TOR for Zinc Baseline Survey in Indonesia

8/10/2019 TOR for Zinc Baseline Survey in Indonesia

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Terms of Reference for baseline survey of the scale up program on

Zinc and ORS for the treatment of childhood diarrhoea in of West Nusa Tenggara Province in

Indonesia

Background

According to the Basic Health Research data RISKESDAS, 2007, the proportion of child deaths

with diarrhea as the first cause of death among under-five children is 25.2% in Indonesia. In

2008, Ministry of Health (MoH), Republic of Indonesia adopted the WHO recommendation of

zinc and ORS supplementation for treatment of childhood diarrhea into the National Diarrhea

Disease Control Program (DDCP). However, this program has not been fully implemented in the

country due to various operational gaps. In addition, limitation of operational budget and delay

in actual inclusion of zinc in the National Essential Medicine List until 2012, have caused the

coverage and utilization of zinc to remain low.

To demonstrate the potential of the public health sector, MI supported a project to increase the

coverage and utilisation for zinc and ORS supplementation in treatment of diarrhea among

children in 2 districts (East Lombok and West Lombok) of West Nusa Tenggara province. MIcollaborated with the Directorate General Communicable Disease and Environment Health

(CD&EH) of the Diarrhea Subdivision within the Ministry of Health and the District Health Office

(DHO) in West Lombok and East Lombok who are the implementers of the IMCI program.

The strategy focused on a) strengthening the supply chain for both zinc and ORS b)

strengthening government commitment c) building capacity of the health system d) Behaviour

Change Communication (BCC) interventions with a focus on Interpersonal Counseling (IPC) e)

modifying the monitoring system to track coverage f) supportive supervision and f) program

evaluation in selected districts.

The coverage for zinc and ORS supplementation increased significantly within the public healthsystem in the demonstration districts. Based on the program evaluation of our demonstration

work in East Lombok and West Lombok districts in West Nusa Tenggara, MI is replicating the

elements of the processes which have worked to improve coverage and compliance of zinc and

ORS in childhood diarrhea treatment across West Nusa Tenggara province and thereafter to two

high mortality provinces of Banten and West Java. The proposed components are:

Strengthening government commitment to promote zinc and ORS for childhood

diarrhea program and it’s integration into current IMCI programs and other programs.

Tailored capacity building and BCI interventions for health staff and cadres.

Streamlining the supply chain of zinc supplements and ORS at district, province and

national levels.

Streamlining program monitoring and supervision

Exploring the support for zinc and ORS program through the private sector

National level technical assistance for the revision of National Guidelines and improving

the MIS.

MI is commissioning a baseline survey with the key objective to measure the coverage and

compliance of use of ORS and Zinc for the treatment of childhood diarrhoea. The study will be

conducted in the West Nusa Tenggara province in Indonesia as this program has the longest



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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 inform the Government of Indonesia, The

Micronutrient Initiative (MI) and other key partners involved in the Diarrhoea management

program on the impact of program activities on the coverage and compliance of zinc and ORS in

the treatment of childhood diarrhea in West Nusa Tenggara province in Indonesia.

Objectives of the baseline survey

The specific objectives of the baseline survey are to:

1.

Measure coverage and compliance of Zinc and ORS during diarrhea episodes of children

6-59 months of age.

2.

Measure knowledge, attitude and practices among mothers in treatment of childhood

diarrhoea

3.

Assess the knowledge, skill and behavior of health workers related to services and

advice of 6-59 months old children suffering from diarrhoea

Key Research Questions

The key research questions are as follows:

1.

What is the coverage of zinc and ORS in diarrhea cases among care givers of children 6-

59 months ?

2.

What is the level of knowledge among care givers of children 6-59 months regarding

diarrhea management?

3.

What is the level of compliance of Zinc and ORS ?

4.

What is the source of treatment for diarrhoea episodes?

5.

What is the source of zinc and ORS?

6.

What are the reasons for non-compliance of zinc and ORS?7.

What is the level of knowledge of health workers and Kader Desa regarding Diarrhoea

management with Zinc and ORS?

8.

Does involving the Kader Desa in zinc distribution improve coverage and utilization rate?

9.

Are supplies of Zinc and ORS adequate at the frontline distribution points?

Study Design

A quasi-experimental pre and post intervention design with a comparison group will be adopted

for the study. In addition to the program province, one appropriate comparison province will be

identified based on similarities in health system and socio-economic indicators to the program

province. Research firms responding to this RfP should propose the comparison province based

on these indicators to be used for this evaluation.

Project Area : The project area comprises the province of West Nusa Tenggara Province.

However, since two districts of East and West Lombok were the sites of a demonstration

program to strengthen the public health system to improve coverage and compliance of zinc

treatment for diarrhea, these two districts will be excluded from the sampling frame to select

the clusters for the survey. The purpose is to assess impact of scale up activities of the program

on project outcomes.



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Target Respondents: The target respondents will be care-givers of children 6- 59 months of age

who had an episode of diarrhea in the one month preceding the survey. The other respondents

for the survey will be the Mid-wives and Kader Desa of the sampled clusters and health officials.

Sample Size

The main indicator of interest considered here is the coverage of zinc for childhood diarrhea

treatment. This sample size assumes coverage of zinc treatment for childhood diarrhea at 23 %

at baseline (based on RISKESDAS estimates for West Nusa Tengara province). It is estimated that

the program activities will improve coverage to 38 % at the end of the project period. To

measure this change, a sample size of 350 children aged 6-59 months, who had diarrhoea at

least for one time in the last one month preceding the survey per province will be required. The

total sample size for the intervention and comparison province comes to 700 (350*2 provinces).

The sample size is based on a confidence level of 95%, adjusted by a design effect of 2.0 to

account for the multi-stage sample selection and incremented by 10% for probable non-

response.

Cluster selection: The selection of the clusters in the two districts will be conducted using theprobability proportionate to size (PPS) method. This means that each district 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 caregivers of

children aged 6-59 months, who had diarrhoea at least for one time in the last one month

preceding the survey per cluster, hence 35 clusters will be sampled by this method in a province.

Each subsequent cluster is determined based on the sampling interval.

Household Selection : The sampling of households within clusters is done by a houselisting

exercise to identify children aged 6 – 59 months with an episode of diarrhea in the past onemonth. For the houselisting, the selected clusters will be divided 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 children aged 6-59

months who had diarrhoea at least for one time in the last one month preceding the survey will

be identified. Ten caregivers of children aged 6-59 months, who had diarrhoea at least for one

time in the last one month preceding the survey 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 number of children who had diarrhoea at least

for one time in the last one month preceding the survey.

Knowledge, Attitude and Practice (KAP) Study among Health Workers: In addition to the

collection of data from respondents from households, the survey will include a sub-study of KAP

Health workers. A semi-structured questionnaire will be administered for this group. The field

teams will visit the related health facility of each cluster for interview with health workers and

for collection of data relating to stock of zinc tablets and ORS. One health worker and one Kader

Desa (community health volunteer) personnel in each cluster will be interviewed. The following

number of health workers will also be interviewed:



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Sample of Health Workers to be interviewed

Health Workers Number

Mid-wife 35*2 province=70

Kader Desa (community health volunteer) 35*2 province=70

In addition to the health workers, the following health officials will also be interviewed. MI will

provide a list of health officers to be interviewed:

Sample of Health Officials to be interviewed in the intervention province

Health Officials Number

Diarrhea Program Officer at Puskesmas 10

Diarrhea Program Manager at the district level 2

MCH Program officer / IMCI clinic coordinator at puskesmas 10

District Health Officers (CDC section, MCH section, etc.) 2

Provincial Health Officers (CDC section, MCH section, etc.) 2

Indicative information to be collected and questions to be asked

Mothers of children 6-59 months of age

1. Consent Agree/Disagree to participate in interview

2. Identifiers Province

District,

Cluster number,

Household number,

Hamlet

Village

Name and Age of Household Head, Name and age of Respondent Mother / caregiver,

Date of interview, Name of Interviewer,

3. Household and

Respondent

Characteristics

Literacy of Respondent Mother; Marital status;

Literacy of father of the child;

Relation of respondent to head of household;

Highest class completed by respondent;

Highest class completed by father of the child;

Size, age and sex composition of household;

;

Source(s) of household income;

Religion of respondent, source of household drinking water; kind

of household toilet facilities; Type of fuel used for cooking;

Assets owned by household (irrigation pumps, working radios,

cycles, rickshaws, almirahs/showcases, cot/bed, clocks, sewing

machines, working televisions, motorcycles, mobile phones,

tubewells, livestock);

Construction material used for house (ground floor walls, roof,

kitchen);

Number of living rooms;



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Mothers of children 6-59 months of age

Presence of household electricity;

Exposure to mass media

5. Health seeking behavior

Episode of

diarrhea in thelast one month

Recent diarrhea affected child;

Type of person who was contacted

Days (i.e. after diarrhea affliction) when treatment was sought;

Information given during treatment;

Prescription given

What type of health worker provided treatment;

What services were provided

What advice was given;

Diarrhea

management

with Zinc and

ORS

Does the respondent have correct knowledge of dosage,

preparation and administration of zinc tablets

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

diarrhea

Did respondent hear about ORS; where?

Did respondent hear about zinc tablets; where?

Whether ORS was given alone or with zinc?

How many were given both Zinc and ORS?

How many were given only ORS?

Did respondent give zinc tablets to her child during diarrhea?

How many zinc tablets did respondent give to her child;?

What was the source of ORS and Zinc?

What other treatment / medicine was given in addition to Zinc and

ORS?

How many packets of ORS was given by the health worker?

How many tablets of zinc was given?

Counselling Who visited the care giver during the episode of diarrhea?

Whether health worker / mid-wife/ Kader Desa visited the care

giver during the episode of diarrhea?

Whether the health worker / mid-wife/ Kader Desa counseled the

respondent?

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

include;

Mid-wives/ Kader (community health volunteer)

1. Consent Agree/Disagree to participate in interview

2. Identifiers District, sub district/puskesmas

Name and Age

Number of households in workers catchment area,3. Characteristics

Highest class completed

Duration of service

Primary functions/activities performed;

4. Catchment area Number of households,

Children <5 years and total population in the catchment area;

Size of catchment area in square kilometers

5. Trainings Training on Management of Childhood Diarrhea



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Mid-wives/ Kader (community health volunteer)

Number, duration and dates of trainings attended on zinc for

diarrhoea treatment

6 Knowledge Understanding of the definition of diarrhea

Understanding of the signs of mild to moderate dehydration

Awareness about the correct dosage of zinc tablets (20 mg/day

for children 6-59 months)

Awareness about the correct duration for zinc tablets intake

(10 days)

Ability of workers to demonstrate preparation of ORS correctly

Ability of workers to demonstrate use of dispersible zinc tablets

correctly

Awareness of benefits of giving zinc tablets in acute diarrhea

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

duration even if diarrhea stops

Workers having latest edition of Diarrhea Disease Control

Program Guideline by Ministry of Health

7 Stock / Supply

Situation

Workers with adequate stock of diarrhea treatment courses -ORS

(e.g. 20 courses i.e., 40 ORS packets & 200 zinc tablets / 20 zincblisters)

Workers with adequate stock of diarrhea treatment courses -Zinc

Number of zinc supplements were received at the health facility

for distribution(check from stock registers and note the number)

Number of ORS sachets were received at the health facility for

distribution

Number of zinc supplements have been distributed in the

previous month(check from stock registers and note the number)

Health facilities reporting no stock outs for zinc supplements/ORS

in the previous month

8 Recording and

Reporting

Whether stock registers are available

Whether reporting forms are availableIn the last month

Number of children of age 6-59 months with diarrhea seen during

the last month

Number of children of age 6-59 months who have received both

zinc supplements and ORS sachets

Number of children of age 6-59 months treated with antibiotics /

anti-protozoal drugs/ anti-motility drugs

Number of children of age 6-59 months referred

Number of health facilities where recording of information is

correct and complete in the register

Number of health facilities where monthly report is submitted in a

timely manner (along with the submission of HMIS report)9 IEC Number of health facilities displaying IEC materials related to

project displayed at the centre

Number of health workers reporting availability of Inter Personal

Communication (IPC) tools

type of tools available (flip chart, pocket book)

Number of service providers using IPC tools (in case the IPC tools

are available with her)

other- health promotion at posyandu, counselling at pustu,





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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 Zinc Baseline Survey in Indonesia