Transforming awareness and training into effective CMAM Performance

By Maureen Gallagher and Armelle Sacher

Maureen Gallagher is the Senior Nutrition & Health Advisor ACF USA based in New York. She has worked for the last 10 years in nutrition (especially CMAM integration into health systems, community mobilisation and coverage), food security and hygiene promotion programming. She has workded in Niger, East Timor, Uganda, Chad, DRC, Burma, Sudan and Nigeria.

Armelle Sacher has worked in different cultural contexts while with ACF, including countries in Africa, Asia and the Caribbean. She has focused specially on strengthening community mobilisation and health promotion and as a graphic designer, has created adapted communication tools for illiterate people.

The authors would like to thank the Yobe State Primary Health Care Management Board (YPHCMB) health workers and communities for their commitment to CMAM and for testing and inputs into the tools developed as part of the initiative. Thanks also to ACF’s Regional Training Centre experts, Paula Tenaglia and Faye Ekong, for their delivery of various trainings of trainers (ToT) and ToT manuals revisions. Thank you to Saul Guerrero and Silke Pietzsch for their contributions to the article. Finally, the authors would like to acknowledge the contribution of the European Commission Humanitarian Office (ECHO) for their support of the CMAM activities in Yobe and Jigawa States.

In February 2011, Action Against Hunger ACF International (ACF) began supporting a sustainable approach to integration of community-based management of acute malnutrition (CMAM) in three Local Government Areas (LGAs) in Yobe State, Nigeria. This was undertaken with support from the European Commission - Humanitarian Aid & Civil Protection (ECHO) and in close collaboration with the Yobe State Primary Health Care Management Board (YSPHCMB).

Since Feb 2011, the ACF approach has evolved in two phases, a basic approach followed by a revised approach, detailed below.

Phase 1: Basic Approach (February - December 2011)

A key component of CMAM, to ensure early detection, referral and access, is community mobilisation. In preparation for integrating CMAM into routine services in Fune, Damaturu and Potsikum LGAs, ACF recruited a Community Team with three Community Officers to support the health system in awareness activities and selection and training of Community Volunteers (CVs). Key activities included:

• Awareness meetings
• CV trainings
• Rapid Socio Cultural Assessment (RSCA)
• Semi Quantitative Evaluation of Access and Coverage (SQUEAC investigation)

In total, over 900 community leaders and CVs participated in awareness and training activities.

Community awareness meetings were held in all targeted health facilities, where traditional, religious and political leaders from the catchment area gathered. During the meetings, the ACF team made presentations about ACF the organisation and its mandate, about malnutrition and treatment, and described the planned CMAM activities to be implemented in collaboration with the local health system. At this stage, community leaders were also requested to select CVs from their respective communities to support the detection and referral of malnourished children to treatment. The voluntary nature of the work was explained with a strong emphasis on the importance of ensuring that all entitled children receive treatment. Discussions were also held about leaders’ roles and responsibilities so that these were jointly defined.

After compiling CV lists from community leaders for the different health facilities in collaboration with the health worker, ACF conducted CV trainings in all health facilities on CMAM detection, referral and follow-up roles of volunteers. Training included sessions overviewing CMAM, the roles and responsibilities of CVs and a demonstration on how to take mid-upper arm circumference (MUAC) measurements. Materials used included photos of malnourished children, samples of Ready to Use Therapeutic Food (RUTF) sachets, MUAC tapes and flipchart/ markers for brainstorming and lecture sessions. The training was participatory and conducted in the Hausa language. CVs were provided with kits for awareness and detection, including the laminated photos illustrated in Figure 1 (as per national guidelines) and a MUAC tape.

A RSCA was also conducted during Phase 1 for identification and understanding of key information, information channels and community perception of acute malnutrition. This led ACF to revise target groups for training (detailed below in Phase 2) and diversify locations for message delivery.

The SQUEAC investigation conducted in Fune LGA in August 2011 found a point coverage of 33%, which is below the target threshold of >50% coverage. One of the key barriers to access identified was limited awareness of both malnutrition and CMAM services available in the various health facilities. Discussions with the field team about barriers to coverage and observations at meetings and trainings identified a number of important issues, including:

• Low literacy rate of CVs and leaders
• Some communities (especially Kanouri women) were not proficient in Hausa
• Training of large groups of CVs prevented everyone from getting practice with MUAC measurements (more participants were present than on the original lists)
• Lack of visual materials and tools to convey messages to CVs and support their detection, referral, follow-up and awareness activities in the communities
• Need to train a wider group of stakeholders for information dissemination

As a result of the review, ACF further developed its approach (Phase 2) so that it was better adapted to the needs of CVs and communities who would then be more engaged in trainings.

Phase 2: Revised Approach (January - April 2012)

In order to broaden and strengthen CMAM community mobilisation, new activities were added:

• Training of key stakeholders (traditional birth attendants (TBAs), traditional healers and hairdressers)
• Training of trainers (ToT) in the ACF team to strengthen their presentation, facilitation and session development skills
• Development of visual materials for awareness meetings, training and community volunteers
• Preparation and practice of awareness meetings
• Preparation and practice of CV trainings with new techniques

Training of other key stakeholders was highly appreciated, especially by the traditional healers, who explained that they can help in referring children, as people often seek traditional treatment first. Religious leaders were also trained with a follow-up meeting during Friday prayer days.

A 5-day ToT was conducted with the ACF and LGA teams that involved sessions on the adult learning cycle, introduction to various interactive training methods, training session development, session preparation and practicals with feedback. To support those returning to field work in the challenge of applying newly acquired skills, a communication specialist worked closely with field teams - particularly in the development of visual materials for training (see pictures in Figure 2 which were printed on A2 vinyl for use in trainings and meetings). The consultant also supported teams to prepare and practice awareness and training sessions before these were conducted with beneficiaries in the field. Activities included increased role playing and new card games (see cards on food groups for Nigeria in Figure 3).

Field teams were filmed and during one-onone feedback sessions, were given pointers for improvement and followed up to ensure progressively stronger and more effective delivery. Feedback from participants was positive as they reported greater enjoyment and understanding in trainings. Health workers felt appre- ciated as they were presented as leaders of CMAM in their areas and recognised by the communities as key to the provision of treatment.

The ACF teams were also enjoying the activities more than before as a result of interactions and use of new materials and techniques. Language issues were also addressed and new members joined the team (from three to six community officers) to ensure trainings in Kanouri and Fofoldi could be delivered. This also helped with gender balance (one male, one female community officer per LGA). CVs were provided with a CV tool kit of visual materials to support their community awareness activities in line with visual materials used during trainings, in A4 form (see a sample on how to use RUTF in Figure 4). The final kits developed for CV training (10 vinyl A2 designs) are shown in Figure 5.

A SQUEAC investigation conducted in June 2012 in Damaturu LGA, where the revised approach was implemented, indicated point coverage of 50.4%. A follow-up of Fune LGA will be done in 2013 (delays resulted because of the security situation) to evaluate more accurately possible impact of the evolved community mobilisation approach.

Moreover, a training toolkit for LGA and health facility workers, including visual aids, matching games, etc. supported by a facilitator’s manual, was created and produced in order to support a specific ToT for community mobilization in Northern Nigeria. Trainings were conducted for Jigawa, Zamfara, and Katsina State and LGA health teams as well as partners (Save the Children, UNICEF) in September 2012.

Conclusions

The experience in the three LGAs in Yobe State has demonstrated a potential strategy to enhance community mobilisation leading to increased CMAM coverage. Strong follow-up in preparation and for delivery of trainings is vital in ensuring new skills are applied and reviewed with clear evidence of improvement captured through films and documentation. The next stage will involve strengthening techniques of LGA and health facility workers as they take on an increasing leadership role in training. In this type of programme, training is a vital activity and if knowledge, skills and attitudes are impressed through adapted learning, this will lead to improved participation and commitment of communities, thereby promoting quality and fuller coverage of CMAM. The training activities outlined here will be further complemented with theatre about CMAM on market days and radio programmes. However, it remains necessary to continuously review, re-evaluate, diversify and refine community mobilisation activities to ensure effective information adoption by communities and thus better CMAM service access for malnourished children.

For more information, contact: Maureen Gallagher, email: mgallagher@actionagainsthunger.org

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