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Terms of Reference (ToR) for a formative qualitative research and quantitative baseline survey for an

improved IFA supplementation program for school going adolescent girls in selected districts of West
Java province in Indonesia
STATEMENT OF SERVICES AND DELIVERABLES
Background and rationale:
The prevalence of anaemia among adolescent girls and women of reproductive age (15-24 years) at
national level is 18.4% (RISKESDAS, Basic Health Research, 2014). However, the data from screening of
junior-high school children in Cimahi and Bandung districts in 2013 revealed the prevalence of anaemia
among adolescents in the range of 40-50% (DHO, Cimahi, 2013). Based on national guidelines (MoH,
1998), it was recommended to give one IFA tablet weekly for 16 weeks consecutively, plus one IFA
tablet daily during menstruation for 10 days to adolescent girls. However, the program was not
implemented as envisaged. Some of the reasons for this are:
non-availability of IFA tablets,
limited promotion of the intervention and
no clear channel for distribution.
Estimation for IFA supplements by government is calculated based on expected population of pregnant
and postpartum women only, and supplies IFA supplements for the adolescent girls is very limited. The
District Health Office (DHO) advocates to other sectors such as education/school to provide IFA tablets
for adolescent girls at school, while the health sector only promotes the benefits of consumption of IFA
supplementation and risk of anaemia, however the provision of IFA tablet is still not available for all
schools.
Therefore, MI Indonesia proposes a trial on Weekly Iron and Folic Acid (WIFA) supplementation for
school-going adolescent girls to reduce the prevalence of anaemia among them and reinstate the focus
of district and national government on the IFA supplementation program for adolescent girls for
improved health outcomes.
In this regard, MI proposes two activities: a qualitative formative research study and a quantitative
baseline survey. Both activities will inform the design of a Behavior Change Communications (BCC)
strategy to improve awareness regarding dosing, adherence, and benefits of IFA supplements and
estimating the coverage of weekly IFA supplementation among school-going girls. The qualitative study
will be conducted in the two program districts of Cimahi and Purwakarta. The quantitative study will be
conducted in two program districts of Cimahi and Purwakarta and one comparison district of West Java
province. The quantitative baseline survey will be carried out with the key objective of estimating the
anaemia prevalence, coverage and adherence of weekly IFA supplementation among school going
adolescent girls. This ToR outlines the scope and activities to be carried out in this survey.
Overall objective: The purpose of the consultancy is to provide MI with information to formulate a BCC
strategy to improve awareness regarding dosing, adherence and benefits of IFA supplements and estimate
prevalence of anaemia, coverage and adherence of weekly IFA supplementation among school going
adolescent girls in selected districts of West Java.

Specific objectives of the quantitative survey :


To achieve the purpose the following specific objectives should be met:
1. Estimate the prevalence of anaemia among school going adolescents girls
2. Estimate the coverage and adherence of IFA supplementation among school going adolescents girls
3. Assess the knowledge, attitude and practices among school going adolescents girls about causes and
consequences of anaemia and the benefits of IFA supplementation
Specific objectives of the qualitative survey :
Specific objectives for school-going adolescent girls include the following:
1. Identify the local terms girls use for listlessness, fatigue, and lack of energy. Determine what
causes these symptoms and (broadly) what girls do to address these conditions.
2. Name the foods girls eat and determine reasons for consuming (or failure to consume) these
foods (with a particular focus on foods that are rich in iron and folic acid such as ASFs).
3. Determine whether girls take any micronutrient supplement or (separately) medicine to address
the symptoms described above.
4. Identify the following for consumption of IFA tablets:
a. Perceived advantages and disadvantages of consumption of IFA tablets.
b. Facilitators and barriers to regular consumption (what might encourage/discourage
adolescent girls from taking tablets?)
c. Adolescents' self-efficacy with respect to taking tablets.
d. Social norms regarding consumption of IFA tablets specifically and micronutrient
supplements generally.
e. Individuals who might influence (one way or another) adolescents' uptake of IFA tablets
(including girls' perceptions about teachers themselves with respect to encouraging IFA
consumption and the practice of nutritious behaviors).
f. Perceptions about IFA tablets and how they might impact the body and girls' health.
g. Concerns about the tablets (for example, the long-term consequences of taking tablets
regularly) as well as potential side effects.
5. Identify perceived advantages/disadvantages, facilitators/barriers, self-efficacy, influential
individuals, perceptions, and concerns with respect to consumption of a diverse, iron-rich diet.
This should take the form of asking girls what they think about consuming specific meats, etc.
The use of the term "iron-rich" should be avoided in all conversations with girls so as not to bias
their responses.
Specific objectives for school teachers include the following:
1. Determine the extent to which adolescent girls in their classrooms suffer from listlessness,
fatigue, and lack of energy. From teachers' perspectives, identify what causes these symptoms
and (broadly) what girls have done or can do to address these conditions.
2. Have teachers name things that they think can be done to mitigate listlessness, fatigue, and lack
of energy in the classroom.
3. For each of the following: 1) promoting the use of IFA tablets 2) promoting a diverse, iron-rich
diet 3) dispensing IFA tablets, and 3) ensuring that adolescent girls take them, gauge:
a. Facilitators and barriers

b. Teachers' self-efficacy with respect to nutrition education and promoting IFA


supplements
c. Social norms surrounding teachers with respect to these promotion of these actions
d. Perceptions about IFA tablets themselves, and
e. Concerns about the tablets (including potential side effects)
4. Probe teachers' understanding of the causes and consequences of anemia.
The following questions layout the types of information that will be required to meet the specific information
these questions should be interpreted as a minimum requirement for the information to be obtained in this
consultancy but consultants should feel free to propose the collection and utilization of any additional
information that may strengthen their ability to respond to the specific objectives.
Key research questions for the quantitative survey
The key research questions are as follows:
1. What is the regimen that is given for IFA supplementation among school going adolescent girls?
2. What is the coverage of weekly IFA supplementation among school going adolescent girls?
3. What is the adherence of weekly IFA supplementation among school going adolescent girls?
4. What are the reasons for non-adherence, if any?
5. What is the knowledge level of school going adolescent girls regarding IFA dosage, duration and
its side effects following consumption?
6. Do teachers counsel the school going adolescents regarding solutions to the side effects from
consumption of IFA?
7. Do health workers counsel the school going adolescents regarding solutions to the side effects
from consumption of IFA?
8. Who supplies the IFA supplements among the school going adolescent girls?
9. Is there a stock out of supplies of IFA in the schools?
Key research questions for the qualitative formative research
1. What media do girls pay attention to most (radio, TV, social media, etc.)?
2. What other sources of support might be helpful (e.g., in school peer support)?
3. What specific messages might appeal to adolescent girls the most? Which ones might be most likely
to encourage girls to take IFA tablets and consume ASFs?
4. What support from teachers and others would help girls not only adopt practices related to
consumption of IFA tablets and ASFs but maintain those practices?
5. What pedagogical methods do teachers currently use to promote health? What facilitators and
barriers might teachers face when implementing hands-on, participatory learning?
6. Which training design and content for teachers will be most appropriate and effective in delivering
the program (knowledge of dosing and benefits of IFA, counseling, adherence, and monitoring)?
7. What other constraints might teachers face in promoting consumption of IFA tablets and ASFs (e.g.,
lack of supervisor's support, negative reaction from parents, girls' disinterest in the topic, etc.)?
Based on results, the consultant(s) will recommend actions to inform MI's program design which is meant to
improve the uptake of IFA tablets as well as healthier diets. This should include 1) impactful messages based
on responses from adolescent girls and teachers 2) individuals who might be especially good at encouraging
girls to consume IFA tablets and eat healthier diets 3) actions teachers can take to improve girls' consumption
of IFAs, and 4) suggestions for teacher training (and in particular, content of that training based on results
from this study and the BEHAVE framework or similar).

Design and method: A pre and post intervention cross-sectional survey design with comparison group will
be adopted for this study. The study will involve the use of both quantitative and qualitative methods of data
collection. The quantitative surveys will be conducted at two time points the two program districts and one
comparison district of West Java. The qualitative formative research is a one-time, cross-sectional, guided by
health behavior theory. This qualitative study relies upon focus groups with in-school adolescent girls and
teachers as well as in-depth interviews with teachers and other influencers and structured observations of
classrooms to assess pedagogical methods. Please note that if there are not enough health instructors to
form a focus group in a particular school, teachers who instruct on similar topics should be included in FGDs.
Target respondents: School going adolescent girls in the age group of 12-19 years will be the respondents
of the quantitative survey. In the formative qualitative research, focus group discussions and in-depth
interviews will be conducted among school teachers, principals, religion officers, health workers like;
midwives, cadres, other potential influences like; parents of unmarried adolescents and husbands and inlaw of married adolescents.
Sample size for the quantitative baseline survey
The target respondents for the study will be school going adolescent girls in the age group of 12-19 1
years from randomly selected households. In the absence of any reliable data on the prevalence of
anaemia among adolescent girls (10-19 years), the sample size is powered to detect a difference
between 18.4% 2 (assumed for the school going adolescent girls at baseline and an anticipated 3% at
endline (based on the end line target mentioned in the Innovation agenda proposal), with 95%
confidence, a power of 80% adjusted for a design effect of 2 and incremented by a probable nonresponse rate of 10%. The sample size is powered to provide combined project area level estimates for
the two program districts. The sample is not powered to provide individual district level estimates 3.
Table 1 : Sample size for the quantitative survey
Outcome variable: prevalence of anaemia
Required sample of households =0.05 and &
= 0.80 and an assumed design effect of 2.0 4
Program areas (two program districts of Cimahi and Purwakarta of
West Java province)
Comparison areas (a district in West Java with similar socio-economic,
demographic and health characteristics to the two program districts)
Total

170
170
340

Sample selection for the quantitative survey


The sample of households will be selected in a two stage sampling design. In the first stage, all the
villages in the two program districts as per census 2010 will be listed and 17 villages will be selected by
probability proportional to size (PPS) method. Similarly, 17 villages will be selected in the selected
comparison district by PPS method. At the second stage, all households in the selected cluster will be
1

12-19 years is being taken considering those who are in junior/ senior secondary high school students would have
had menarche.
2
adolescent girls and women of reproductive age (15-24 years) at national level is 18.4% (RISKESDAS, Basic Health
Research, 2014)
3
For separate district level estimates, we need a higher sample size, which will have higher cost implications.
4
The sample size has been computed using Stata 12.0 Statistical Software for two sample tests with standard
statistical assumptions (two-sided test; alpha= 0.05; 0.8 power, and non-continuity) and have been increased to
account for design effect and assumed non-response rate and rounded off.
4

listed to prepare a sampling frame for households with a school going adolescent girl in the age group of
12-19 years. The required number of respondents (10 in each cluster) will be selected by a systematic
sampling method from the sampling frame of households. A cluster/ village with more than 200
households will be divided into two equal segments, with each segment of about 100 households. Then,
one segment will be randomly selected for the preparation of the sampling frame. In case, the desired
number of households is not available in the selected segment, then the nearby segment will be covered
to get the required number of respondents.
In addition to canvassing of a structured questionnaire with the 340 school going adolescent girls in the
age group of 12-19 years regarding coverage and adherence of IFA and their knowledge, attitude and
practices related to anaemia and IFA supplementation, haemoglobin tests will be conducted among
them by drawing blood samples from them during the baseline and end line surveys to measure
anaemia prevalence. An Ethical Committee will guide the blood sample collection, testing device,
method of testing and disposal procedures that will be undertaken in the survey, adhering to the
international standards. Prior to collection of the blood samples, informed consent will be obtained
from the adolescents. Trained health investigators from the commissioned research agency/ institution/
organization will be employed to collect the blood samples for testing at the field level. The health
investigator will read out a detailed informed consent statement to the adolescent girl informing her
about anaemia, describing the procedure to be followed for the test and emphasizing the voluntary
nature of the test. The health investigator will sign the questionnaire to indicate that the informed
consent statement has been read to the adolescent girl and it will then be signed by her. If the test is
performed, at the end of the test, the adolescent girl will be given a written record of the haemoglobin
status. In addition, the health investigator will interpret the results to her and advise the adolescent girl
regarding IFA supplementation. In cases of severe anaemia, an additional statement will be read to the
adolescent to help her determine whether or not she would give permission to the research
organization to inform a local health official about the problem so that appropriate medical treatment
can be provided.
Sample size for the qualitative survey
The optimal behavior MI's programs seek to improve upon is consumption (according to national guidelines)
of one IFA tablet weekly by adolescent girls for 16 weeks consecutively plus one IFA tablet daily during
menstruation for 10 days. Secondary behaviors the MI project seeks to improve relate to diet and will be
determined with greater specificity in the coming weeks but include increased dietary diversity and
consumption of animal source foods (ASFs) where religion or other influences do not dictate otherwise.
Sample selection for the qualitative survey
The respondents for the qualitative survey will be selected from the neighbouring villages of the two
program districts not covered in the quantitative survey.
For the purposes of this research, adolescent girls are defined as school-attending young women 12-19 years
of age living in two districts of Cimahi and Purwakarta in West Java province who may or may not be taking
iron folic acid (any frequency, including 0).
Table 2 : Sampling of Adolescent girls 12-19 years old
Method of data
collection
Focus group

Information needed
1. Local terms for listlessness, fatigue, and
5

Number of FGDs
Cimahi (West
Purwakarta (West
Java)
Java)
5 FGDs among
5 FGDs among 12-14

discussions
(FGDs) that
include pile
sorts

2.
3.
4.

5.
6.
7.

lack of energy as well as perceived


12-14 years olds
etiology and treatment.
+ 5 among 1519 year olds=10
Names of foods girls eat/don't eat and
reasons for doing so.
Existing use of micronutrients and/or
medicines to address symptoms.
For consumption of IFA tablets and
ASFs:
a. Perceived advantages and
disadvantages.
b. Facilitators and barriers.
c. Self-efficacy.
d. Social norms.
e. Influential others (including
teachers).
f. Perceptions about IFA tablets
and ASFs and how they might
impact the body and girls'
health.
g. Concerns about tablets and
ASFs.
Media of importance to girls.
Additional sources of support girls need
to adopt practices (IFA tablet
consumption and consumption of ASFs.
Appealing messages.

years olds + 5 among


15-19 year olds=10

The optimal behaviors MI's programs seek to improve upon with respect to teachers are promoting IFA
tablets and consumption of iron rich foods, dispensing IFA tablets, resolving any concerns adolescents have
regarding tablets, and ensuring that adolescent girls take them. For the purpose of this research, teachers are
defined as men and women employed by the State or by a private school who instruct adolescent girls 12-19
years of age. Given the small number of teachers per school, it will not be possible to limit this sample to only
teachers who are responsible for promoting the use of IFA and consumption of iron-rich foods, dispensing
IFA tablets, and ensuring that adolescent girls take them.
Table 3 : Sampling of Teachers, Principals of schools of school going adolescent girls 12-19 years old
Number of FGDs/ IDIs/ Observations
Method of data Information needed
Cimahi (West Java)
Purwakarta (West
collection
Java)
Focus groups
1. Perceived extent to which
5 FGDs among teachers 5 FGDs among
adolescent girls suffer from of 12-14 years olds + 5
teachers of 12-14
listlessness, fatigue, and
among teachers of 15years olds + 5 among
lack of energy. Perceived
19 year olds=10
teachers of 15-19 year
causes and actions to
olds=10
address symptoms.
2. Actions teachers can take to
mitigate listlessness,
fatigue, and lack of energy
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3.

4.
In-depth
interviews (IDIs)
with teachers
and principals

1.
2.
3.

4.

Classroom
observation
(conducted
during health
promotion
sessions)

1.
2.

in the classroom.
For each of the following: 1)
promoting the use of IFA
tablets 2) promoting a
diverse, iron-rich diet 3)
dispensing IFA tablets, and
3) ensuring that adolescent
girls take them:
a. Facilitators and
barriers
b. Teachers' selfefficacy with
respect to nutrition
education and
promoting IFA
supplements
c. Social norms.
d. Perceptions about
IFA tablets and
ASFs.
Perceived causes and
consequences of anemia.
Pedagogical
methods
teachers currently use to
promote health.
Facilitators and barriers to
implementing
hands-on,
participatory learning?
Thoughts on training design
and content for teachers that
will be most appropriate and
effective in delivering the
program.
Other constraints teachers
face
in
promoting
consumption of IFA tablets
and ASFs.
Pedagogical methods do
teachers currently use in the
classroom.
Which training design and
content for teachers will be
most
appropriate
and
effective in delivering the
program (knowledge of
dosing and benefits of IFA,
counseling, adherence, and
monitoring)?
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10 teachers + 1
principal

10 teachers + 1
principal

Observations of 5
classroom sessions (5
different teachers)

Observations of 5
classroom sessions (5
different teachers)

3. What other constraints might


teachers face in promoting
consumption of IFA tablets
and ASFs (e.g., lack of
supervisor's
support,
negative
reaction
from
parents, girls' disinterest in
the topic, etc.)?

Method of data
collection
Focus groups

Indepth
interviews (IDIs)

Table 4 : Sampling of Religion officers/ Midwives/ Cadres


Number of FGDs/ IDIs/ Observations
Information needed
Cimahi (West Java)
Purwakarta (West
Java)
1. Perceived causes and
1 FGD among Midwives 1 FGD among
consequences of
+ 1 FGD among Cadres
Midwives + 1 FGD
anemia.
=2
among Cadres =2
2. Regimen of IFA among
school going
adolescents
3. Awareness about
weekly IFA
supplementation
4. Awareness about IFA
dosage, duration and
benefits, methods to
overcome side effects
5. Counselling provided
6. Availability and use of
IEC/ BCC / BCI materials
7. Stocks and supplies of
IFA to schools
8. Recording and
reporting of IFA
distribution
1. Opinion about the
1 Religion officer
1 Religion officer
program
2. facilitators and barriers

Table 5 : Sampling of Parents of unmarried adolescents/ Husbands and in-laws of married adolescents
Number of FGDs/ IDIs/ Observations
Method of data Information needed
Cimahi (West Java)
Purwakarta (West
collection
Java)
Focus groups
1. Awareness about
2 FGDs among parents
2 FGDs among parents
weekly IFA
of unmarried school
of unmarried school
supplementation
going adolescent girls
going adolescent girls
2. Awareness about IFA
dosage, duration and
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3.
Focus groups

1.
2.

3.
Indepth
interviews (IDIs)

1.
2.

3.

benefits, methods to
overcome side effects
Opinion about
adolescents getting IFA
in schools
Awareness about
weekly IFA
supplementation
Awareness about IFA
dosage, duration and
benefits, methods to
overcome side effects
Opinion about
adolescents getting IFA
in schools
Awareness about
weekly IFA
supplementation
Awareness about IFA
dosage, duration and
benefits, methods to
overcome side effects
Opinion about
adolescents getting IFA
in schools

1 FGD among parentsin-law of married school


going adolescent girls

1 FGD among parentsin-law of married


school going
adolescent girls

2 IDIs with husbands of


married school going
adolescent girls in the
age group of 12-19
years

2 IDIs with husbands


of married school
going adolescent girls
in the age group of 1219 years

The survey will collect information on the following in addition to other details to be incorporated in the
questionnaire from the adolescent girls:
Socio-economic-demographic background characteristics of the households and adolescent
girls
Exposure to mass media, interpersonal communication and social media
Knowledge of anaemia and IFA supplements (dosage, duration and benefits)
Regimen of IFA for school going adolescent girls
Receipt and adherence of IFA
Supervision of receipt and consumption of IFA among adolescents in schools
Counseling provided by teachers/ principals/ health workers
Side effects and knowledge of methods to overcome side effects
Deliverables
The following deliverables are to be submitted in hard copy and electronic form by the firm as the
implementation progresses to the Micronutrient Initiative:
Timeline to complete the survey
Ethical clearance
Final English and Bahasa Indonesia structured questionnaires
Final English and Bahasa Indonesian FGD guides and guides for in-depth interviews
Final English and Bahasa Indonesian checklists for classroom observation
Plan for training interviewers and supervisors
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Field procedures manual in English and Bahasa Indonesia.


Detailed procedure used for multi-stage sampling including list of clusters and respective
population size.
Codebook including questions, variable names, value names
Detailed documentation of procedures used for sampling
Data analysis and tabulation plan (to be provided earlier)
Cleaned and labeled quantitative datasets in SPSS format
Codebook including nodes and their definitions as well as structure
All field notes and interviews legibly transcribed and translated in electronic forms
Cleaned and labeled qualitative transcripts in Word
Report of survey finalized after review by MI
Power point presentation summarizing the key findings

Report Outline
The selected agency/ consultant will submit to MI a report which has the following sections / chapters:
1. Executive summary
2. Introduction
3. Study design
4. Key findings from interviews of school going adolescent girls
5. Key findings from interviews of teachers and other potential influencers
6. Discussion and Conclusions
7. Annexures : Questionnaires, interview and FGD guides, observation checklists
The agency/ consultant will submit a draft report to MI for review and will be finalized after
incorporating suggestions and comments from MI.
Timeline
The selected agency for this consultancy will adhere to the following timeline. The timeline is in
reference to the time of signing the contract with MI. It is expected that period of consultancy will be 16
weeks and the final report will be finalized within this period.
Table 6 : Timeline

Translating and Pretesting


data collection instruments
(semi-structured
questionnaires, FGD guides,
guides for in-depth
interviews, and checklists for
structured observations ) and
sampling plan
IRB clearance
Training of investigators
Data collection
Data entry and analysis

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Week
9 10 11 12 13 14 15 16

Report writing and finalization

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