA tablet daily during menstruation for 10 days. Secondary behaviors the MI project seeks to improve relate to diet and will be determined with greater specificity in the coming weeks but include increased dietary diversity and consumption of animal source foods (ASFs) where religion or other influences do not dictate otherwise. Sample selection for the qualitative survey The respondents for the qualitative survey will be selected from the neighbouring villages of the two program districts not covered in the quantitative survey. For the purposes of this research, adolescent girls are defined as school-attending young women 12-19 years of age living in two districts of Cimahi and Purwakarta in West Java province who may or may not be taking iron folic acid (any frequency, including 0).

Table 2 : Sampling of Adolescent girls 12-19 years old Number of FGDs Method of data collection

Information needed Cimahi (West Java)

Purwakarta (West Java)

Focus group 1. Local terms for listlessness, fatigue, and 5 FGDs among 5 FGDs among 12-14

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discussions (FGDs) that include pile sorts

lack of energy as well as perceived etiology and treatment.

2. Names of foods girls eat/don't eat and reasons for doing so.

3. Existing use of micronutrients and/or medicines to address symptoms.

4. For consumption of IFA tablets and ASFs:

a. Perceived advantages and disadvantages.

b. Facilitators and barriers. c. Self-efficacy. d. Social norms. e. Influential others (including

teachers). f. Perceptions about IFA tablets

and ASFs and how they might impact the body and girls' health.

g. Concerns about tablets and ASFs.

5. Media of importance to girls. 6. Additional sources of support girls need

to adopt practices (IFA tablet consumption and consumption of ASFs.

7. Appealing messages.

12-14 years olds + 5 among 15-19 year olds=10

years olds + 5 among 15-19 year olds=10

The optimal behaviors MI's programs seek to improve upon with respect to teachers are promoting IFA tablets and consumption of iron rich foods, dispensing IFA tablets, resolving any concerns adolescents have regarding tablets, and ensuring that adolescent girls take them. For the purpose of this research, teachers are defined as men and women employed by the State or by a private school who instruct adolescent girls 12-19 years of age. Given the small number of teachers per school, it will not be possible to limit this sample to only teachers who are responsible for promoting the use of IFA and consumption of iron-rich foods, dispensing IFA tablets, and ensuring that adolescent girls take them.

Table 3 : Sampling of Teachers, Principals of schools of school going adolescent girls 12-19 years old

Number of FGDs/ IDIs/ Observations Method of data collection

Information needed Cimahi (West Java) Purwakarta (West Java)

Focus groups 1. Perceived extent to which adolescent girls suffer from listlessness, fatigue, and lack of energy. Perceived causes and actions to address symptoms.

2. Actions teachers can take to mitigate listlessness, fatigue, and lack of energy

5 FGDs among teachers of 12-14 years olds + 5 among teachers of 15-19 year olds=10

5 FGDs among teachers of 12-14 years olds + 5 among teachers of 15-19 year olds=10

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in the classroom. 3. For each of the following: 1)

promoting the use of IFA tablets 2) promoting a diverse, iron-rich diet 3) dispensing IFA tablets, and 3) ensuring that adolescent girls take them:

a. Facilitators and barriers

b. Teachers' self-efficacy with respect to nutrition education and promoting IFA supplements

c. Social norms. d. Perceptions about

IFA tablets and ASFs.

4. Perceived causes and consequences of anemia.

In-depth interviews (IDIs) with teachers and principals

1. Pedagogical methods teachers currently use to promote health.

2. Facilitators and barriers to implementing hands-on, participatory learning?

3. Thoughts on training design and content for teachers that will be most appropriate and effective in delivering the program.

4. Other constraints teachers face in promoting consumption of IFA tablets and ASFs.

10 teachers + 1 principal

10 teachers + 1 principal

Classroom observation (conducted during health promotion sessions)

1. Pedagogical methods do teachers currently use in the classroom.

2. Which training design and content for teachers will be most appropriate and effective in delivering the program (knowledge of dosing and benefits of IFA, counseling, adherence, and monitoring)?

Observations of 5 classroom sessions (5 different teachers)

Observations of 5 classroom sessions (5 different teachers)

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3. What other constraints might teachers face in promoting consumption of IFA tablets and ASFs (e.g., lack of supervisor's support, negative reaction from parents, girls' disinterest in the topic, etc.)?

Table 4 : Sampling of Religion officers/ Midwives/ Cadres

Number of FGDs/ IDIs/ Observations Method of data collection

Information needed Cimahi (West Java) Purwakarta (West Java)

Focus groups 1. Perceived causes and consequences of anemia.

2. Regimen of IFA among school going adolescents

3. Awareness about weekly IFA supplementation

4. Awareness about IFA dosage, duration and benefits, methods to overcome side effects

5. Counselling provided 6. Availability and use of

IEC/ BCC / BCI materials 7. Stocks and supplies of

IFA to schools 8. Recording and

reporting of IFA distribution

1 FGD among Midwives + 1 FGD among Cadres =2

1 FGD among Midwives + 1 FGD among Cadres =2

Indepth interviews (IDIs)

1. Opinion about the program

2. facilitators and barriers

1 Religion officer 1 Religion officer

Table 5 : Sampling of Parents of unmarried adolescents/ Husbands and in-laws of married adolescents Number of FGDs/ IDIs/ Observations Method of data collection

Information needed Cimahi (West Java) Purwakarta (West Java)

Focus groups 1. Awareness about weekly IFA supplementation

2. Awareness about IFA dosage, duration and

2 FGDs among parents of unmarried school going adolescent girls

2 FGDs among parents of unmarried school going adolescent girls

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benefits, methods to overcome side effects

3. Opinion about adolescents getting IFA in schools

Focus groups 1. Awareness about weekly IFA supplementation

2. Awareness about IFA dosage, duration and benefits, methods to overcome side effects

3. Opinion about adolescents getting IFA in schools

1 FGD among parents-in-law of married school going adolescent girls

1 FGD among parents-in-law of married school going adolescent girls

Indepth interviews (IDIs)

1. Awareness about weekly IFA supplementation

2. Awareness about IFA dosage, duration and benefits, methods to overcome side effects

3. Opinion about adolescents getting IFA in schools

2 IDIs with husbands of married school going adolescent girls in the age group of 12-19 years

2 IDIs with husbands of married school going adolescent girls in the age group of 12-19 years

The survey will collect information on the following in addition to other details to be incorporated in the questionnaire from the adolescent girls:

Socio-economic-demographic background characteristics of the households and adolescent girls

Exposure to mass media, interpersonal communication and social media Knowledge of anaemia and IFA supplements (dosage, duration and benefits) Regimen of IFA for school going adolescent girls Receipt and adherence of IFA Supervision of receipt and consumption of IFA among adolescents in schools Counseling provided by teachers/ principals/ health workers Side effects and knowledge of methods to overcome side effects

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 Final English and Bahasa Indonesia structured questionnaires Final English and Bahasa Indonesian FGD guides and guides for in-depth interviews Final English and Bahasa Indonesian checklists for classroom observation Plan for training interviewers and supervisors

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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 Detailed documentation of procedures used for sampling Data analysis and tabulation plan (to be provided earlier) Cleaned and labeled quantitative datasets in SPSS format Codebook including nodes and their definitions as well as structure All field notes and interviews legibly transcribed and translated in electronic forms Cleaned and labeled qualitative transcripts in Word Report of survey finalized after review by MI Power point presentation summarizing the key findings

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. Key findings from interviews of school going adolescent girls 5. Key findings from interviews of teachers and other potential influencers 6. Discussion and Conclusions 7. Annexures : Questionnaires, interview and FGD guides, observation checklists

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 16 weeks and the final report will be finalized within this period.

Table 6 : Timeline

Week

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Translating and Pretesting data collection instruments (semi-structured questionnaires, FGD guides, guides for in-depth interviews, and checklists for structured observations ) and sampling plan

IRB clearance

Training of investigators Data collection Data entry and analysis

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Report writing and finalization

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STATEMENT OF SERVICES AND DELIVERABLES