Helping Children Thrive: How a Flow Chart Is Improving Integrated Counseling on Nutrition And Nurturing Care in Ghana

By Kelsey Torres, Nutrition and SBC Advisor, and Fauzia Abukari, ECD and MEL Specialist, USAID Advancing Nutrition

“Yes, I was comfortable to talk with the nurse,” shared a caregiver from Gushegu, Ghana about her experience receiving young child feeding and care counseling. “She was happy and cheerful and that made me feel happy and comfortable to talk to her. Her conversation was interesting and relevant to my child’s growth and development and that made me comfortable to talk to her,” The health worker counseling her was testing an innovative job aid co-designed by USAID Advancing Nutrition and health workers in the Ghana Health Service. The job aid is a flow chart that streamlines workflow to ensure children at the highest risk of malnutrition and/or developmental delays receive the tailored counseling they need. Using the flow chart, the health worker could better tailor the session to address the caregiver's concerns and unique circumstances.

Children thrive in nurturing environments where their essential needs are met: safety and security, responsive care, good nutrition, and early learning opportunities. Though evidence shows that integrated nutrition and caregiving interventions offer clear benefits for children’s health and development outcomes, practical implementation examples are limited, particularly across routine service delivery platforms.

USAID Advancing Nutrition, the Agency’s flagship multi-sectoral nutrition project, developed the Responsive Care and Early Learning (RCEL) Addendum package to address this gap.?This new package helps health workers include responsive care and early learning during nutrition or child health counseling. We piloted the RCEL Addendum in Ghana and the Kyrgyz Republic to assess its feasibility, acceptability, and effectiveness.

Recognizing contextual challenges with counseling that often go unaddressed (e.g., limited time, heavy workloads, practical integration of nurturing care), we partnered with health workers to develop the decision-making flow chart as a job aid in the RCEL Addendum package in Ghana. This algorithm-based tool helps health workers prioritize caregivers needing in-depth counseling (e.g., at-risk for malnutrition or developmental delays), streamline workflows, and provide tailored infant and young child feeding (IYCF) and RCEL counseling based on individual needs. It also guides health workers to integrate counseling to address developmental concerns like limited caregiver-child interaction, lack of learning activities, or caregiver stress when appropriate based on assessment and analysis. The flow chart’s unique opening questions, adapted from Breakthrough ACTION’s Nourishing Connections job aid , aim to level power dynamics and build rapport and trust between the counselor and caregiver. This approach puts the caregiver at ease and encourages open dialogue, allowing the counselor and caregiver to partner effectively and focus the session on what is most needed. As a health worker in Sagnarigu described, “...asking them [caregivers] these questions makes them feel you are on the same level as them. With this they feel they belong, which makes them come out of their shells, they would feel free to talk to you.”

Health workers and caregivers confirmed the flow chart helped them stay on course during counseling sessions and use related job aids effectively (e.g., Maternal and Child Health Record Book, counseling cards). Caregivers said they received more individualized counseling because they had more time with the health worker. Health workers recommended different sizes of the flow chart—a smaller version for community outreach and a poster-sized wall chart with larger text and pictures for health facilities.

In collaboration with the Ghana Health Service, we finalized the flow chart, printed and distributed more than 800 copies to health facilities in 55 districts of northern Ghana, and trained 1,176 health workers on its use. Given its strong reception and proven feasibility, the flow chart offers a novel approach to integrated nutrition and RCEL counseling. The flow chart is adaptable to different contexts, offering a valuable tool for scaling up effective integrated counseling practices in Ghana and beyond.

Visit USAID Advancing Nutrition’s website to view and download the tool and to read more about USAID Advancing Nutrition’s RCEL work !

Related resources:

• Responsive Care and Early Learning Addendum
• Responsive Care and Early Learning (RCEL) Addendum Resources for Ghana
• Responsive Care and Early Learning (RCEL) Addendum Resources for Kyrgyz Republic
• Responsive Care and Early Learning Videos Series
• What Tools do Community Health Workers Want to Help Them Practice Compassionate Counseling on Nutrition?