Processes and challenges of integrating nutrition assessment, counselling, and support into health systems in Uganda: A case study of Tororo district

Processes and challenges of integrating nutrition assessment, counselling, and support into health systems in Uganda: A case study of Tororo district | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Processes and challenges of integrating nutrition assessment, counselling, and support into health systems in Uganda: A case study of Tororo district Samalie Namukose, Suzanne N Kiwanuka, Fredrick Edward Makumbi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6792049/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Nutrition assessment, counselling and support is a holistic strategy designed to combat malnutrition and enhance health outcomes. Uganda has been implementing this strategy for a decade; however, a comprehensive documentation of the processes and experiences of integrating nutrition assessment, counselling and support in health systems remains scarce. This study aimed at describing the processes and experiences associated with integrating nutrition assessment counselling, and support into the health system. Methods A cross-sectional study design employing qualitative techniques was used to document the process and experiences of health workers in integrating nutrition assessment, counselling and support into the health system. The study utilised four focus group discussions, 24 key informant interviews and 22 in-depth interviews to gather insights. The interviews were recorded, transcribed verbatim and analysed thematically using ATLAS. ti version 22. Results Four themes emerged from the study: service delivery and quality for nutrition assessment, counselling and support; challenges and barriers associated with integrating nutrition assessment, counselling and support; community involvement and client empowerment; and capacity building and sustainability. From these themes, the processes and experiences included structured mentorship, performance reviews, supervision, capacity building of health workers, male involvement and community sensitisation on the utilisation of locally available foods. The challenges included staff shortages, inadequate continuous training, a lack of essential equipment, difficulties in managing nutritional assessment data and heavy reliance on donor support. Conclusion The effective integration of nutrition assessment, counselling, and support programs into the health system requires a structured and well-supported approach at all levels of service delivery. By addressing these challenges and leveraging the lessons learned, a more robust and effective nutrition service delivery system can be achieved. Nutrition assessment counselling support health system integration process experience service delivery Background In recent decades, recognition of the complex relationship between nutrition and overall health has increased, emphasising the need for integrated approaches within health systems to address malnutrition and related health issues. The Global Nutrition Report of 2020 called for a shift from isolated interventions to a more interconnected and holistic approach within health systems for sustained positive impacts on global health and well-being [1]. In addition, the World Health Organisation (WHO) and the United Nations International Children's Emergency Fund (UNICEF) have consistently emphasised the importance of integrating nutrition services into health systems to address the dual burden of malnutrition and other health challenges [2,3]. Furthermore, several studies highlight the need to address structural barriers to the successful integration of nutrition services into the health system [4–6]. At the national level, the Uganda National Development Plan (NDP) outlines the government's commitment to improving health outcomes and reducing malnutrition by emphasising the importance of a comprehensive and integrated healthcare system [7]. The current literature and national strategies provide a strong rationale and evidence base for the importance and feasibility of integrating nutrition assessment counselling and support (NACS) into health systems. Hence, this study explored practical ways to implement NACS integration, identified challenges, and proposed strategies for better health and outcomes. Specifically, this study sought to contribute to this growing body of knowledge by exploring the process, experience, and challenges associated with the integration of NACS in Tororo district in eastern Uganda. Uganda, like many other developing countries, faces considerable public health challenges, with malnutrition being a persistent burden. In response, there has been a concerted effort by the Ministry of Health and stakeholders to strengthen health systems by integrating the NACS into the broader healthcare framework [8]. Various authors have proposed a comprehensive framework for integrating nutrition into health programs, emphasising the need for cross-sector collaboration, evidence-based policies, and continuous monitoring and evaluation [9–11]. These studies provide a strong foundation for understanding the importance of integrating nutrition into health programs and highlight the key components required for successful implementation. The current study explored the challenges and enhancers to successful integration. The journey of integrating the NACS into the health system in Uganda represents a multifaceted approach aimed at improving its population's overall health and well-being. Several studies have underscored the importance of such integration, emphasising its potential to enhance the quality of health service delivery and health outcomes [12,13]. Tesfay and colleagues examined nutritional counselling within HIV care in the Tigray region of Ethiopia and reported that nutrition counselling in HIV care lacked structure and a comprehensive approach, hindering its effectiveness [14]. This current study explored experiences beyond the HIV setting. On the demand side, Mastellos and colleagues, in their study on integrated care, reported that this approach increased patient involvement, improved patient–provider relationships, improved organisation and access to care, and enhanced interprofessional communication [15]. As Uganda continues its journey towards a more integrated and resilient health system, understanding the contextual processes, successes, best practices, challenges, and lessons learned from integrating NACS is crucial. This study therefore aimed at describing the processes, experiences, and challenges of integrating Nutrition Assessment Counselling and support into the health system using Tororo district in eastern Uganda as a case study. Methods and materials The methods used in this study followed the Consolidated Criteria for Reporting Qualitative (COREQ) guidelines [16]. Study setting and context The study was conducted at the district level in Tororo District, Eastern Uganda. The health facilities involved in the study included hospitals, health centre fours (HCIVs), and health centre threes (HCIIIs) to capture a broad range of experiences and document the process related to the integration of the Nutrition Assessment, Counselling and Support (NACS). The selection of the health facilities was made in consultation with the District Health Officer (DHO) to ensure a representative sample. Study Design A qualitative approach was employed, utilising in-depth interviews (IDIs) with health workers trained in NACS to explore their personal experiences with NACS integration [17,18]. Key-informant interviews (KIIs) were conducted to gather comprehensive insights from individuals with extensive knowledge and experience in the integration of NACS. Participants included district health educators, the Assistant District Health Officer, medical superintendents of hospitals, facility in-charges, and nutritionists. Additionally, focus group discussions (FGDs) with each group comprising 8 to 12 participants, as is prescribed for FGDs [19], were held with heads of maternal and child health clinics, outpatient departments, ART clinics, and facility administrators to explore collective experiences and opinions regarding the NACS integration process, as is the standard practice of qualitative methods [20,21]. Participant selection Health workers at the district and facility levels were purposively selected on the basis of their experience with the NACS strategy. District leadership identified the health facilities to be visited and facility in-charges identified health workers to be interviewed on the basis of their NACS experience. A total of 33 participants took part in the FGDs, 24 in the KIIs, and 22 in the IDIs. One individual (the DHO) declined participation due to other commitments. Data collection The principal investigator (PI) conducted all the district-level interviews, including those with hospital heads and HCIVs in charge, while the research assistants were engaged in recording and note-taking during the FGDs. The PI had a master’s degree, postgraduate diplomas (PGDs) in nutrition, and specialised training in qualitative methods. The research team consisted of three research assistants with degrees and one with a diploma, all of whom were experienced in qualitative research. One research assistant was a nutritionist at Tororo Hospital, another was a nurse/midwife, and the remaining two were qualitative researchers from the School of Public Health. The PI and one research assistant were female, whereas the other three were male. The PI had received one month of specialised virtual training in qualitative methods from Stellenbosch University and had prior experience collecting qualitative data for food and nutrition surveys at the Ministry of Health. All the research assistants were trained in qualitative research methodology before the data was collected via materials from the Stellenbosch University course. There was no prior relationship between the researchers and participants, but the participants were informed about the researchers’ affiliation and study purpose. Two research assistants (the nutritionist and nurse) were based in Tororo district, while the other two were from the School of Public Health. The data for this study were gathered from participants at health facilities and district health offices. During the data collection process, only the researchers and participants were present. Gender information was collected for the participants, with 20 females and 13 males participating in the FGDs, 18 females and 4 males in the IDIs, and 14 females and 10 males in the KIIs. The discussion and interview guides were pretested on health workers in Kampala before actual data collection to ensure clarity and relevance. Interviews and FGD sessions were audio-recorded with the participants’ consent, and research memos were written at each stage to document observations and reflections. The focus group sessions lasted between 60 and 120 minutes, whereas the interviews ranged from 16-31 minutes. While the transcripts were not returned to the participants, the researchers compared the findings with those of other researchers for consistency. Data analysis The principal investigator (PI) and one research assistant, a nutritionist, were responsible for coding the data. A code book was developed to systematically aggregate the codes into sub-themes, eventually forming the main themes. These themes emerged naturally from the data, followed by the researchers’ thematic analysis. The coding and thematic organisation of the data were managed by Atlas. ti version 22 software. The analysis included 24 key informant interviews, four FGDs, and 22 IDIs. Audio recordings from the focus group discussions and interviews were transcribed and analysed using a thematic approach. Data coding involves grouping transcribed materials into categories, which are further grouped into themes. Quotations from participants were used to illustrate key study findings. Memo writing was integral throughout the analysis, enhancing the researchers’ understanding of the study context and contributing to the development of themes. To ensure internal validity, additional health workers from the same facilities were asked to review and comment on the findings. External validity checks were performed by comparing the results with those of similar studies conducted by other researchers to ensure consistency. The research assistants were thoroughly trained in qualitative research methodologies to ensure precise data collection and adherence to the study protocols. The study findings are presented clearly in the results section, reflecting the major themes identified during analysis. Results Four themes from the study emerged and are presented: service delivery and quality for the NACS, challenges and barriers associated with NACS integration, community involvement and client empowerment, and capacity building and sustainability. Some of the findings are compared within groups and across groups. Service delivery and quality for NACS The majority of the key informants said that structured mentorship, performance reviews, and supervision enhanced service delivery. They noted that mentorship improved service quality and addressed issues such as insufficient knowledge among health workers. In addition, the key informants intimated that data-related challenges were mitigated through mentorship, coaching, and nutrition dashboards for performance monitoring. What seemed to be overarching through most interviews was that the dissemination of information and establishment of demonstration gardens to educate mothers on nutrition were highlighted as crucial for passing on knowledge. Additionally, the informants mentioned that involving women in income-generating activities helped reduce malnutrition, as it lessened their financial dependence on their spouses. One key informant stated the following: “We organised support supervision, mentorships, and performance reviews to improve our nutrition services. We had trained teams who went out to mentor health staff at health centre IIIs, health centre IVs, and hospitals. Our district mentors were joined by regional mentors to provide supervision and mentorships at these health facilities. Owing to limited resources, not all staff had received training in NACS, resulting in knowledge gaps. These orientations, supervisions, mentorships, and use of nutrition dashboards to monitor performance have helped address those gaps and improved the situation,” _KII_District administrator_Tororo district Another key informant reinforced this point, adding the following: After the NACS training, we came back and mentored our colleagues who had not been trained so that we could move at the same pace. We also conducted food demonstrations and set up demonstration gardens to enhance health and nutrition education. Some mothers participated in income-generating activities that supported them to become self-independent and improve their families’ food and nutrition situations. _KII_Health worker_Nangongera HCIV Similarly, most of the in-depth interviewees emphasised the importance of continuous mentorship and training in enhancing health workers’ skills. They noted that this process made health workers more proficient in using tools such as Mid-Upper Arm Circumference (MUAC) tapes for nutritional assessment. Mentorship was also reported to boost their confidence in diagnosing malnutrition and interpreting assessment results. A key point raised was the integration of nutrition services into routine work, such as antenatal care sessions and general patient assessments, with health workers offering nutrition counselling and referring cases to specialised services when needed, as illustrated by the following quote: “We initially lacked confidence due to inadequate knowledge, but with continuous mentorship and training from the district, our confidence grew. At first, we only recorded MUAC measurements in centimetres and could not categorise malnutrition levels using colour codes such as green or yellow, but over time, we learned to do everything correctly… .Now, we can integrate nutrition assessment into our antenatal sessions instead of treating it as a separate service and it should be part of the routine package of services we provide to clients,” IDI_Health worker_Nagongera HCIV The majority of the focus group discussions highlighted that involving the community, including male partners and NACS service beneficiaries, improved service uptake. The participants noted that community sensitisation effectively created a demand for service uptake. Village health teams (VHTs) are recognised for their vital role in screening for malnutrition and referring cases to health facilities. However, the volunteerism model has encountered challenges due to the absence of incentives. A participant from the FGD explained that: “The community faces numerous cases of illness, often attributed to witchcraft, and some individuals die without accessing proper care. To address this, preventive measures and community-based structures such as VHTs offering NACS services are needed. Only severe cases would then require hospital referrals. Nongovernmental organisations (NGOs) working at the community level could focus on nutrition education, as the issue is not food availability but proper utilisation. Many families have food but lack knowledge on how to use it properly, often selling nutritious food and keeping unhealthy options. There are also families with no food at all, and government support is needed to either provide food or empower these families to produce their own. Additionally, many people suffering from severe or moderate acute malnutrition and infections could benefit from integrated approaches that treat underlying conditions, preventing the body from utilising food properly. Supplements and formulas can also be helpful,” FGD_Health worker, Tororo hospital Across the groups, there was a consensus that mentorship, community engagement, and improving both health worker competency and service accessibility strengthened NACS integration. However, there were noticeable differences across groups concerning professional service improvement and community-driven outcomes. Challenges and barriers associated with NACS integration KIIs revealed that many health centres face staffing shortages, resulting in inconsistent and lower-quality service delivery. The limited number of health workers increases their workload, which directly impacts the quality of NACS services. Additionally, the respondents stressed the need for continuous training, noting that while initial training sessions were conducted, follow-up training and mentorship remain inadequate. This gap hampers the effective implementation of NACS. Another significant challenge was the lack of essential equipment, such as weighing scales, height boards and mid-upper arm circumference (MUAC) tapes. One key informant said: “At times, clients come in big numbers, and yet we are few health workers. If they enter the consultation room without first conducting a nutrition assessment, the health worker becomes exhausted, ignores nutrition and concentrates on treating the diseases of patients, so manpower is a big challenge,” KII_Health worker_Molo HCIII Another key informant added that: “Inadequate tools and equipment are our problem. There are a few height boards, weighing scales, MUAC tapes, BMI wheels and Z-score charts. Those from the Ministry of Health and its partners were given high-volume facilities, so we still have a gap. The MUAC tapes are wearing off. The coloured tapes are better. Some partners at times do not consult, and they procure plain white tapes, yet categorisation is key. So they can’t categorise unless they are well trained,” KII District administrator_Tororo During IDIs, health workers voiced concerns about understaffing, which made it challenging to dedicate sufficient time to nutrition counselling and assessments in addition to other routine responsibilities. They also highlighted difficulties in managing nutrition assessment data, citing a lack of clear guidance on proper data management as a significant obstacle to delivering quality services. Furthermore, health workers noted insufficient follow-up after initial training sessions. Some admitted to relying more on the knowledge acquired during medical school rather than on updated guidelines and protocols from NACS training. This gap in continuous education limits their ability to implement best practices effectively, as illustrated in the following quote: “Those who are not assessed are those who come when the staff is alone and there is a heavy workload. If there is an emergency, the health staff may rush to attend to the emergency and may not attend to nutritional assessments. In addition, documenting nutrition services is a gap since several staff have not been trained and are using the knowledge they gained while in school,”_ IDI_Health worker_ Molo HCIII FGDs revealed that some communities have limited knowledge of the importance of nutrition and nutrition services. The group members reported that individuals refuse to eat recommended nutritious foods because of cultural beliefs or misconceptions about their value. The participants noted that many nutrition programs were heavily dependent on external donors, which made the continuity of services uncertain. The withdrawal of funding was therefore identified as a significant barrier to maintaining NACS activities. In the FGDs, the participants mentioned that there was limited knowledge about which partners were involved in supporting NACS, leading to missed opportunities for collaboration and sustained service provision. This is illustrated by the following quote: “In the community, the biggest challenge is the lack of well-established structures to address nutrition issues. The community has inadequate knowledge about the importance of nutrition and still holds on to beliefs that certain foods should not be eaten by women. Although patients improve in the ward, are discharged, counselled, and linked to other support, the real challenge arises when they return home. Despite the counselling, it can be difficult for them to implement what they have learned due to their financial situation. We are supposed to follow up with them after some time, but the lack of funds to facilitate our movements is a major issue. Partner funding for such activities has stopped, which has become a significant challenge,”_FGD_Health worker_Tororo Hospital Across groups, key informants and in-depth interviewees highlighted internal challenges such as staffing shortages and a lack of equipment, with a focus on the need for continuous training and better data management. Focus group discussants, however, emphasised external barriers such as community resistance to nutrition education and reliance on donor funding as barriers to NACS integration. Community involvement and client empowerment Key informants stressed the need to sensitise communities utilising locally available foods and improving food preparation methods to address malnutrition at the grassroots level. They highlighted that empowering people to make better use of what they have would significantly reduce malnutrition. The majority of the key informants shared how they applied knowledge from NACS training to educate communities on preparing nutritious meals. Some informants recommended better integration of the NACS into community health outreach programs, allowing health workers to demonstrate and provide guidance directly in communities. This approach ensures that the intervention reaches the core of malnutrition issues. The respondents also emphasised the role of community leaders in driving the adoption of nutrition services. By involving these leaders in nutrition interventions, they can promote food security and encourage households to grow and prepare nutritious foods, strengthening local efforts to combat malnutrition effectively. The key informant from Tororo Hospital explained: “It is better to address the problem at its source. What we have been doing is going into the communities where malnutrition cases originate. We educate the community on food security, emphasising the use of locally available foods and proper food preparation, activities that cannot be handled solely by hospitals. We need community leaders to mobilise and engage people on food security. Often, communities either produce food but do not know how to store it properly and prepare it or produce food and sell it. For mothers who have children but do not know how to breastfeed them, we can hold sessions with the community on breastfeeding and caring for children and new-borns to prevent malnutrition early enough,” KII_ health worker_Tororo hospital Another key informant added: “The solution is to empower the communities economically and make use of the linkage facilitators to support these clients in communities. This will offload work from health workers. Strengthening family planning is crucial,”_ KII_Health worker_ Poyameri HCIII On the other hand, the majority of the health workers involved in the in-depth interviews highlighted the use of demonstration gardens as valuable tools for teaching mothers how to grow and prepare nutritious foods. These gardens provided a practical, visual learning experience, making it easier for participants to retain information. Family support groups were also established, where mothers were taught how to prepare balanced meals and improve overall nutritional practices. In some sessions, food was provided to demonstrate local preparation techniques, with a strong emphasis on counselling about exclusive breastfeeding. The respondents noted that teaching mothers practical food preparation skills empowered them to make healthier choices for their families. This newfound confidence in managing their children’s nutrition resulted in better health outcomes, positively impacting the entire community. The combination of hands-on learning and community support effectively promoted sustainable nutrition practices. One participant stated the following: “Yes, I also had to counsel mothers on exclusive breastfeeding and conduct cooking demonstrations. I had a garden and a nutrition corner where I could demonstrate proper nutrition. After counselling them about nutrition, I would bring them to the nutrition corner to display different foods, show them how to grow food, and explain the various food categories,” IDI_Health worker_St. Anthony Hospital This sentiment was echoed by another participant who added: “However, if we had a demonstration garden, we could pick crops or fruits and demonstrate in front of the clients. It would be much harder for them to forget what was demonstrated, and it would empower mothers to make the right food combinations for their children, thereby improving their health and that of their babies. Simply talking verbally isn’t as effective, as they may leave having already forgotten,” IDI_Health worker_Merikit HCIII During focus discussions, participants recalled successful past programs, such as those by PLAN International, where health workers conducted demonstrations of food preparation within communities. These community-based interventions allowed broader participation, making nutrition training accessible to more people and promoting greater engagement in nutrition improvement activities. However, participants expressed concerns about the sustainability of these programs, particularly when donor support ended. For example, after some programs were phased out, it became difficult to maintain demonstration gardens due to a lack of materials and resources. The role of VHTs was highlighted as essential in connecting communities to health services. VHTs play a vital role in mobilising mothers for training and facilitating nutritional assessments. Nevertheless, reliance on volunteers, without sufficient support or resources, was identified as a significant challenge, potentially limiting the long-term effectiveness of these interventions. The establishment of and support for community-level nutrition committees were highlighted as key to facilitating the implementation of nutrition and other interventions, strengthening the referral system and coordinating between the community and health facilities. One participant remarked: “PLAN International also had a program in the community where they identified some health workers and VHTs, went to the community, and held demonstrations on preparing locally available foods. They allowed mothers and parents within the community to participate in demonstrations, which helped improve their nutritional status. However, I think occasional reminders are needed, as people can forget how to do things after being shown once. Otherwise, the community members have always been involved in food preparation demonstrations within their community,” FGD_Health worker_Tororo Hospital Another participant added: “… there is a need to create a nutrition committee first. It is that committee which will develop a work plan, present it to the health facility in charge, to solicit potential funding. The committee should also ensure strong linkages between the health facility and the community in the case of referrals, family planning services and others,”_FGD_Health worker_Kwapa HCIII In contrast, another participant stated: “Currently, we’ve been facing challenges with demonstration materials. We lack the necessary items and foodstuffs to demonstrate the concept of a balanced diet, as most people do not understand it. The demonstration gardens have also collapsed since TASO left, and we may need to reactivate them. Additionally, the VHTs have been supporting nutrition assessments, but they do so voluntarily, which also presents challenges,” FGD_Health worker_Malaba HCIII Across the groups, key informants emphasised the role of community leaders and integrating the NACS into existing health programmes. In contrast, in-depth interviews and focus group discussions focused on practical tools such as demonstration gardens and food preparation workshops. FGDs raised concerns about sustaining interventions after donor support ends, whereas KIIs emphasised local empowerment and self-reliance. Capacity building and sustainability The process began with the development of NACS implementation protocols at the national level. This was followed by training of trainers who supported the training of a critical mass of cadres at the district and health facility levels. Partners such as the AIDS Support Organisation (TASO), ASSIST, and RIGHTS-E provided support for capacity building, the procurement of anthropometric equipment, registers, food demonstration materials and the establishment of demonstration gardens. This is illustrated in the following quote: “The Ministry of Health worked on training manuals on NACS and used these to train trainers. We did not have staff trained in NACS, but eventually, we had training, and when we came back, we had to take others through NACS, so the starting point was training, then we had a CME with all the staff, and then we also had to ensure that we had the MUAC tapes, the height boards and the weighing scales in place. These were provided by partners. Unfortunately, we have only two height boards in the facility: one is placed in the outpatient department, and the other is at the mother‒baby pair point; it is also shared with children who come for immunisation. We are also doing BMI for the adults, and then after that, we identified staff at the various entry care points to do the assessment so at the different entry points. We are using linkage facilitators, RCT volunteers and VHTs who are helping us in performing the assessment, and if they find a malnourished client, they have to physically hand it over to a health worker who then handles the client _ KII_Health worker_Mukujju HCIV The majority of the key informants said that health workers were trained in key nutritional assessment tools, such as MUAC and how to perform nutritional assessments in various service areas. This training was vital for enhancing staff knowledge and skills in delivering nutrition services. The key informants emphasised the importance of continuous mentorship and on-the-job training, which helped sustain the knowledge and skills acquired during initial training. The capacity-building process also allowed health workers to manage more complex cases, leading to improved service delivery. However, some informants noted gaps in training coverage, as not all health workers were trained. In many cases, only a few staff members received training, with the expectation that they would share their knowledge with colleagues. This peer-to-peer training approach, however, was not always effective in ensuring consistent skill development across all staff members, as illustrated by the following quotes: “..as I mentioned, not everybody was trained in NACS, and of course, this makes us not perform to our expectations. Those who are trained are those who provide nutrition services, not those who are trained on weekends. It is this records officer who calculates the BMI,” KII_Healthworkers_Kiyeyi HCIII “To build the capacity of others, we focused on having more mentors. We chose and worked with general mentors because of limited resources for training everyone. Over the four days, these mentors were guided and trained: on the first day, they listened and observed; on the second and third days, they learned by doing, and on the fourth day, they were able to perform the tasks themselves. This approach enabled them to supervise and mentor others, particularly within their facilities,” KII- District Administrator_Tororo Health workers in in-depth interviews emphasised the importance of continuous professional development (CPD) sessions as a peer-to-peer learning approach for staying updated on current knowledge and practices in nutrition. Despite initial training, several respondents highlighted the need for regular refresher courses to maintain the knowledge acquired. They also noted that new staff members or those transferred from other departments often lack basic nutrition training, creating gaps in service delivery. To address this, trained health workers took the initiative to educate their peers, ensuring continued capacity to provide nutritional services. However, concerns were raised about the quality and consistency of this peer-to-peer training, as it was not always sufficient to cover all aspects of nutrition service delivery, leading to uneven skill development among staff members. One participant from Molo HCIII remarked: “The nursing officer attended NACS training, and when she returned, she oriented all the staff on the basics of conducting nutrition assessments through continuous professional development sessions. The aim was to ensure that nutritional assessments were conducted at all health care points, including the outpatient department (OPD), which had not yet started this practice. At the OPD, we had only been recording weight during that period, and three of the staff were new and had not yet acquired the skills for conducting nutrition assessments using MUAC or providing nutrition counselling,” IDI_Health worker_ Molo HCIII. Another participant echoed the same sentiment and emphasised the need for refresher training: “Concerning nutrition services, as you know, medicine keeps evolving. I think the last training I had was in 2014, not 2016. Since then, I haven’t received any other training, and I know my colleagues haven’t either. It would be helpful if we could have a refresher training outside the facility. Although we have continuous professional development sessions, they are not comparable to the comprehensive coverage of a full training,” IDI_Health worker_ Kiyeyi HCIII FGDs emphasised the crucial role of VHTs and linkage facilitators in conducting nutrition assessments and referrals. These community volunteers were trained to use tools such as MUAC tapes and identify malnourished children for referral for further management by trained health staff. Expanding capacity-building efforts into the community was viewed as essential for sustaining NACS interventions. FGD participants called for regular refresher training, not only for health workers but also for community volunteers. Ongoing training was seen as vital for maintaining the skills and motivation of VHTs, who played a key role in detecting malnutrition in their villages. One participant said that: “What I would emphasise regarding training is the need to continuously build the capacity of those providing nutrition services. Midwives and clinicians may acquire this knowledge during their formal education, but they require regular refresher training to stay updated with advancements in science and best practices. In addition, VHTs and linkage facilitators, who assist in screening for malnutrition using MUAC tapes both at the facility and within communities, also need thorough training. Another critical aspect to address is the issue of staff transfers. We need a strategy to ensure that the knowledge and skills remain within the health facility, even when personnel are transferred. By training a larger number of staff members, we can create a system that preserves knowledge, ensuring continuity in service delivery regardless of staff transfers,” FDG_Health workers_Malaba HC III Concerning intergroup differences, the key informants emphasised formal training and mentorship for health workers, highlighting the need for comprehensive staff training. IDIs stress continuous learning through continuous professional development, with a focus on peer training. FGDs underscore the involvement of VHTs and providing ongoing support and refresher training for sustained community service delivery. Discussion The study aimed at describing the processes, experiences, and challenges of integrating NACS into the health system. Four themes emerged from the study: service delivery and quality for NACS, challenges and barriers associated with NACS integration, community involvement and client empowerment, and capacity building and sustainability. From these themes, the processes and experiences included structured mentorship, performance reviews, supervision, capacity building of health workers, male involvement and community sensitisation on the utilisation of locally available foods. The challenges included: staff shortages, inadequate continuous training, a lack of essential equipment, difficulties in managing nutrition assessment data and heavy reliance on donor support. The findings are discussed with other studies, and their implications are highlighted below. Processes and experiences The process of NACS integration into the health system followed a structured process starting with the national-level development of NACS implementation protocols, followed by training trainers. This structured process was embedded with elements of performance reviews aimed at checking the progress of integration as well as supporting supervision to ascertain whether the nutrition counselling was taking place and addressing any arising challenges. The structured process also included mentorship, which improved service quality and addressed insufficient knowledge among health workers and mothers. The findings from this study agree with those of other studies that show that mentorship programs improve the clinical management of infectious diseases and maternal, neonatal, and childhood illnesses, leading to better adherence to clinical guidelines and protocols and thereby enhancing the overall quality of care provided by health workers [ 22 , 23 ]. These results imply that health interventions may benefit from clear, centralised guidelines, which ensure consistent and effective implementation across initiatives. Secondly, regular performance evaluations keep programs on track and address issues promptly, improving service delivery. Additionally, mentorship programs enhance service quality by filling knowledge gaps among health workers, making mentorship a crucial element in future health interventions. The process of NACS integration also involved capacity building for health workers through training in Key nutrition assessments, which improved the use of MUAC tapes height boards and boosted the confidence of health workers in diagnosing malnutrition and interpreting assessment results. These results are in tandem with research performed by other scholars, which shows that training approaches that involve work-based learning demonstrate that hands-on experience and project-based learning within healthcare institutions lead to improved diagnostic accuracy [ 24 , 25 ]. These approaches not only address knowledge gaps but also promote sustained improvements in clinical decision-making and service delivery quality. For NACS integration to be successful, involving male partners and NACS service beneficiaries improved service uptake. Community sensitisation was one of the ways identified as being effective in creating demand for service uptake among NACS service beneficiaries. Studies performed elsewhere have also revealed that involving men in family planning increases contraceptive use among women by improving spousal communication, increasing knowledge of contraceptive options, and reducing male opposition [ 26 ]. Additionally, a systematic review of interventions to boost the demand for sexual and reproductive health services among young people demonstrated the effectiveness of community mobilisation strategies, including training service providers and raising community awareness about available services [ 27 ]. These results imply that male involvement should be a key element of health systems, particularly in interventions related to maternal and child health, nutrition, and reproductive health. Additionally, health systems must invest in community awareness campaigns, as community mobilisation has proven effective in driving demand for health services across various sectors. Practical demonstrations were also identified as a good way of integrating NACS into the health system. The communities welcomed the idea of demonstrating how utilising locally available foods and improving food preparation methods can be beneficial in addressing malnutrition at the grassroots level. The involvement of community leaders was also said to be key during the adoption of nutrition services, as leaders encourage households to grow and prepare nutritious foods, strengthening local efforts to combat malnutrition effectively. These results mirror what has been published by other researchers, showing that demonstrations help to increase the capacity of healthcare providers by offering hands-on experience, which improves the implementation of new services and interventions. For instance, a systematic review revealed that integrating health interventions through practical demonstrations and the active involvement of healthcare providers enhances service uptake and quality of care, particularly in contexts such as maternal and child health, HIV, and tuberculosis services [ 13 , 14 ]. In addition, studies indicate that involving community leaders in the design and implementation of health interventions promotes trust, resilience, and more effective governance, which are essential for the long-term success of health programs [ 28 , 29 ]. As such, integrating practical demonstrations and community leadership into health interventions strengthens service delivery and promotes sustainable health system development, particularly in resource-constrained settings. Challenges of NACS integration The challenges of NACS integration into the health system were multifaceted and included but were not limited to, staff shortages, resulting in inconsistent and lower-quality service delivery. The limited number of health workers faced with an increased workload impacted the quality of NACS integration. Scholars in Uganda have reported similar findings and reported that inadequate staffing leads to increased workloads for existing health workers, resulting in physical and mental fatigue [ 30 ]. The aforementioned situation compromises the quality of care provided, as overworked staff are less able to meet patient needs effectively, leading to poorer health outcomes and lower retention rates among health professionals. While the initial training of NACS integration was good, there was a need for continuous training because follow-up training and mentorship remained inadequate, which affected sustainability. Like the results of this study, several studies have shown that continuous professional development (CPD) helps healthcare workers stay updated with rapidly changing medical technologies and healthcare demands. However, if follow-up training is inadequate, the benefits of initial training may diminish, leading to poor service delivery and limited sustainability of interventions [ 31 ]. Additionally, healthcare interventions that include consistent mentorship and feedback tend to improve knowledge retention, skill development, and quality of care [ 32 ]. It is therefore imperative that health systems prioritise continuous training and structured mentorship to sustain the benefits of initial training efforts, improve service delivery, and ensure the longevity of healthcare interventions. Health workers in facilities also described the lack of essential equipment, such as weighing scales, height boards and MUAC tapes. Without essential equipment, health workers may struggle to accurately identify cases of acute malnutrition in children, which is key to NACS integration in the health system. Surveys conducted in Mozambique have also shown that discrepancies between weight-for-height scores (WHZ) and MUAC measurements exist when adequate tools are not available or are not properly used, leading to potential misclassification of malnourished children [ 33 ]. Therefore, without accurate anthropometric measurements, health workers are unable to correctly identify children in need of treatment, which affects the overall success of NACS integration. In addition, misclassification of malnourished children, as seen in the Mozambique surveys, can lead to inappropriate interventions, either missing cases or overtreatment of children who do not require intensive care. There were also difficulties in managing nutrition assessment data because of a lack of clear guidelines that affected the delivery of quality services. The results of this study may be related to those of another study, which revealed that unclear or insufficient guidelines for dietary assessment in healthcare settings may lead to inconsistencies in data collection and hinder the ability to accurately monitor nutritional outcomes [ 34 ]. This lack of clarity affects the quality of nutritional interventions and ultimately reduces the effectiveness of healthcare services related to nutrition. With respect to financial support, the heavy reliance on donor support made the continuity of services uncertain. The lack of sustainable, domestic funding resources creates a fragile situation where health interventions, workforce training, and even basic service delivery may be disrupted. For example, countries that rely on international grants or loans for healthcare delivery, such as Uganda, may struggle to maintain programs if donor funds are reduced, affecting the long-term sustainability of critical health services [ 35 ]. It is therefore important for health systems to develop more resilient financing structures that reduce their dependence on external donors to ensure the sustainability and continuity of essential health services. Conclusion The successful integration of the Nutrition Assessment, Counselling, and Support (NACS) program into the health system requires a structured and well-supported approach at all levels of service delivery. By addressing these challenges and leveraging the lessons learned, a more robust and effective nutrition service delivery system can be achieved. Recommendations We recommend that the government invest in the integration of nutrition interventions at all levels of service delivery and provide financial incentives for health facilities that show significant nutritional improvements. The Ministry of Health should expand therapeutic feeding programs and engage communities through local dialogues and sensitisation involving local leaders. Partnerships between health facilities and community organisations should be strengthened to boost coverage and effectiveness. Continuous capacity-building activities, including refresher and on-the-job training, should be prioritised to bridge nutrition knowledge gaps. Finally, ensuring the availability and maintenance of anthropometric equipment is crucial for consistent service delivery, and establishing community demonstration gardens with home-based counselling and follow-up for malnourished clients is recommended for community-based approaches. Future research could focus on exploring the best strategies for integrating nutrition interventions in the health system via a human-centred design. Declarations Ethics approval and consent to participate This study received approval from the Uganda National Council of Science and Technology (SS 4251) and the Office of the President in Uganda (ADM/194/212/01). Permission to conduct the study was obtained from the Tororo District Health Officer and the Ministry of Health. The Principal Investigator briefed both the Tororo District Health Officer and the District Resident Commissioner on the study plan before its commencement. Informed consent was obtained from all the study participants after the purpose and objective of the study were clearly explained. For confidentiality and privacy, the participants’ information was anonymised. The study was conducted in line with the World Medical Association (WMA) Declaration of Helsinki ethical principles for medical research involving human participants. Consent for publications Not applicable Availability of data and materials The ATLAS.ti 22 datasets generated and analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ contributions SN, SNK, GWM and FEM contributed to the conception and design of the study. SN contributed to the data acquisition. SN was involved in the data processing, analysis and interpretation of the findings. SN drafted the initial manuscript, while all the authors contributed to the subsequent revisions and approval of the final manuscript. Acknowledgements Our sincere appreciation is extended to the political and administrative authorities of Tororo districts for granting us the necessary permission to conduct this study. Health workers from Tororo districts are commended and encouraged for their dedicated participation in advancing this research. Author details 1 Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala Uganda 2 Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala Uganda 3 Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala Uganda References GNR. Global Nutrition Report. The Global Nutrition Report’s Independent Expert Group. North Quay House, Quay Side, Temple Back, Bristol, BS1 6FL, UK: Development Initiatives Poverty Research Ltd.; 2020. World Health Organisation. Nutrition in universal health coverage. World Heal Organ (WHO/NMH/NHD/1924) Licence CC BY-NC-SA30 IGO. 2019; 19. Available: https://www.jstor.org/stable/resrep28227 UNICEF. The UNICEF Health Systems Strengthening Approach. New York. 2016; 1–76. 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Sandelowski M. What ’ s in a Name ? Qualitative Description Revisited. 2010; 77–84. doi:10.1002/nur.20362 Carlsen B, Glenton C. What about N ? A methodological study of sample-size reporting in focus group studies. 2011. Sandelowski M. Focus on research methods real qualitative researchers do not count: The use of numbers in qualitative research. Res Nurs Heal. 2001;24: 230–240. doi:10.1002/nur.1025 Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description – the poor cousin of health research ? 2009;5: 1–5. doi:10.1186/1471-2288-9-52 Manzi A, Hirschhorn LR, Sherr K, Chirwa C, Baynes C, Awoonor-Williams JK, et al. Mentorship and coaching to support strengthening healthcare systems: Lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa. BMC Health Serv Res. 2017;17. doi:10.1186/s12913-017-2656-7 Feyissa GT, Balabanova D, Woldie M. How effective are mentoring programs for improving health worker competence and institutional performance in africa? A systematic review of quantitative evidence. J Multidiscip Healthc. 2019;12: 989–1005. doi:10.2147/JMDH.S228951 Joseph KB Matovu1*, Rhoda K Wanyenze1, 2, Susan Mawemuko1, Olico Okui3 WB and DS. Strengthening health workforce capacity through work-based training Joseph. BMC Int Heal Hum Rights. 2013. doi:10.3109/13625189809167254 Decorby-Watson K, Mensah G, Bergeron K, Abdi S, Rempel B, Manson H. Effectiveness of capacity building interventions relevant to public health practice: A systematic review. BMC Public Health. 2018;18: 1–15. doi:10.1186/s12889-018-5591-6 Kabagenyi A, Jennings L, Reid A, Nalwadda G, Ntozi J, Atuyambe L. 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The effectiveness of community engagement in public health interventions for disadvantaged groups: A meta-analysis. BMC Public Health. 2015;15: 1–23. doi:10.1186/s12889-015-1352-y Twineamatsiko A, Mugenyi N, Kuteesa YN, Livingstone ED. Factors associated with retention of health workers in remote public health centers in Northern Uganda: a cross-sectional study. Hum Resour Health. 2023;21: 1–9. doi:10.1186/s12960-023-00870-0 Yu X, Huang Y, Liu Y. Nurses’ perceptions of continuing professional development: a qualitative study. BMC Nurs. 2022;21: 1–8. doi:10.1186/s12912-022-00940-z Toh RQE, Koh KK, Lua JK, Wong RSM, Quah ELY, Panda A, et al. The role of mentoring, supervision, coaching, teaching and instruction on professional identity formation: a systematic scoping review. BMC Med Educ. 2022;22: 1–14. doi:10.1186/s12909-022-03589-z Zaba T, Nyawo M, Álvarez Morán JL. Does weight-for-height and mid upper-arm circumference diagnose the same children as wasted? An analysis using survey data from 2017 to 2019 in Mozambique. Arch Public Heal. 2020;78: 1–14. doi:10.1186/s13690-020-00462-7 Vilar-Compte M, Burrola-Méndez S, Lozano-Marrufo A, Ferré-Eguiluz I, Flores D, Gaitán-Rossi P, et al. Urban poverty and nutrition challenges associated with accessibility to a healthy diet: a global systematic literature review. Int J Equity Health. 2021;20. doi:10.1186/s12939-020-01330-0 Ejughemre U. Donor Support and the Impacts on Health System Strengthening in Sub-Saharan Africa : Assessing the Evidence through a Review of the Literature. 2015;1: 146–151. doi:10.12691/ajphr-1-7-1 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6792049","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495292227,"identity":"e5f4340c-ea58-494f-8dcf-8332c6107ccc","order_by":0,"name":"Samalie Namukose","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYNCCA0AswQwmZUjRwpYAInlI0cJjAGIS1iI/u/npZp4zNvb80j2fX92oseBhYD98dAM+LQZ3jpnd5rmRljhzztlt1jnHgA7jSUu7gVeLRAJQy4fDCQY3crcZ57ABtUjwmOHVIj8j/RtIi739jZxnxjn/iNDCcCMH5LDDjBskcpgf57YRocXgRk7ZzTln0hJnAD3FnNsnwcNGyC9Ah2278eYYMMRmNz/+nPOtTo6f/fAx/A5DAmwSYJJY5SDA/IEU1aNgFIyCUTByAABtbUu0rMg4DgAAAABJRU5ErkJggg==","orcid":"","institution":"Makerere University","correspondingAuthor":true,"prefix":"","firstName":"Samalie","middleName":"","lastName":"Namukose","suffix":""},{"id":495292228,"identity":"517bb18e-6f1a-4119-950a-64d89e07d1ed","order_by":1,"name":"Suzanne N Kiwanuka","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Suzanne","middleName":"N","lastName":"Kiwanuka","suffix":""},{"id":495292229,"identity":"ed02891e-c631-4420-b5a7-3ec1b01d99fd","order_by":2,"name":"Fredrick Edward Makumbi","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Fredrick","middleName":"Edward","lastName":"Makumbi","suffix":""},{"id":495292230,"identity":"921172b5-ab63-44d6-bc03-d36da81e34e9","order_by":3,"name":"Gakenia Wamuyu Maina","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Gakenia","middleName":"Wamuyu","lastName":"Maina","suffix":""}],"badges":[],"createdAt":"2025-05-31 16:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6792049/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6792049/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88353918,"identity":"64a9bb8d-9607-45d3-9a1c-31cc774f1d63","added_by":"auto","created_at":"2025-08-05 14:50:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":636742,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6792049/v1/63053cbc-0926-4960-9053-b6825619aaaf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Processes and challenges of integrating nutrition assessment, counselling, and support into health systems in Uganda: A case study of Tororo district","fulltext":[{"header":"Background","content":"\u003cp\u003eIn recent decades, recognition of the complex relationship between nutrition and overall health has increased, emphasising the need for integrated approaches within health systems to address malnutrition and related health issues. The Global Nutrition Report of 2020 called for a shift from isolated interventions to a more interconnected and holistic approach within health systems for sustained positive impacts on global health and well-being [1]. In addition, the World Health Organisation (WHO) and the United Nations International Children's Emergency Fund (UNICEF) have consistently emphasised the importance of integrating nutrition services into health systems to address the dual burden of malnutrition and other health challenges [2,3]. Furthermore, several studies highlight the need to address structural barriers to the successful integration of nutrition services into the health system [4–6]. At the national level, the Uganda National Development Plan (NDP) outlines the government's commitment to improving health outcomes and reducing malnutrition by emphasising the importance of a comprehensive and integrated healthcare system [7]. The current literature and national strategies provide a strong rationale and evidence base for the importance and feasibility of integrating nutrition assessment counselling and support (NACS) into health systems. Hence, this study explored practical ways to implement NACS integration, identified challenges, and proposed strategies for better health and outcomes. Specifically, this study sought to contribute to this growing body of knowledge by exploring the process, experience, and challenges associated with the integration of NACS in Tororo district in eastern Uganda.\u003c/p\u003e\n\u003cp\u003eUganda, like many other developing countries, faces considerable public health challenges, with malnutrition being a persistent burden. In response, there has been a concerted effort by the Ministry of Health and stakeholders to strengthen health systems by integrating the NACS into the broader healthcare framework [8]. Various authors have proposed a comprehensive framework for integrating nutrition into health programs, emphasising the need for cross-sector collaboration, evidence-based policies, and continuous monitoring and evaluation [9–11].\u0026nbsp;These\u0026nbsp;studies provide a strong foundation for understanding the importance of integrating nutrition into health programs and highlight the key components required for successful implementation. The current study explored the challenges and enhancers to successful integration.\u003c/p\u003e\n\u003cp\u003eThe journey of integrating the NACS into the health system in Uganda represents a multifaceted approach aimed at improving its population's overall health and well-being. Several studies have underscored the importance of such integration, emphasising its potential to enhance the quality of health service delivery and health outcomes [12,13]. Tesfay and colleagues examined nutritional counselling within HIV care in the Tigray region of Ethiopia and reported that nutrition counselling in HIV care lacked structure and a comprehensive approach, hindering its effectiveness [14]. This current study explored experiences beyond the HIV setting.\u003c/p\u003e\n\u003cp\u003eOn the demand side, Mastellos and colleagues, in their study on integrated care, reported that this approach increased patient involvement, improved patient–provider relationships, improved organisation and access to care, and enhanced interprofessional communication [15].\u003c/p\u003e\n\u003cp\u003eAs Uganda continues its journey towards a more integrated and resilient health system, understanding the contextual processes, successes, best practices, challenges, and lessons learned from integrating NACS is crucial. This study therefore aimed at describing the processes, experiences, and challenges of integrating Nutrition Assessment Counselling and support into the health system using Tororo district in eastern Uganda as a case study.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cp\u003eThe methods used in this study followed the Consolidated Criteria for Reporting Qualitative (COREQ) guidelines [16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting and context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at the district level in Tororo District, Eastern Uganda. The health facilities involved in the study included hospitals, health centre fours (HCIVs), and health centre threes (HCIIIs) to capture a broad range of experiences and document the process related to the integration of the Nutrition Assessment, Counselling and Support (NACS). The selection of the health facilities was made in consultation with the District Health Officer (DHO) to ensure a representative sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative approach was employed, utilising in-depth interviews (IDIs) with health workers trained in NACS to explore their personal experiences with NACS integration [17,18]. Key-informant interviews (KIIs) were conducted to gather comprehensive insights from individuals with extensive knowledge and experience in the integration of NACS. Participants included district health educators, the Assistant District Health Officer, medical superintendents of hospitals, facility in-charges, and nutritionists. Additionally, focus group discussions (FGDs) with each group comprising 8 to 12 participants, as is prescribed for FGDs [19], were held with heads of maternal and child health clinics, outpatient departments, ART clinics, and facility administrators to explore collective experiences and opinions regarding the NACS integration process, as is the standard practice of qualitative methods [20,21].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers at the district and facility levels were purposively selected on the basis of their experience with the NACS strategy. District leadership identified the health facilities to be visited and facility in-charges identified health workers to be interviewed on the basis of their NACS experience. A total of 33 participants took part in the FGDs, 24 in the KIIs, and 22 in the IDIs. One individual (the DHO) declined participation due to other commitments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe principal investigator (PI) conducted all the district-level interviews, including those with hospital heads and HCIVs in charge, while the research assistants were engaged in recording and note-taking during the FGDs. The PI had a master’s degree, postgraduate diplomas (PGDs) in nutrition, and specialised training in qualitative methods. The research team consisted of three research assistants with degrees and one with a diploma, all of whom were experienced in qualitative research. One research assistant was a nutritionist at Tororo Hospital, another was a nurse/midwife, and the remaining two were qualitative researchers from the School of Public Health. The PI and one research assistant were female, whereas the other three were male. The PI had received one month of specialised virtual training in qualitative methods from Stellenbosch University and had prior experience collecting qualitative data for food and nutrition surveys at the Ministry of Health. All the research assistants were trained in qualitative research methodology before the data was collected via materials from the Stellenbosch University course. There was no prior relationship between the researchers and participants, but the participants were informed about the researchers’ affiliation and study purpose. Two research assistants (the nutritionist and nurse) were based in Tororo district, while the other two were from the School of Public Health.\u003c/p\u003e\n\u003cp\u003eThe data for this study were gathered from participants at health facilities and district health offices. During the data collection process, only the researchers and participants were present. Gender information was collected for the participants, with 20 females and 13 males participating in the FGDs, 18 females and 4 males in the IDIs, and 14 females and 10 males in the KIIs. The discussion and interview guides were pretested on health workers in Kampala before actual data collection to ensure clarity and relevance.\u003c/p\u003e\n\u003cp\u003eInterviews and FGD sessions were audio-recorded with the participants’ consent, and research memos were written at each stage to document observations and reflections. The focus group sessions lasted between 60 and 120 minutes, whereas the interviews ranged from 16-31 minutes. While the transcripts were not returned to the participants, the researchers compared the findings with those of other researchers for consistency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe principal investigator (PI) and one research assistant, a nutritionist, were responsible for coding the data. A code book was developed to systematically aggregate the codes into sub-themes, eventually forming the main themes. These themes emerged naturally from the data, followed by the researchers’ thematic analysis. The coding and thematic organisation of the data were managed by Atlas. ti version 22 software. The analysis included 24 key informant interviews, four FGDs, and 22 IDIs. Audio recordings from the focus group discussions and interviews were transcribed and analysed using a thematic approach. Data coding involves grouping transcribed materials into categories, which are further grouped into themes. Quotations from participants were used to illustrate key study findings.\u003c/p\u003e\n\u003cp\u003eMemo writing was integral throughout the analysis, enhancing the researchers’ understanding of the study context and contributing to the development of themes. To ensure internal validity, additional health workers from the same facilities were asked to review and comment on the findings. External validity checks were performed by comparing the results with those of similar studies conducted by other researchers to ensure consistency.\u003c/p\u003e\n\u003cp\u003eThe research assistants were thoroughly trained in qualitative research methodologies to ensure precise data collection and adherence to the study protocols. The study findings are presented clearly in the results section, reflecting the major themes identified during analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFour themes from the study emerged and are presented: service delivery and quality for the NACS, challenges and barriers associated with NACS integration, community involvement and client empowerment, and capacity building and sustainability. Some of the findings are compared within groups and across groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eService delivery and quality for NACS\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe majority of the key informants said that structured mentorship, performance reviews, and supervision enhanced service delivery. They noted that mentorship improved service quality and addressed issues such as insufficient knowledge among health workers. In addition, the key informants intimated that data-related challenges were mitigated through mentorship, coaching, and nutrition dashboards for performance monitoring. What seemed to be overarching through most interviews was that the dissemination of information and establishment of demonstration gardens to educate mothers on nutrition were highlighted as crucial for passing on knowledge. Additionally, the informants mentioned that involving women in income-generating activities helped reduce malnutrition, as it lessened their financial dependence on their spouses. One key informant stated the following:\u003c/p\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;We organised support supervision, mentorships, and performance reviews to improve our nutrition services. We had trained teams who went out to mentor health staff at health centre IIIs, health centre IVs, and hospitals. Our district mentors were joined by regional mentors to provide supervision and mentorships at these health facilities. Owing to limited resources, not all staff had received training in NACS, resulting in knowledge gaps. These orientations, supervisions, mentorships, and use of nutrition dashboards to monitor performance have helped address those gaps and improved the situation,\u0026rdquo; _KII_District administrator_Tororo district\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother key informant reinforced this point, adding the following:\u003c/p\u003e\u003cp\u003e\u003cem\u003eAfter the NACS training, we came back and mentored our colleagues who had not been trained so that we could move at the same pace. We also conducted food demonstrations and set up demonstration gardens to enhance health and nutrition education. Some mothers participated in income-generating activities that supported them to become self-independent and improve their families\u0026rsquo; food and nutrition situations. _KII_Health worker_Nangongera HCIV\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSimilarly, most of the in-depth interviewees emphasised the importance of continuous mentorship and training in enhancing health workers\u0026rsquo; skills. They noted that this process made health workers more proficient in using tools such as Mid-Upper Arm Circumference (MUAC) tapes for nutritional assessment. Mentorship was also reported to boost their confidence in diagnosing malnutrition and interpreting assessment results. A key point raised was the integration of nutrition services into routine work, such as antenatal care sessions and general patient assessments, with health workers offering nutrition counselling and referring cases to specialised services when needed, as illustrated by the following quote:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We initially lacked confidence due to inadequate knowledge, but with continuous mentorship and training from the district, our confidence grew. At first, we only recorded MUAC measurements in centimetres and could not categorise malnutrition levels using colour codes such as green or yellow, but over time, we learned to do everything correctly\u0026hellip; .Now, we can integrate nutrition assessment into our antenatal sessions instead of treating it as a separate service and it should be part of the routine package of services we provide to clients,\u0026rdquo; IDI_Health worker_Nagongera HCIV\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe majority of the focus group discussions highlighted that involving the community, including male partners and NACS service beneficiaries, improved service uptake. The participants noted that community sensitisation effectively created a demand for service uptake. Village health teams (VHTs) are recognised for their vital role in screening for malnutrition and referring cases to health facilities. However, the volunteerism model has encountered challenges due to the absence of incentives. A participant from the FGD explained that:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The community faces numerous cases of illness, often attributed to witchcraft, and some individuals die without accessing proper care. To address this, preventive measures and community-based structures such as VHTs offering NACS services are needed. Only severe cases would then require hospital referrals. Nongovernmental organisations (NGOs) working at the community level could focus on nutrition education, as the issue is not food availability but proper utilisation. Many families have food but lack knowledge on how to use it properly, often selling nutritious food and keeping unhealthy options. There are also families with no food at all, and government support is needed to either provide food or empower these families to produce their own. Additionally, many people suffering from severe or moderate acute malnutrition and infections could benefit from integrated approaches that treat underlying conditions, preventing the body from utilising food properly. Supplements and formulas can also be helpful,\u0026rdquo; FGD_Health worker, Tororo hospital\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAcross the groups, there was a consensus that mentorship, community engagement, and improving both health worker competency and service accessibility strengthened NACS integration. However, there were noticeable differences across groups concerning professional service improvement and community-driven outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges and barriers associated with NACS integration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eKIIs revealed that many health centres face staffing shortages, resulting in inconsistent and lower-quality service delivery. The limited number of health workers increases their workload, which directly impacts the quality of NACS services. Additionally, the respondents stressed the need for continuous training, noting that while initial training sessions were conducted, follow-up training and mentorship remain inadequate. This gap hampers the effective implementation of NACS. Another significant challenge was the lack of essential equipment, such as weighing scales, height boards and mid-upper arm circumference (MUAC) tapes. One key informant said:\u003c/p\u003e\u003cp\u003e\u0026ldquo;At \u003cem\u003etimes, clients come in big numbers, and yet we are few health workers. If they enter the consultation room without first conducting a nutrition assessment, the health worker becomes exhausted, ignores nutrition and concentrates on treating the diseases of patients, so manpower is a big challenge,\u0026rdquo; KII_Health worker_Molo HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother key informant added that:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Inadequate tools and equipment are our problem. There are a few height boards, weighing scales, MUAC tapes, BMI wheels and Z-score charts. Those from the Ministry of Health and its partners were given high-volume facilities, so we still have a gap. The MUAC tapes are wearing off. The coloured tapes are better. Some partners at times do not consult, and they procure plain white tapes, yet categorisation is key. So they can\u0026rsquo;t categorise unless they are well trained,\u0026rdquo; KII District administrator_Tororo\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDuring IDIs, health workers voiced concerns about understaffing, which made it challenging to dedicate sufficient time to nutrition counselling and assessments in addition to other routine responsibilities. They also highlighted difficulties in managing nutrition assessment data, citing a lack of clear guidance on proper data management as a significant obstacle to delivering quality services. Furthermore, health workers noted insufficient follow-up after initial training sessions. Some admitted to relying more on the knowledge acquired during medical school rather than on updated guidelines and protocols from NACS training. This gap in continuous education limits their ability to implement best practices effectively, as illustrated in the following quote:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Those who are not assessed are those who come when the staff is alone and there is a heavy workload. If there is an emergency, the health staff may rush to attend to the emergency and may not attend to nutritional assessments. In addition, documenting nutrition services is a gap since several staff have not been trained and are using the knowledge they gained while in school,\u0026rdquo;_ IDI_Health worker_ Molo HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFGDs revealed that some communities have limited knowledge of the importance of nutrition and nutrition services. The group members reported that individuals refuse to eat recommended nutritious foods because of cultural beliefs or misconceptions about their value. The participants noted that many nutrition programs were heavily dependent on external donors, which made the continuity of services uncertain. The withdrawal of funding was therefore identified as a significant barrier to maintaining NACS activities. In the FGDs, the participants mentioned that there was limited knowledge about which partners were involved in supporting NACS, leading to missed opportunities for collaboration and sustained service provision. This is illustrated by the following quote:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In the community, the biggest challenge is the lack of well-established structures to address nutrition issues. The community has inadequate knowledge about the importance of nutrition and still holds on to beliefs that certain foods should not be eaten by women. Although patients improve in the ward, are discharged, counselled, and linked to other support, the real challenge arises when they return home. Despite the counselling, it can be difficult for them to implement what they have learned due to their financial situation. We are supposed to follow up with them after some time, but the lack of funds to facilitate our movements is a major issue. Partner funding for such activities has stopped, which has become a significant challenge,\u0026rdquo;_FGD_Health worker_Tororo Hospital\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAcross groups, key informants and in-depth interviewees highlighted internal challenges such as staffing shortages and a lack of equipment, with a focus on the need for continuous training and better data management. Focus group discussants, however, emphasised external barriers such as community resistance to nutrition education and reliance on donor funding as barriers to NACS integration.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCommunity involvement and client empowerment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eKey informants stressed the need to sensitise communities utilising locally available foods and improving food preparation methods to address malnutrition at the grassroots level. They highlighted that empowering people to make better use of what they have would significantly reduce malnutrition. The majority of the key informants shared how they applied knowledge from NACS training to educate communities on preparing nutritious meals. Some informants recommended better integration of the NACS into community health outreach programs, allowing health workers to demonstrate and provide guidance directly in communities. This approach ensures that the intervention reaches the core of malnutrition issues. The respondents also emphasised the role of community leaders in driving the adoption of nutrition services. By involving these leaders in nutrition interventions, they can promote food security and encourage households to grow and prepare nutritious foods, strengthening local efforts to combat malnutrition effectively. The key informant from Tororo Hospital explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is better to address the problem at its source. What we have been doing is going into the communities where malnutrition cases originate. We educate the community on food security, emphasising the use of locally available foods and proper food preparation, activities that cannot be handled solely by hospitals. We need community leaders to mobilise and engage people on food security. Often, communities either produce food but do not know how to store it properly and prepare it or produce food and sell it. For mothers who have children but do not know how to breastfeed them, we can hold sessions with the community on breastfeeding and caring for children and new-borns to prevent malnutrition early enough,\u0026rdquo; KII_ health worker_Tororo hospital\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother key informant added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The solution is to empower the communities economically and make use of the linkage facilitators to support these clients in communities. This will offload work from health workers. Strengthening family planning is crucial,\u0026rdquo;_ KII_Health worker_ Poyameri HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, the majority of the health workers involved in the in-depth interviews highlighted the use of demonstration gardens as valuable tools for teaching mothers how to grow and prepare nutritious foods. These gardens provided a practical, visual learning experience, making it easier for participants to retain information. Family support groups were also established, where mothers were taught how to prepare balanced meals and improve overall nutritional practices. In some sessions, food was provided to demonstrate local preparation techniques, with a strong emphasis on counselling about exclusive breastfeeding. The respondents noted that teaching mothers practical food preparation skills empowered them to make healthier choices for their families. This newfound confidence in managing their children\u0026rsquo;s nutrition resulted in better health outcomes, positively impacting the entire community. The combination of hands-on learning and community support effectively promoted sustainable nutrition practices. One participant stated the following:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I also had to counsel mothers on exclusive breastfeeding and conduct cooking demonstrations. I had a garden and a nutrition corner where I could demonstrate proper nutrition. After counselling them about nutrition, I would bring them to the nutrition corner to display different foods, show them how to grow food, and explain the various food categories,\u0026rdquo; IDI_Health worker_St. Anthony Hospital\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis sentiment was echoed by another participant who added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;However, if we had a demonstration garden, we could pick crops or fruits and demonstrate in front of the clients. It would be much harder for them to forget what was demonstrated, and it would empower mothers to make the right food combinations for their children, thereby improving their health and that of their babies. Simply talking verbally isn\u0026rsquo;t as effective, as they may leave having already forgotten,\u0026rdquo; IDI_Health worker_Merikit HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDuring focus discussions, participants recalled successful past programs, such as those by PLAN International, where health workers conducted demonstrations of food preparation within communities. These community-based interventions allowed broader participation, making nutrition training accessible to more people and promoting greater engagement in nutrition improvement activities. However, participants expressed concerns about the sustainability of these programs, particularly when donor support ended. For example, after some programs were phased out, it became difficult to maintain demonstration gardens due to a lack of materials and resources. The role of VHTs was highlighted as essential in connecting communities to health services. VHTs play a vital role in mobilising mothers for training and facilitating nutritional assessments. Nevertheless, reliance on volunteers, without sufficient support or resources, was identified as a significant challenge, potentially limiting the long-term effectiveness of these interventions. The establishment of and support for community-level nutrition committees were highlighted as key to facilitating the implementation of nutrition and other interventions, strengthening the referral system and coordinating between the community and health facilities. One participant remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;PLAN International also had a program in the community where they identified some health workers and VHTs, went to the community, and held demonstrations on preparing locally available foods. They allowed mothers and parents within the community to participate in demonstrations, which helped improve their nutritional status. However, I think occasional reminders are needed, as people can forget how to do things after being shown once. Otherwise, the community members have always been involved in food preparation demonstrations within their community,\u0026rdquo; FGD_Health worker_Tororo Hospital\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother participant added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; there is a need to create a nutrition committee first. It is that committee which will develop a work plan, present it to the health facility in charge, to solicit potential funding. The committee should also ensure strong linkages between the health facility and the community in the case of referrals, family planning services and others,\u0026rdquo;_FGD_Health worker_Kwapa HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn contrast, another participant stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Currently, we\u0026rsquo;ve been facing challenges with demonstration materials. We lack the necessary items and foodstuffs to demonstrate the concept of a balanced diet, as most people do not understand it. The demonstration gardens have also collapsed since TASO left, and we may need to reactivate them. Additionally, the VHTs have been supporting nutrition assessments, but they do so voluntarily, which also presents challenges,\u0026rdquo; FGD_Health worker_Malaba HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAcross the groups, key informants emphasised the role of community leaders and integrating the NACS into existing health programmes. In contrast, in-depth interviews and focus group discussions focused on practical tools such as demonstration gardens and food preparation workshops. FGDs raised concerns about sustaining interventions after donor support ends, whereas KIIs emphasised local empowerment and self-reliance.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCapacity building and sustainability\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe process began with the development of NACS implementation protocols at the national level. This was followed by training of trainers who supported the training of a critical mass of cadres at the district and health facility levels. Partners such as the AIDS Support Organisation (TASO), ASSIST, and RIGHTS-E provided support for capacity building, the procurement of anthropometric equipment, registers, food demonstration materials and the establishment of demonstration gardens. This is illustrated in the following quote:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The Ministry of Health worked on training manuals on NACS and used these to train trainers. We did not have staff trained in NACS, but eventually, we had training, and when we came back, we had to take others through NACS, so the starting point was training, then we had a CME with all the staff, and then we also had to ensure that we had the MUAC tapes, the height boards and the weighing scales in place. These were provided by partners. Unfortunately, we have only two height boards in the facility: one is placed in the outpatient department, and the other is at the mother‒baby pair point; it is also shared with children who come for immunisation. We are also doing BMI for the adults, and then after that, we identified staff at the various entry care points to do the assessment so at the different entry points. We are using linkage facilitators, RCT volunteers and VHTs who are helping us in performing the assessment, and if they find a malnourished client, they have to physically hand it over to a health worker who then handles the client _ KII_Health worker_Mukujju HCIV\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe majority of the key informants said that health workers were trained in key nutritional assessment tools, such as MUAC and how to perform nutritional assessments in various service areas. This training was vital for enhancing staff knowledge and skills in delivering nutrition services. The key informants emphasised the importance of continuous mentorship and on-the-job training, which helped sustain the knowledge and skills acquired during initial training. The capacity-building process also allowed health workers to manage more complex cases, leading to improved service delivery. However, some informants noted gaps in training coverage, as not all health workers were trained. In many cases, only a few staff members received training, with the expectation that they would share their knowledge with colleagues. This peer-to-peer training approach, however, was not always effective in ensuring consistent skill development across all staff members, as illustrated by the following quotes:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;..as I mentioned, not everybody was trained in NACS, and of course, this makes us not perform to our expectations. Those who are trained are those who provide nutrition services, not those who are trained on weekends. It is this records officer who calculates the BMI,\u0026rdquo; KII_Healthworkers_Kiyeyi HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;To build the capacity of others, we focused on having more mentors. We chose and worked with general mentors because of limited resources for training everyone. Over the four days, these mentors were guided and trained: on the first day, they listened and observed; on the second and third days, they learned by doing, and on the fourth day, they were able to perform the tasks themselves. This approach enabled them to supervise and mentor others, particularly within their facilities,\u0026rdquo; KII- District Administrator_Tororo\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealth workers in in-depth interviews emphasised the importance of continuous professional development (CPD) sessions as a peer-to-peer learning approach for staying updated on current knowledge and practices in nutrition. Despite initial training, several respondents highlighted the need for regular refresher courses to maintain the knowledge acquired. They also noted that new staff members or those transferred from other departments often lack basic nutrition training, creating gaps in service delivery. To address this, trained health workers took the initiative to educate their peers, ensuring continued capacity to provide nutritional services. However, concerns were raised about the quality and consistency of this peer-to-peer training, as it was not always sufficient to cover all aspects of nutrition service delivery, leading to uneven skill development among staff members. One participant from Molo HCIII remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The nursing officer attended NACS training, and when she returned, she oriented all the staff on the basics of conducting nutrition assessments through continuous professional development sessions. The aim was to ensure that nutritional assessments were conducted at all health care points, including the outpatient department (OPD), which had not yet started this practice. At the OPD, we had only been recording weight during that period, and three of the staff were new and had not yet acquired the skills for conducting nutrition assessments using MUAC or providing nutrition counselling,\u0026rdquo; IDI_Health worker_ Molo HCIII.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother participant echoed the same sentiment and emphasised the need for refresher training:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Concerning nutrition services, as you know, medicine keeps evolving. I think the last training I had was in 2014, not 2016. Since then, I haven\u0026rsquo;t received any other training, and I know my colleagues haven\u0026rsquo;t either. It would be helpful if we could have a refresher training outside the facility. Although we have continuous professional development sessions, they are not comparable to the comprehensive coverage of a full training,\u0026rdquo; IDI_Health worker_ Kiyeyi HCIII\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFGDs emphasised the crucial role of VHTs and linkage facilitators in conducting nutrition assessments and referrals. These community volunteers were trained to use tools such as MUAC tapes and identify malnourished children for referral for further management by trained health staff. Expanding capacity-building efforts into the community was viewed as essential for sustaining NACS interventions. FGD participants called for regular refresher training, not only for health workers but also for community volunteers. Ongoing training was seen as vital for maintaining the skills and motivation of VHTs, who played a key role in detecting malnutrition in their villages. One participant said that:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;What I would emphasise regarding training is the need to continuously build the capacity of those providing nutrition services. Midwives and clinicians may acquire this knowledge during their formal education, but they require regular refresher training to stay updated with advancements in science and best practices. In addition, VHTs and linkage facilitators, who assist in screening for malnutrition using MUAC tapes both at the facility and within communities, also need thorough training. Another critical aspect to address is the issue of staff transfers. We need a strategy to ensure that the knowledge and skills remain within the health facility, even when personnel are transferred. By training a larger number of staff members, we can create a system that preserves knowledge, ensuring continuity in service delivery regardless of staff transfers,\u0026rdquo; FDG_Health workers_Malaba HC III\u003c/em\u003e\u003c/p\u003e\u003cp\u003eConcerning intergroup differences, the key informants emphasised formal training and mentorship for health workers, highlighting the need for comprehensive staff training. IDIs stress continuous learning through continuous professional development, with a focus on peer training. FGDs underscore the involvement of VHTs and providing ongoing support and refresher training for sustained community service delivery.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study aimed at describing the processes, experiences, and challenges of integrating NACS into the health system. Four themes emerged from the study: service delivery and quality for NACS, challenges and barriers associated with NACS integration, community involvement and client empowerment, and capacity building and sustainability. From these themes, the processes and experiences included structured mentorship, performance reviews, supervision, capacity building of health workers, male involvement and community sensitisation on the utilisation of locally available foods. The challenges included: staff shortages, inadequate continuous training, a lack of essential equipment, difficulties in managing nutrition assessment data and heavy reliance on donor support. The findings are discussed with other studies, and their implications are highlighted below.\u003c/p\u003e\u003cp\u003e\u003cb\u003eProcesses and experiences\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe process of NACS integration into the health system followed a structured process starting with the national-level development of NACS implementation protocols, followed by training trainers. This structured process was embedded with elements of performance reviews aimed at checking the progress of integration as well as supporting supervision to ascertain whether the nutrition counselling was taking place and addressing any arising challenges. The structured process also included mentorship, which improved service quality and addressed insufficient knowledge among health workers and mothers. The findings from this study agree with those of other studies that show that mentorship programs improve the clinical management of infectious diseases and maternal, neonatal, and childhood illnesses, leading to better adherence to clinical guidelines and protocols and thereby enhancing the overall quality of care provided by health workers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These results imply that health interventions may benefit from clear, centralised guidelines, which ensure consistent and effective implementation across initiatives. Secondly, regular performance evaluations keep programs on track and address issues promptly, improving service delivery. Additionally, mentorship programs enhance service quality by filling knowledge gaps among health workers, making mentorship a crucial element in future health interventions.\u003c/p\u003e\u003cp\u003eThe process of NACS integration also involved capacity building for health workers through training in Key nutrition assessments, which improved the use of MUAC tapes height boards and boosted the confidence of health workers in diagnosing malnutrition and interpreting assessment results. These results are in tandem with research performed by other scholars, which shows that training approaches that involve work-based learning demonstrate that hands-on experience and project-based learning within healthcare institutions lead to improved diagnostic accuracy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These approaches not only address knowledge gaps but also promote sustained improvements in clinical decision-making and service delivery quality.\u003c/p\u003e\u003cp\u003eFor NACS integration to be successful, involving male partners and NACS service beneficiaries improved service uptake. Community sensitisation was one of the ways identified as being effective in creating demand for service uptake among NACS service beneficiaries. Studies performed elsewhere have also revealed that involving men in family planning increases contraceptive use among women by improving spousal communication, increasing knowledge of contraceptive options, and reducing male opposition [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, a systematic review of interventions to boost the demand for sexual and reproductive health services among young people demonstrated the effectiveness of community mobilisation strategies, including training service providers and raising community awareness about available services [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These results imply that male involvement should be a key element of health systems, particularly in interventions related to maternal and child health, nutrition, and reproductive health. Additionally, health systems must invest in community awareness campaigns, as community mobilisation has proven effective in driving demand for health services across various sectors.\u003c/p\u003e\u003cp\u003ePractical demonstrations were also identified as a good way of integrating NACS into the health system. The communities welcomed the idea of demonstrating how utilising locally available foods and improving food preparation methods can be beneficial in addressing malnutrition at the grassroots level. The involvement of community leaders was also said to be key during the adoption of nutrition services, as leaders encourage households to grow and prepare nutritious foods, strengthening local efforts to combat malnutrition effectively. These results mirror what has been published by other researchers, showing that demonstrations help to increase the capacity of healthcare providers by offering hands-on experience, which improves the implementation of new services and interventions. For instance, a systematic review revealed that integrating health interventions through practical demonstrations and the active involvement of healthcare providers enhances service uptake and quality of care, particularly in contexts such as maternal and child health, HIV, and tuberculosis services [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, studies indicate that involving community leaders in the design and implementation of health interventions promotes trust, resilience, and more effective governance, which are essential for the long-term success of health programs [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. As such, integrating practical demonstrations and community leadership into health interventions strengthens service delivery and promotes sustainable health system development, particularly in resource-constrained settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges of NACS integration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe challenges of NACS integration into the health system were multifaceted and included but were not limited to, staff shortages, resulting in inconsistent and lower-quality service delivery. The limited number of health workers faced with an increased workload impacted the quality of NACS integration. Scholars in Uganda have reported similar findings and reported that inadequate staffing leads to increased workloads for existing health workers, resulting in physical and mental fatigue [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The aforementioned situation compromises the quality of care provided, as overworked staff are less able to meet patient needs effectively, leading to poorer health outcomes and lower retention rates among health professionals.\u003c/p\u003e\u003cp\u003eWhile the initial training of NACS integration was good, there was a need for continuous training because follow-up training and mentorship remained inadequate, which affected sustainability. Like the results of this study, several studies have shown that continuous professional development (CPD) helps healthcare workers stay updated with rapidly changing medical technologies and healthcare demands. However, if follow-up training is inadequate, the benefits of initial training may diminish, leading to poor service delivery and limited sustainability of interventions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, healthcare interventions that include consistent mentorship and feedback tend to improve knowledge retention, skill development, and quality of care [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. It is therefore imperative that health systems prioritise continuous training and structured mentorship to sustain the benefits of initial training efforts, improve service delivery, and ensure the longevity of healthcare interventions.\u003c/p\u003e\u003cp\u003eHealth workers in facilities also described the lack of essential equipment, such as weighing scales, height boards and MUAC tapes. Without essential equipment, health workers may struggle to accurately identify cases of acute malnutrition in children, which is key to NACS integration in the health system. Surveys conducted in Mozambique have also shown that discrepancies between weight-for-height scores (WHZ) and MUAC measurements exist when adequate tools are not available or are not properly used, leading to potential misclassification of malnourished children [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, without accurate anthropometric measurements, health workers are unable to correctly identify children in need of treatment, which affects the overall success of NACS integration. In addition, misclassification of malnourished children, as seen in the Mozambique surveys, can lead to inappropriate interventions, either missing cases or overtreatment of children who do not require intensive care.\u003c/p\u003e\u003cp\u003e There were also difficulties in managing nutrition assessment data because of a lack of clear guidelines that affected the delivery of quality services. The results of this study may be related to those of another study, which revealed that unclear or insufficient guidelines for dietary assessment in healthcare settings may lead to inconsistencies in data collection and hinder the ability to accurately monitor nutritional outcomes [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This lack of clarity affects the quality of nutritional interventions and ultimately reduces the effectiveness of healthcare services related to nutrition.\u003c/p\u003e\u003cp\u003eWith respect to financial support, the heavy reliance on donor support made the continuity of services uncertain. The lack of sustainable, domestic funding resources creates a fragile situation where health interventions, workforce training, and even basic service delivery may be disrupted. For example, countries that rely on international grants or loans for healthcare delivery, such as Uganda, may struggle to maintain programs if donor funds are reduced, affecting the long-term sustainability of critical health services [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. It is therefore important for health systems to develop more resilient financing structures that reduce their dependence on external donors to ensure the sustainability and continuity of essential health services.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe successful integration of the Nutrition Assessment, Counselling, and Support (NACS) program into the health system requires a structured and well-supported approach at all levels of service delivery. By addressing these challenges and leveraging the lessons learned, a more robust and effective nutrition service delivery system can be achieved.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe recommend that the government invest in the integration of nutrition interventions at all levels of service delivery and provide financial incentives for health facilities that show significant nutritional improvements. The Ministry of Health should expand therapeutic feeding programs and engage communities through local dialogues and sensitisation involving local leaders. Partnerships between health facilities and community organisations should be strengthened to boost coverage and effectiveness. Continuous capacity-building activities, including refresher and on-the-job training, should be prioritised to bridge nutrition knowledge gaps. Finally, ensuring the availability and maintenance of anthropometric equipment is crucial for consistent service delivery, and establishing community demonstration gardens with home-based counselling and follow-up for malnourished clients is recommended for community-based approaches.\u003c/p\u003e\u003cp\u003eFuture research could focus on exploring the best strategies for integrating nutrition interventions in the health system via a human-centred design.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from the Uganda National Council of Science and Technology (SS 4251) and the Office of the President in Uganda (ADM/194/212/01). Permission to conduct the study was obtained from the Tororo District Health Officer and the Ministry of Health. The Principal Investigator briefed both the Tororo District Health Officer and the District Resident Commissioner on the study plan before its commencement. Informed consent was obtained from all the study participants after the purpose and objective of the study were clearly explained. For confidentiality and privacy, the participants’ information was anonymised. The study was conducted in line with the World Medical Association (WMA) Declaration of Helsinki ethical principles for medical research involving human participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ATLAS.ti 22 datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSN, SNK, GWM and FEM contributed to the conception and\u0026nbsp;design of the study. SN contributed to the data acquisition. SN was involved in the data processing, analysis and interpretation of the findings. SN drafted the initial manuscript, while all the authors contributed to the subsequent revisions and approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur sincere appreciation is extended to the political and administrative authorities of Tororo districts for granting us the necessary permission to conduct this study. Health workers from Tororo districts are commended and encouraged for their dedicated participation in advancing this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala Uganda\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003csup\u003e2\u003c/sup\u003eDepartment of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala Uganda\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eDepartment of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala Uganda\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGNR. Global Nutrition Report. 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Arch Public Heal. 2020;78: 1\u0026ndash;14. doi:10.1186/s13690-020-00462-7\u003c/li\u003e\n \u003cli\u003eVilar-Compte M, Burrola-M\u0026eacute;ndez S, Lozano-Marrufo A, Ferr\u0026eacute;-Eguiluz I, Flores D, Gait\u0026aacute;n-Rossi P, et al. Urban poverty and nutrition challenges associated with accessibility to a healthy diet: a global systematic literature review. Int J Equity Health. 2021;20. doi:10.1186/s12939-020-01330-0\u003c/li\u003e\n \u003cli\u003eEjughemre U. Donor Support and the Impacts on Health System Strengthening in Sub-Saharan Africa : Assessing the Evidence through a Review of the Literature. 2015;1: 146\u0026ndash;151. doi:10.12691/ajphr-1-7-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nutrition assessment counselling, support, health system, integration, process, experience, service delivery","lastPublishedDoi":"10.21203/rs.3.rs-6792049/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6792049/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eNutrition assessment, counselling and support is a holistic strategy designed to combat malnutrition and enhance health outcomes. Uganda has been implementing this strategy for a decade; however, a comprehensive documentation of the processes and experiences of integrating nutrition assessment, counselling and support in health systems remains scarce. This study aimed at describing the processes and experiences associated with integrating nutrition assessment counselling, and support into the health system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eA cross-sectional study design employing qualitative techniques was used to document the process and experiences of health workers in integrating nutrition assessment, counselling and support into the health system. The study utilised four focus group discussions, 24 key informant interviews and 22 in-depth interviews to gather insights. The interviews were recorded, transcribed verbatim and analysed thematically using ATLAS. ti version 22.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u0026nbsp;\u003c/strong\u003eFour themes emerged from the study: service delivery and quality for nutrition assessment, counselling and support; challenges and barriers associated with integrating nutrition assessment, counselling and support; community involvement and client empowerment; and capacity building and sustainability. From these themes, the processes and experiences included structured mentorship, performance reviews, supervision, capacity building of health workers, male involvement and community sensitisation on the utilisation of locally available foods. The challenges included staff shortages, inadequate continuous training, a lack of essential equipment, difficulties in managing nutritional assessment data and heavy reliance on donor support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e The effective integration of nutrition assessment, counselling, and support programs into the health system requires a structured and well-supported approach at all levels of service delivery. By addressing these challenges and leveraging the lessons learned, a more robust and effective nutrition service delivery system can be achieved.\u003c/p\u003e","manuscriptTitle":"Processes and challenges of integrating nutrition assessment, counselling, and support into health systems in Uganda: A case study of Tororo district","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 14:42:28","doi":"10.21203/rs.3.rs-6792049/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-27T12:18:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-08T16:13:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T17:40:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312674921242704324826316196117476921906","date":"2025-09-25T08:07:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4150281061504692815755884530852632354","date":"2025-09-23T23:46:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T16:33:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315980565134936765488130708765414201316","date":"2025-07-31T10:03:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-31T02:46:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-31T02:43:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-21T09:49:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-18T17:10:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2025-07-18T16:09:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1546a95-4e8f-4094-a3ff-81b28b71ced8","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T12:54:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 14:42:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6792049","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6792049","identity":"rs-6792049","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}