Adaptations to community-based acute malnutrition treatment during the COVID-19 pandemic

This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored by Maria Wrabel, Sarah King and Heather Stobaugh

Maria Wrabel is CMAM Adaptations Project Officer with Action Against Hunger USA through the Congressional Hunger Center’s Leland International Hunger Fellowship.

Sarah King is Field Research Coordinator with Action Against Hunger USA.

Heather Stobaugh is Senior Research and Learning Specialist at Action Against Hunger USA.

Background

Following the start of the COVID-19 pandemic, guidance on adaptations to acute malnutrition management programmes was quickly released by UNICEF, the Global Nutrition Cluster, Global Technical Assistance Mechanism for Nutrition and the World Health Organization. Action Against Hunger, supported by the United States Agency for International Development (USAID) and in collaboration with UNICEF and the United States Centers for Disease Control and Prevention, began to document and synthesise information on the adaptations implemented around the world to explore what adaptations were implemented by whom and where. Data collection included an online survey for implementing organisations, semi-structured interviews with programme staff and secondary analyses of programmatic data. Full results should be available in mid-2021.

As of November 2020, 19 organisations (17 non-governmental organisations (NGOs) and two United Nations organisations) in 36 countries had completed the survey and 36 semi-structured interviews had been conducted. Responses indicated that most implementers began modifying protocols in April 2020. Existing structures were used to select adaptations and decisions were often made at national level, with leadership and input from the Ministry of Health, the national Nutrition Cluster and NGOs. Adaptations made by programmes included the introduction of caregiver-measured mid-upper-arm circumference (MUAC) (Family MUAC), a reduced frequency of follow-up visits, modified admission and/or discharge criteria, modified dosage of therapeutic and/or supplementary foods and the treatment of acute malnutrition by community health workers (CHWs) (Figure 1).  

While some countries are returning to ‘pre-COVID-19’ protocols, most are unsure if or when protocols will revert. This article highlights some of the feedback from respondents on the adaptations as well as recommendations. The original Field Exchange article includes a selection of specific case studies from countries exploring how adaptations were implemented in practice. 

Figure 1: Protocol adaptations implemented for detection and treatment

Family MUAC

During the pandemic, movement restrictions and social distancing inhibited screening and surveillance by health professionals and volunteers. As a result, governments and implementing partners either piloted or scaled up the Family MUAC approach whereby caregivers were trained to monitor their own children’s MUAC.

Programme staff reported that Family MUAC implementation was largely successful. Some programmes built on to existing structures (such as Care Groups) and others used stand-alone training models, either virtually or in person. Caregivers were eager to monitor their children’s health and clinic staff anecdotally reported an increase in self-referrals. However, implementation was limited by the lack of MUAC tapes commonly available. Respondents recommended follow-up with caregivers after training to enhance measurement accuracy.

Respondents recommended that, in addition to measuring MUAC, mothers should be trained to check for oedema and educated on the prevention of malnutrition, suppliers should be engaged to provide sufficient MUAC tapes for maximum distribution and coverage, with vulnerable children being targeted if tapes are insufficient, and that the roles of community volunteers, clinic staff and caregivers in screening and referrals should be clearly communicated. Respondents also recommended that clinics be prepared for elevated caseloads as a result of self-referrals, caregivers who self-refer children with inaccurate measurements should be retrained and encouraged to continue health-seeking behaviours and Family MUAC should complement, rather than replace, traditional community-based screening and surveillance.

Modified frequency of follow-up appointments

To limit crowding at clinics, the frequency of follow-up visits during treatment programmes was reduced, typically to fortnightly or monthly visits. Respondents indicated that this approach successfully reduced crowding at clinics and demands on caregivers’ time. Uptake improved when CHWs conducted home visits and supported families between appointments. However, in many contexts, families sold or shared nutrition products. There was also a concern that children’s nutrition status may deteriorate during the longer gaps between visits. Some staff experienced reduced workloads due to fewer children presenting at clinics while others reported higher workloads to accommodate scheduling and logistical support.

Respondents recommended that communities are adequately sensitised to new schedules to reduce confusion and increase uptake, existing supply chains provide for larger nutrition product rations and storage alternatives be explored for families unable to safely manage these additional products. Other recommendations were that home visits should be increased to ensure caregiver support and that more frequent appointments be scheduled for high-risk children.

Modifying admission/discharge criteria

To reduce contact between staff and children, some programmes reduced the number of anthropometric measurements taken. Most adapted protocols included the assessment of MUAC and oedema only and/or expanded MUAC thresholds to capture children with low weight-for-height Z-scores (WHZ). Staff expressed concerns about discontinuing weight and height measurements and, although in theory reducing the number of anthropometric measurements reduces staff workload, in practice this gain may be offset by expanding MUAC thresholds. Recommendations include assessing the ability of higher MUAC thresholds to capture children identified by WHZ, increasing staff and supply capacity to meet potentially increased caseloads, sensitising staff and communities to revised clinical definitions of malnutrition and the potential long-term consequences of switching admission and/or discharge criteria and providing additional training to staff and caregivers to ensure the proper implementation of new criteria.  

Continuing treatment when facilities are inaccessible

Many health and nutrition providers were forced to use alternative methods, such as phone and/or video calls, to reach malnourished children when COVID-19 lockdowns and movement restrictions were implemented. Where this was not possible, programme staff and CHWs conducted home visits. Phone-based counselling allowed for continued contact with children in wasting treatment programmes. However, this inhibited visual assessment of a child’s progress. Home visits were often preferred by caregivers. Since individual home visits are time consuming, this approach was maximised in contexts with low caseloads or increased staffing.

Recommendations in this area include the integration of video or photo components into tele-health visits for visual anthropometry assessment where possible, ensuring staff and volunteer safety when supplies are transported to children’s homes and facilitating open communication between community workers, health facilities and local police to coordinate severe or deteriorating case referral particularly in light of movement restrictions.

Conclusions

As the pandemic continues, nutrition programmes innovate and adapt. Preliminary data from this project highlights key takeaways from the most frequently implemented adaptations as follows:

Family MUAC is the most widely implemented adaptation and is likely to continue beyond the pandemic. However, a greater supply of MUAC tapes and standard monitoring and evaluation indicators are necessary for successful implementation and scale-up.  

Reduced frequency of follow-up visits helps to control crowding at sites and reduces burdens on caregivers’ time. Successful implementation relies on clear communication with caregivers. There are unknowns surrounding the potential implications for treatment outcomes.

Modifications to admission and discharge criteria successfully reduce contact between staff and children. Expanded MUAC thresholds can lead to increased caseloads and a need to sensitise communities on new thresholds.

Regardless of the adaptation, close collaboration and clear communication between caregivers, communities, partners and government entities have been shown to be critical. Virtual trainings and meetings should be used as much as possible and appropriate and sufficient personal protective equipment given to staff. Innovations and adaptability rely on flexible funding sources and partnerships. Above all, the health of children, caregivers, communities and staff remains paramount during and beyond the pandemic.

For more information, please contact Heather Stobaugh at: hstobaugh@actionagainsthunger.org