Training Packages and Patient Management Tools for Healthcare Staff Working with Small, Nutritionally At-Risk Infants Aged under 6 Months: A Mixed-Methods Study †
- To improve the future management of small and nutritionally at-risk infants and their mothers via an improved understanding of currently available training packages and patient management tools.
- To identify how many training programs and tools are currently available and their differences.
- To identify perceived issues and gaps in the practical application of training.
- To identify how training can be improved to ensure optimal delivery.
2.1. Study Design
2.2. Review of the Literature
2.3. Qualitative Research
2.3.1. Participant Selection
2.3.2. Data Collection
2.3.3. Data Management and Analysis
2.3.4. Ethical Considerations
3.1. Identification of Training Programs and Patient Support Tools
3.2.1. Participant Profile
3.2.2. Training and Management Tool Characteristics According to Key Informants
3.2.3. Themes Arising
3.2.4. Skills and Needs
“Because it is actually really important to get the technical knowledge for the staff but actually if they don’t know how to do counselling and I have seen it in so many different countries, then it is not gonna be successful.”ID3
“…they know it is the best thing for the baby, but they have too many other problems and so listening to those other problems I think is important.”ID9
“I mean, skills are one thing but really engaging with people’s attitudes and values (…) think we neglect that part (...) I mean for example in lot of what we are talking about are differences in life and death, so it is about how do you take the responsibility for that role and what does that mean to you as a person, why are you motivated to do this job, that kind of stuff.”ID2
“…especially when it comes to helping with breastfeeding which is a lot of (...) in the dark, you need to understand malnutrition and you need to understand about breastfeeding and also a little bit about how you can spot a preterm baby. I mean a lot of those babies are actually not malnourished, but they are born preterm unless you know the gestational age of the baby then you label it as malnourished.”ID2
3.2.5. Perceived Issues and Gaps
“There was a little bit of practical on it, but with the extent of this one-day orientation the team does not feel confident to then cascade it down when I was checking last week. And this is from some who are experienced in IYCF and acute malnutrition.”ID8
“…it is still heavily NGO-supported because we made it a bit too complicated and if we keep changing the admission and discharge cut offs, because this is what happened with CMAM, it’s gone from weight for height to weight for age and then it is three MUAC cut offs now it’s got two, you know you can only do a certain amount of changes otherwise people get confused.”ID8
“…I think that is one of the problems that there is still confusion if it falls under infant feeding or acute malnutrition because of the name cMAMI. (…) The very first version of cMAMI was referred to as community-based management of acute malnutrition, and that affords what we call CMAM or IMAM in the community and that would be maybe at sometimes a different team, if you work with government it would be the same health worker but if you are working in like in the refugee context it is slightly different programmatically…”ID8
“I mean helping a mum breastfeeding takes time, you have to be sitting there for 40 min, half an hour, and I think when you do the training, people think oh yeah I understand this, but the actual transition into practice it is quite a big jump there.”ID2
“…is because it builds skills, it builds skills of counsellors because it includes clinical practice, so you learn a skill and then you go out and practice. You learn a new skill you keep building them and then you go out and practice.”ID7
“…like when I was looking for simple tools to do breastfeeding assessment, they weren’t really available, especially not evidence based,”ID1
“...the whole idea of counselling is quite foreign to many of our staff in emergency settings. So because it does take quite of analytical skills, I was thinking of maybe a gap that there is of how do you do a good breastfeeding assessment and then not just doing the assessment but then the next step is okay this is the issue and this is what we are going to address.”ID1
“So I probably say this again one of the main thing is supporting the non-breastfeed, or even relactation so trying to get them back to breastfeeding, and then I think people see it as very complicated with for example wet nursing, (…) from my experience it is actually very challenging to implement because it is not a lot of guidance on it,”ID3
“…it is very rare that I actually find skilled staff who know how to competently give relactation support, but I think as a sector as well we just assume that relactation works and I would actually just throw out there that I have a lot of doubts as to where lactation protocols work.”ID7
“I think we have a tendency to focus on breastfeeding just general recommendation and lactation ahem but when you really dig in to the reasons why women are not succeeding in reaching their goals it comes back down to quite a lot of lactation management problems and issues or lack of support either wasn’t available or did not work (…).”ID7
“I think you need quite highly qualified staff to be able to give that training (…). So, I think my biggest kind of need, but I am not sure that is training per se related, is just a greater clarification and more guidance on how to implement.”ID2
“I just don’t feel we are quite at that point yet where we know how to do it effectively, because I think we are having the right conversations and we are getting the right information together of how to assess and how to report the mothers and if she has mental health problems but I think it is just on the ground where it is not quite working.”ID3
“(…) any other NGO, they don’t have that (…)”, but “Action against Hunger they have mental health and IYCF together, so they have quite a good position that they do that really well (…)(ID3).
Participants voiced a gap in giving trainees the chance to apply and practice newly acquired knowledge, and thus to properly consolidate and refine their skills, in supporting mothers. Training programs were often found to be too theoretical, making it hard for trainees to “transition from abstract training, to how to apply it.”(ID2).
“But you know, it’s only when they actually to talk to mothers or even in the role play that they realise that they are not using the word they should. Like not using judgmental words, but it comes to them and they have (...) and stop themselves from using it, so they only do it if somebody is observing them.”ID9
“Having ongoing mentorship is also really important to be able to follow up and give people support outside of the classroom so I think that should really be considered during implementation.”ID5
“I would say the problems with trainings is that they are given in a very rushed manner when disaster strikes and that is probably not the best, because this is really prevention, with the under six months it should be a preventive measure and it should be in areas which are prone to disasters. For instance, if you have now the Syrian refugees coming to so many countries and people know that they will be coming, so staff should be trained there on the ground to be trained of how to help mothers in how to help them to continue breastfeeding.”ID9
3.2.6. Areas for Improvement: What Would Ideal Training/Support Packages Be Like?
“So again, it is about making the tool comprehensive (…) if you give someone a tool that takes them an hour to read, to document everything and they got 50 patients to see, and one takes an hour, you cannot do it.”ID2
“I don’t think there is a need of new training packages but maybe to go into detail, to some of the topics or modules, that maybe need to be more extended (…)”ID6
“So, to me it is at some point all these things have to come together. You got the early child development, you got to stimulate the child, you got baby WASH, you got to then look at the environment and separate from animals, you got the cMAMI you got to really look at breastfeeding practices and look at the status of the mother. If we think of the end point, of getting a health worker and the health systems delivering this, how can they deliver all of these different packages.ID9
“You know as a range of expertise in the trainer team so you have someone who is an expert and someone who is really quite new to it, but letting them run and be involved in a few trainings and build their confidence and while it is on and if they don’t know the answer, the expert trainer can answer for them, I think that works really well.”ID2
“Just engaging with the materials in lots of different ways, role plays, drill like asking fast questions, sitting and thinking about it, looking at the paper. IMCI does it well, they do lots of different ways, looking at photographs and I think there are lots of different learning styles in a room, so you can kind of compensate all of it and that makes them more comfortable, rather than being forced into a learning style they are not comfortable with.”ID2
“But then I would personally say for things like counselling and mental health it should be like a very practical workshop type. So, I think really technique content needs to be covered for a couple of days and everything else should be very, very practical.”ID3
“One has to prioritise so whoever who is there really needs to know what the setting is like, what the staff who are dealing with these people, what information they already had, what are the other NGOs that are already there, what information, what support they are giving?”ID9
- Rather than developing completely new additional trainings, future research should focus on how to effectively integrate care of small and nutritionally at-risk infants u6m into future editions of existing training programs available across health and nutrition. The update to Integrated Management of Childhood Illness currently underway by WHO provides one critical opportunity to do so.
- More evidence is needed on how, where, and in what way the training packages we flagged feed into developing heath policies, including policies on breastfeeding support.
- As breastfeeding and relactation support needs are varied and may be complex, more specific training on how to provide this is needed at all stages of a healthcare worker’s career (i.e., undergraduate, postgraduate in-service training, postgraduate formal, and specialist training). Training should include skills in how to effectively re-establish exclusive breastfeeding in at-risk infants u6m and growth outcomes.
- More evidence is needed regarding how to provide health workers without psychological backgrounds with the skills to assess and provide effective mental health counseling.
- Evaluation of the effect of training programs on the quality of services is needed, as well as strategies to sustain quality care provision.
- Training programs should incorporate context-specific practical implementation; the complexity that will limit educational approaches on how best to achieve this requires exploration.
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|Curriculum Covered||Harmonised Training Package (HTP) ||Breastfeeding Counselling a Training Course ||Community IYCF Counselling Pack ||IYCF Counselling:|
an Integrated Course 
|IMCI ||Infant Feeding in Emergencies “Module 2” ||HIV Infant Feeding Counselling ||Think Healthy|
|Getting to Know Cerebral Palsy ||IYCF-E Toolkit ||Baby Friendly Spaces ||Feeding + Positioning Manual|
|IYCF Counselling Community-Focused Approach |
|The Sick Child||X||X||X|
|Nutrition, Physical Health||X||X||X||X||X||X||X||X||X||X|
|HIV and Infant Feeding||X||X||X||X||X||X||X||X||X||X|
|Management of Artificial Feeding/Donations||X||X||X||X||X|
|Integration into Other Nutrition Programs||X||X||X||X|
|Participant ID||Organization Type||Setting|
|2||Academic/Research Institution||Inpatient Care|
|5||NGO||In- and Outpatient Care|
|ID||Training Used||Setting||Target Audience||Duration||Costs||Curriculum||Guidelines Followed|
|1||cMAMI||Emergencies, communities||IYCF counselors, nurses||2 days on cMAMI, 3-day IYCF plus 2 days and then once a week||No direct costs or travel costs for staff||Save the Children IYCF training||Modified from cMAMI guidance, national guidelines, WHO|
|2||IMCI, IYCF, cMAMI||Hospital, communities||CHW, IMCI: doctors, nurses, paramedics||3 to 5 days, IMCI and IYCF often running for 3 to 4 months in inpatient||N/A||IMCI curriculum, IYCF curriculum, breastfeeding||IYCF, FANTA|
|3||IYCF, IYCF-E, cMAMI||Emergencies||IYCF counselors, managers, trainers||5 days for managers, for counselors usually 3 days||Venue, food during trainings, material, baby dolls, relactation kit||IYCF-E curriculum, relactation, exclusive BF, topics related to <6 months, counseling skills, setting up an artificial feeding program, psychosocial support, staffing||WHO, UNICEF|
|4||Tailor-Made Course||Hospital||HW, doctors, nurses, nutritionists, peer supporters||5 days||N/A||Pathology of malnutrition, clinical management of malnutrition||Baby-friendly hospital initiative, |
national guidelines for management of acute malnutrition
|5||Neonatal Feeding Training||Inpatient clinic||Nurses, social workers/HW with different backgrounds, midwives||5 days||N/A||Assessment, diagnosis, treatment, what is good BF: how many times a day, breastfeeding assessment, counseling, monitoring||National guidelines, malnutrition guidelines from WHO, UNICEF, FANTA|
|6||Community IYCF Counseling Pack||Community||Nutrition officers, protection officers, community mobilisers, nutrition coordinators||3 to 5 days||N/A||Community awareness, community sensitization, content for under six months||WHO, UNICEF|
|7||40h Breastfeeding Course, Tailor-Made Course, Infants With Feeding Difficulties||Inpatient||Front-line community workers, healthcare staff||5 days||N/A|
|8||cMAMI||Emergencies||Nurses with nutrition experience||1 to 3 days||N/A||cMAMI toolkit, national guidelines|
|9||Training Based on WHO, UNICEF and Later Modified Version, IYCF-E||Emergencies||Variety off people with different backgrounds||Depending on setting and resources||N/A||Growth monitoring, taking anthropometrics|
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Engler, R.; McGrath, M.; Kerac, M. Training Packages and Patient Management Tools for Healthcare Staff Working with Small, Nutritionally At-Risk Infants Aged under 6 Months: A Mixed-Methods Study. Children 2023, 10, 1496. https://doi.org/10.3390/children10091496
Engler R, McGrath M, Kerac M. Training Packages and Patient Management Tools for Healthcare Staff Working with Small, Nutritionally At-Risk Infants Aged under 6 Months: A Mixed-Methods Study. Children. 2023; 10(9):1496. https://doi.org/10.3390/children10091496Chicago/Turabian Style
Engler, Ramona, Marie McGrath, and Marko Kerac. 2023. "Training Packages and Patient Management Tools for Healthcare Staff Working with Small, Nutritionally At-Risk Infants Aged under 6 Months: A Mixed-Methods Study" Children 10, no. 9: 1496. https://doi.org/10.3390/children10091496