TOR for Baseline Survey of IFA in Indonesia

8/10/2019 TOR for Baseline Survey of IFA in Indonesia

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Terms of Reference for baseline survey of

Strengthening of the Iron Folic Acid Supplementation Scale up Program in Indonesia

Background

MI supported the Government of Indonesia to demonstrate a model for increasing coverage and

adherence of Iron Folic Acid supplements among pregnant women to reduce iron deficiency and

iron deficiency anemia among pregnant women between 2011 and 2014 in one district each of

Banten (Lebak) and West Java (Purwakarta) provinces. This demonstration project focused on

improving:

Strengthening the supply chain of the IFA supplements.

Strengthening government commitment.

Capacity building of health staff and frontline workers.

Behavior Change Interventions for increasing adherence, with a focus on Interpersonal

Counseling,

Modifying the monitoring system to track coverage.

Supportive supervision

During this demonstration phase, MI forged strong partnerships with Directorate General of

Community Nutrition (MoH), UNICEF, Centre of Health Research at the University of Indonesia

and several local NGO’s for implementation of this program.

Based on the findings of the demonstration project, MI is replicating the elements of the

processes which have worked to improve coverage and adherence of the IFA program in 4

provinces (West Java, Banten, West Nusa Tenggara and Riau). During the first 2 years, MI will

scale up the program in West Java and Banten province followed by West Nusa Tenggara and

Riau in years 3 and 4.The proposed project component will focus on:

Strengthening government commitment and integrate with other programs. Tailored capacity building and BCI interventions for health staff, midwives and cadres to

provide effective counselling to ensure high utilization rates.

Streamlining the supply chain of IFA program at district, province and national levels.

Streamlining program monitoring and supervision from national until district levels.

National level technical assistance on improving the IFA supplement re-formulation,

HMIS and revision of national guidelines.

MI is commissioning a baseline survey with the key objective to establish baseline estimates of

coverage and compliance of IFA. The study will be conducted in two provinces (West Java and

Banten) and two comparison (non-intervention) provinces / districts. The rationale of choosing

only two provinces of the four for the purposes of evaluation is because these provinces would

have had maximum program exposure. This ToR outlines the scope and activities to be carried

out in this assessment.

Overall Objective

The overall objective of this exercise is to establish baseline estimates of coverage and

compliance of IFA and other indicators (mentioned subsequently) among pregnant women in

two project provinces (West Java and Banten) in Indonesia supported by MI.



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Specific Objectives of the baseline survey

The specific objectives of the baseline survey are to:

1.

Estimate the coverage and compliance of IFA supplementation among pregnant women

2.

Assess the knowledge, attitude and practices among women and health workers about

causes and consequences of Anaemia and the benefits of IFA supplementation

3.

Identify knowledge, skill and behavior levels of health workers related to services of

Anaemia and IFA supplementation

Key Research questions

The key research questions are as follows:

1.

What is the coverage of IFA among pregnant women?

2.

What is the compliance of IFA among pregnant women?

3.

What are the reasons for non-compliance?

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 Mid-wives and Kader Desa (community health volunteer)

regarding causes and consequences of Anaemia ?6.

What is the level of knowledge of Mid-wives and Kader Desa (community health

volunteer) regarding the benefits of IFA supplementation?

7.

Do Mid-wives and the Kader Desa (community health volunteer) counsel the 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?

Study Design

A pre and post intervention survey design in intervention and comparison provinces will be

adopted for the assessment. Two appropriate districts will be identified based on similarities in

health system and socio-economic indicators in the two program provinces. Research firms

responding to this RfP should propose the two comparison provinces based on these indicatorsto be used for this evaluation.

Study Area :

The study will be conducted in the provinces of West Java and Banten. The district of Lebak in

Banten and Purwakarta in West Java would be excluded from the survey (and the sampling

frame for selection of villages) as they were sites of the demonstration program. The objective

of the evaluation is to assess impact on the scale up strategies to improve coverage and

utilization among pregnant women. The inclusion of demonstration districts will contaminate

the measurement of this impact of scale up activities.

Target Respondents: The target respondents will be women, who have recently delivered in the

last six months preceding the survey. The other respondents for the survey will be the health

workers of the sampled clusters and health officials in the two provinces.



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Sample Size

The main indicator of interest for the study is the compliance of at least 90 IFA tablets during

pregnancy. It is estimated that the compliance of 90+ IFA tablets in the two provinces is 40 %1.

The program targets to increase this compliance to 60 % in the program provinces. After

adjusting for a design effect of 2.0, IFA coverage of 75 % as per DHS 2012, the sample size works

out to be 300 mothers in each of the project provinces. The total sample size will be 1,200

women who had delivered in the past 6 months preceding the survey (2 project provinces and 2

comparison provinces).

Cluster and household selection: The selection of the clusters in the 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. It is proposed to

take ten women delivered in the last six months per cluster and hence 30 clusters will be

sampled by this method in a province. Each subsequent cluster is determined based on thesampling interval. The sampling of households within clusters is 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 houselisted and households

with recently delivered women in the last six months will be identified. Ten recently delivered

women, who have delivered in the last six months will be selected randomly from this list. In

case, the sample size is not achieved, a neighboring segment will be selected randomly and

houselisted to identify the required additional recently delivered women in the last six months.

Knowledge, Attitude and Practices among Health Workers: In addition to the collection of data

from respondents from households, the evaluation will include a sub-study of KAP Health

workers in both the provinces. A semi-structured questionnaire will be administered for thisgroup. 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. One mid-wife and one Kader Desa (community health volunteer) personnel in

each cluster will be interviewed. The following number of health workers will also be

interviewed:

Sample of Health Workers to be interviewed

Health Workers Number

Mid-wife 120

Kader Desa (community health volunteer) 120

In addition to the health workers, the following health officials will also be interviewed (only in

the project provinces) to understand their perspective about the project strategies. The list of

health workers to be interviewed will be provided by MI.



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Sample of Health Officials to be interviewed

Health Officials Number

Nutrition programmer at Puskesmas (in the areas covered in the

household survey)

10*2 program provinces = 20

Nutrition programmer at the district level 1*in 2 program provinces=2

District Health Officer 1*in 2 program provinces=2Provincial Health Officer 1*2 program provinces=2

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.

Recently delivered woman

1. Consent

2. Identifiers District,

Household number,

Hamlet

Village

Name and Age of Household Head,

Name and age of Respondent,

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;

Exposure to mass-media

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;

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 ,



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Recently delivered woman

Months running (i.e. gestational age) when pregnancy was

registered;

Information given during pregnancy registration; only relevant to

anemia 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, anemia, 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;

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

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-compliance

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

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

include;

Mid-wives/ Kader (community health volunteer)

1. Consent



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2. Identifiers District, village, (and for cadres) hamlet / posyandu name.

Name and Age

Number of households in workers catchment area,

3. Characteristics Age of Mid-wife/ Kader;

Highest class completed by Mid-wife/ Kader (community healthvolunteer);

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

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 IFAsupplementation program for pregnant women? (Ask specifically

for the training conducted by IBU Foundation)

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 anemia examination by Hb meter

to 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



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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 atleast 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?)

Health Officials

1. Consent

2 Identifiers

District

Name of Official

Designation

Date of interview, Name of Interviewer

3. Opinion of the

Government

officials at the

province and

district level

Adequacy of budget for procurement of supplies

Any policy/guideline adopted following MI’s intervention to improve

IFA coverage and compliance

Perception towards MI’s current strategies and suggestions for

improvement in coverage and compliance

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 baseline Survey

Ethical clearance to conduct the study need to be sought from an internationally

accredited review authority/board

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

Cleaned and labeled datasets in SPSS format

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



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2.

Introduction

3.

Study design

4.

Key findings from interview of recently delivered women

5.

Key findings from interview of health officials and workers

6.

Conclusion and Recommendations

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

Week

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Translating and Pretesting

data collection instruments

and sampling plan

IRB clearance

Training of investigators

Data collection

Data entry and analysis

Report writing and finalization

Documents

TOR for Baseline Survey of IFA in Indonesia