Implementing the Family MUAC approach for infants under six months in the context of COVID-19 in Ethiopia

This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored by Ritu Rana, Hatty Barthorp, Mary T Murphy and Alemayhu Beri

Ritu Rana is a GOAL Nutrition Research Advisor (Management of At-risk Mothers and Infants under six months (MAMI)).

Hatty Barthorp is a GOAL Global Nutrition Advisor.

Mary T Murphy is a Refugee Programme Manager at GOAL Ethiopia.

Alemayhu Beri is a supervisor for MAMI and Senior Community Management of Acute Malnutrition (CMAM) Programme Officer at GOAL Ethiopia.

Background

The measurement of mid-upper arm circumference (MUAC) by caregivers is a promising approach to improving the frequency and coverage of screening and case identification for child wasting. To ensure its effectiveness, adequate operational support, training and the supervision of community health workers and caregivers are required. While evidence shows that MUAC is effective in identifying infants at increased risk of mortality, there are no globally established thresholds for infants under six months of age. The accuracy and reliability of MUAC measurements taken by caregivers in this age group is also unknown.  

Since 2014, GOAL has been implementing a programme for the management of small and nutritionally ‘at risk’ infants under six months and their mothers (MAMI)¹ in four refugee camp sites in Gambella, Ethiopia. In response to the COVID-19 emergency, GOAL introduced adaptations to its MAMI programme guided bythe World Health Organization and UNICEF 2020 guidance.² This recommends the use of MUAC as a ‘reduced physical contact’ approach for identifying nutritional risk in infants under six months of age using the following thresholds: <11.0 cm for 0-6 weeks and <11.5 cm for 7 weeks to 6 months. The guidance also recommends the use of the Family MUAC³ approach whereby caregivers screen their infants for malnutrition at home.

To support these programme changes, GOAL developed a specially designed MUAC tape⁴ called MAMI-MUAC (Figures 1a and 1b). This tape is reversible so that one side can be used for infants under six months and the other for older children and pregnant and lactating women. Two versions are available – one numbered for use by community outreach agents (COAs) (Figure 1a) and the other without numbers for use by caregivers (Figure 1b). This article describes the implementation of this approach in the MAMI programme in Gambella.  

Figure 1a: Enumerated, colour-coded reversible MAMI-MUAC tape for community health workers

Top: infants <6 months
Bottom: children 6-59 months and pregnant and lactating women

Figure 1b: Non-enumerated reversible MAMI-MUAC tape for caregivers

Top: infants <6 months
Bottom: children 6-59 months and pregnant and lactating women

Implementation of the Family MUAC approach for infants under six months

Figure 2: Implementation steps

COAs across all four camp locations were trained in the use of the new tapes in March 2020. The GOAL MAMI supervisor trained a maximum of 30 COAs per session, after which they began using the tapes in the community. COAs then trained caregivers in a series of short, house-to-house training sessions using social distancing measures. Caregivers were given their own MUAC tapes and all tapes used by COAs and caregivers were wiped with a soap and water solution before each measurement.    

A first follow-up assessment was carried out in July 2020, two months after caregiver training, during which caregivers’ screening performance was compared with that of the COAs. The same assessment was repeated in November 2020, six months after caregiver training. At this point, caregivers’ experiences of using the MAMI-MUAC tape were also assessed using a simple checklist that collected information on the tape’s wear and tear, its place of storage, any reported confusion over using the tape, the frequency of screening and any barriers to referral to health facilities.   

Any changes in case referrals following the training were also analysed using enrolment data from the MAMI programme database.⁵ MAMI referrals were recorded as follows: self-referral (referral by caregivers), outreach referral (referral by COAs), health facility referral, inpatient referral and monthly screening referral. Average monthly referrals were compared before (May 2019-April 2020) and after (May 2020-December 2020) training.

Findings

Overall, 112/125 (89.7%) COAs and 1,289/1,289 (100%) caregivers with infants under six months of age received training. Two months after training, the sensitivity (the ability to correctly identify cases of wasting) and specificity (the ability to correctly identify those children without wasting) were 100% and 98.6%, respectively. Six months after training, sensitivity was 88.9% and specificity was 96.2%.    

Overall, the total number of referrals increased after Family MUAC training. Prior to training, there was an average of 11.6 monthly referrals which increased to 19.1 after training. Outreach referrals contributed to most of the average monthly referrals prior to training (77.0%) and there were no self-referrals. After training, there was a reduction in outreach referrals to 45.3% of monthly referrals and an increase of self-referrals to 41.4% of total referrals.  

Findings showed that 56% of caregivers experienced no wear and tear of MUAC tapes, 67% reported no confusion while using the tapes and 93% reported no barriers to referral. Of caregivers who experienced wear and tear on tapes, this was minimal and did not affect the functionality of the tape. The majority of caregivers who reported confusion when using the tapes attributed this to their reversible nature. The majority of caregivers (65%) stored tapes in a bag, one fifth (19%) kept them on a table, a wall or on the front of a door, 4% kept them in a book and 2% had lost the tape. The majority of caregivers reported using the tape weekly (69%) while 7% reported monthly use, 12% reported use every 15 days and 12% reported daily use.

Discussion

Despite the COVID-19 pandemic, high coverage of training was achieved (>90%) for COAs and caregivers of infants under six months of age. The majority of caregivers correctly identified the MUAC of their infants up to six months after training. A large proportion of caregivers were actively screening and self-referring their infants alongside widespread, active case finding by COAs in their communities.

Experiences from this MAMI programme show that the screening of infants under six months of age using MAMI-MUAC tapes by COAs and caregivers is a feasible and effective approach. This highlights the value of MUAC screening in the context of COVID-19. It also shows the effective functioning of the MAMI-MUAC tape when appropriate training and supervision are provided.  

In light of these findings, the feasibility of moving exclusively to Family MUAC for screening infants under six months of age is being explored by GOAL. This would reduce physical contact between health workers and beneficiaries and minimise the risk of COVID-19 transmission. The time saved by health workers could also be used to provide other services such as community-based nutrition education or counselling, tracing of absentee and defaulted infants and programme monitoring.

For more information, please contact Hatty Barthorp at: hbarthorp@goal.ie

GTAM Conversations on how programmes are adapting in light of COVID-19: Implementing the Family MUAC approach in Gambella, Ethiopia. https://www.ennonline.net//mediahub/podcast/gtamconversationsmuacethiopia