RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

RAPID REVIEW:
Screening of Acute
Malnutrition by the Family
at community level

1
 Contents

3 Rapid review protocol

3 A. Background on the Family-MUAC approach

and the justification for the rapid review

3 B. Objectives

3 C. Methodology

5 Rapid review: results

5 A. Quick assessment of evidence

6 B. Outcomes: effectiveness, cost-effectiveness

and gaps

21 C. Implementation and related recommendations

34 Summary of recommendations

37 Bibliography
 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Rapid review protocol

A. Background on the Family-MUAC approach C1. Review question

and the justification for the rapid review
The review questions were mainly oriented
The Family-MUAC approach is widely around effectiveness and cost-effectiveness of
implemented in countries across Africa and Asia, this community approach to detect malnutrition.
but predominantly in in the West and Central This review presents the main results in terms of
Africa region. Also known as “MUAC for mothers” detection, quality of treatment, cost-effectiveness
or “Mother-MUAC”, this approach trains mothers and coverage of the Family-MUAC approach.
and other caregivers to identify early signs of
malnutrition in their children using a simple to Main review question:
use Mid-Upper Arm Circumference (MUAC) tape. What is the effectiveness and cost-
The approach was developed with the objective effectiveness of the Family-MUAC approach?
of improving coverage of treatment services,
detecting cases earlier and improving awareness Additional sub-questions:
on malnutrition. What are the effectiveness outcomes of the
Family-MUAC approach (quality and timing
B. Objectives of screening/quality of treatment/impact on
coverage)?
The overall aim of the rapid review is to provide an What is the cost-effectiveness of the Family-
assessment of the current evidence and practice MUAC approach?
on the Family-MUAC approach.
Other operational questions:
The specific objectives of the review are: What are the implementation approaches
To present a clear overview of the available of the Family-Approach (what context are
evidence considered? What tools? What trainings? What
To summarize the available evidence, showing M&E mechanism…)?
what is known about the impacts, outcomes and
implementation of this approach C2. Study inclusion criteria
To appraise about what is still not known,
or difficult to establish (i.e. to identify critical The rapid review used peer-reviewed literature,
weaknesses in the evidence and practice). grey literature (reports, evaluations/assessments,
webinars, briefs…), unpublished evidence
C. Methodology (workshop reports, internal reports, guidance
note, M&E tools, training tools) and expert
A rapid review of published and unpublished consultations.
evidence was conducted, including future
evidence (coming between April 2020 and Population/Intervention: Mothers/caregivers
October 2020). Implementers of the Family- screening malnutrition using a MUAC-tape at
MUAC approach in the West and Central Africa community-level, in any countries, any context.
region were also contacted.

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Comparators (potential): Community Health Field Exchange website and the State of Acute
Workers screening acute malnutrition at Malnutrition website to locate evidence on field
community level, Standard protocol. experiences and to have an overview on simplified
Outcomes: The effectiveness of the intervention approaches experimentations.
will be assessed through the timing of detection Websites of known implementers of the Family-
(early detection) and its quality (capacities MUAC approach: GOAL, World Vision, COOPI,
of mothers to correctly detect and diagnose ALIMA, ACF, Concern Worldwide, IRC, IMC, MSF.
malnutrition and edema), the quality of treatment Reference lists of relevant studies and of papers
(fewer hospitalization/faster recovery), the impact that have been identified by the database searches
on coverage, the cost-effectiveness and the to identify further studies of interest.
sustainability/feasibility of the approach. Google and clinical trials to identify recent/future
evidence and implementers of the approach
The cost-effectiveness will be assessed through in countries. For operational evidence which
the available data (cost per child, total cost, cost was not available online (“invisible evidence”),
of tools, costs of trainings, cost-effectiveness implementers were contacted.
analysis)
The search structure consisted of the following
C3. Search strategy (simplified for the rapid key words:
review) Community-based management of acute
malnutrition; Mid-upper arm circumference;
Electronic bibliographic databases to locate peer- Screening by mothers; Severe acute
reviewed literature: PubMed and ClinicalTrials. malnutrition; Family-MUAC, screening at
This type of evidence was also obtained directly community-level; task shifting
through authors sharing their publication.

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Rapid review: results

A. Quick assessment of evidence Wasted Lives coalition which has gathered and
coordinated evidence for acute malnutrition on
In total, 46 pieces of evidence have been a single platform1. Peer-reviewed studies mainly
included in this review: 6 peer-reviewed focus on assessing the ability of mothers to
evidence, 1 document on preliminary results, 1 take MUAC measurements and/or comparing
trial, 1 landscape review, 1 conference abstract, outcomes with screening by CHWs but also
10 case-studies, 4 guidance notes, 20 documents include some evidence on the timing of detection
related to implementation (5 training guides, and its association with the cost-effectiveness of
3 capitalization reports, 4 M&E tool kits, 5 final treatment (fewer hospitalizations/faster recovery).
reports/evaluation, 3 coverage surveys), 1 webinar
and 1 workshop report including case-studies. Countries
Regarding countries covered by the available
Type of evidence evidence, 16 countries (out of 25 countries
Most of the available evidence on the Family- where the approach is known to be implemented;
MUAC approach consists of operational evidence https://www.acutemalnutrition.org/en/Family-
(87%) such as case-studies and documents MUAC) have produced the available evidence on
related to implementation (e.g. training guides the Family-MUAC approach, mainly countries on
and final reports). the African continent.

There are several documents linked to Only 3 countries are covered by peer-reviewed
implementation, such as case-studies or evidence: Kenya (ACF), Niger (ALIMA, MSF)
capitalization reports in different countries which and Burkina Faso (ALIMA). In Niger, trials were
provide an overview of outcomes linked to undertaken in the Zinder region (2 by ALIMA) and
this approach and contexts where it has been in the Maradi region (1 by MSF).
implemented. Several of these case-studies
have been produced with the support of the No

GRAPH 1. Type of available evidence on the GRAPH 2. Countries covered by collected evidence
Family-MUAC approach (n=46) on the Family-MUAC approach for this review (n=16)

13%
Peer-reviewed
evidence

87%
Operational
Documents

1. https://www.acutemalnutrition.org/en 5
 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Implementers GRAPH 3. Production of evidence depending on

ACF (26%), ALIMA (15%) and GOAL (13%) are organizations (n=46)

the 3 main organizations who contributed to the

wider available evidence on the Family-MUAC
Concern
approach (see graph 3).
IRC 2% MSF Other - 4%
Croix Rouge 2%
Evidence from ACF comes from the Eastern and Francaise - 7%
2%
Alima
Southern part of the African continent (Kenya, Save the Children 15%
International- 7%
Tanzania), from the Western part (Senegal) and
UNICEF &
from Asia (India) whereas ALIMA has produced partners - 9% Cortasam
5%
large and solid evidence for countries in the World Vision
4%
WCA region (Niger and Burkina Faso). Whilst COOPI ACF
26%
ALIMA provided more data/evidence on different 2%
IMC
effectiveness outcomes of the approach, ACF 2%
GOAL - 13%
publications have focused on sharing information
on the approach in different contexts and
capitalizing on operational experiences.
Cost (potential reduction per case treated)
B. Outcomes: effectiveness, cost-effectiveness Coverage (potential improved coverage through
and gaps massive and repetitive screening by mothers at
the household level)
The Family-MUAC approach considers that (Sustainability/Implementation: contextualization
caregivers are positioned to detect signs of and limitations)
nutritional deterioration in their own children, and
that training caregivers to regularly screen by B1. Quality of detection: Ability of mothers to
MUAC and check for edema is the next step in a measure MUAC
process of improved access to CMAM services.
The rationale for teaching caregivers to perform The peer-reviewed studies give solid information
MUAC is to achieve an early detection of on the effectiveness of this approach in terms
wasting, which if acted upon in a timely manner of quality of detection by demonstrating the
would decrease mortality and morbidity related effectiveness of the measurements made by
to malnutrition, reduce program costs due to caregivers compared to CHWs and/or experienced
shorter treatment times and lower the proportion worker (see table 1).
of children requiring expensive in-patient care
for wasting with complications (Ale et 2016; 6 peer-reviewed studies (including 1 systematic
Blackwell et al, 2015; Grant et al, 2018; Puett et al, review) have clearly assessed the capacity of
2013; Sadler et al, 2011; Daures et al, 2020). caregivers to make MUAC measurements.

The effectiveness and cost-effectiveness of this Blackwell et al (2015) and Ale et al (2016) have
approach can be assessed through the available identified the capacity of caregivers to make
evidence (published evidence and operational MUAC measurements. Ale et al (2016) have also
findings) in terms of: assessed capacity of edema measurements and
Quality of detection (correct MUAC compared cost between mothers and CHWs
measurements, MUAC measurement protocol) Grant et al (2018) have compared and assessed
Timing of detection (potential earlier detection) the sensitivity of tools used by caregivers in a
Quality of treatment: rate of hospitalization/need Family-MUAC approach (1 study)
for inpatient care (potential lower rate), average Bliss et al (2018) have concluded that
length of stay (potential shorter stay), recovery caregivers and CHWs are able to use MUAC
(potential faster recovery) to detect SAM after a systematic review of the
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available evidence on the use of MUAC by Novel except the percentage of self-referral by mothers).
Community Platforms Isanaka et al (2020) have assessed the feasibility
Daures et al (2020) have assessed the of engaging caregivers in at‐home surveillance
effectiveness of a simplified protocol for of children with uncomplicated severe acute
treatment of wasting which included a Family- malnutrition. They found that caregivers could
MUAC approach (no direct indicator to assess correctly perform a MUAC measurement after
effectiveness of the Family-MUAC approach a short training (less than 30 min).

TABLE 1. Results on the quality of detection

(published peer-reviewed studies including the Family-MUAC approach)

Peer-reviewed Results on Quality

Objective
evidence of detection (sensitivity)

All devices yielded high sensitivity (>93%) for

Grant, 2018 To test the sensitivity of 3 MUAC classification
detecting SAM. Sensitivity for SAM was highest
(Kenya) devices when used by caregivers/mothers (Kenya)
(100%) with the standard MUAC insertion tapes.

Good ability of mothers: Mothers’ ability to classify

To determine whether minimally trained mothers
GAM and SAM had high sensitivity (>90% of GAM
Blackwell, 2015 could identify children with SAM, using either
and >73% of SAM cases correctly identified as such)
(Niger) arm and without measuring the specific midpoint
and high specificity (>80% of GAM and >98% of
(Niger)
non-cases correctly identified as such).

Good capacity of mothers (compared to/superior

To compare the efficacy and cost-effectiveness of to CHWs): Mothers’ MUAC measurements were
Ale et al, 2016
maternal measurement of child MUAC and edema in agreement with those of health workers more
(Niger)
with CHW measurement (Niger) frequently than those made by CHWs (non-inferiority.
75.42% vs 40.11%, P<.0001).

To determine whether OptiMA (strategy

including training mothers to use mid upper arm
Daures et al, circumference (MUAC) bracelets for screening
2020 and targets treatment to children with MUAC < No mention
(Burkina Faso) 125 mm or oedema with one therapeutic food at
a gradually reduced dose) conforms to SPHERE
standards (recovery rate > 75 %).

To summarize published and operational evidence

published describing the use of MUAC for
Bliss et al, 2018 Caregivers can use MUAC to detect SAM in their
detection and diagnosis of SAM in children aged
(systematic children with little apparent risk and many potential
6–59 months by caregivers and CHWs, and of
review) benefits to early case detection and coverage
management of uncomplicated SAM by CHWs, all
outside of formal health care settings

Agreement between nurse–caregiver mid‐upper

arm circumference color classifications was 77%
To assess the feasibility of shifting clinical (98/128) immediately after training These findings
Isanaka et al,
surveillance to caregivers in the outpatient lend preliminary support to pursue further study
2020 (Niger)
management of SAM of alternative models of care that allow for greater
engagement of caregivers in the clinical and
anthropometric surveillance of children with SAM.

Errors only at boundaries. Regarding errors, (Blackwell et al, 2015; Ale et al, 2016), which
MUAC classification errors (or discordance) reinforce the demonstration of the effectiveness
occurred at class boundaries, i.e. the border of the Family-MUAC approach.
between red (SAM) and yellow (MAM), and
yellow and green (normal), rather than randomly, What are the operational findings telling us
and there are no gross discordances. Thus, about the capacity of caregivers?
caregivers do not classify a child as normal when Among operational findings and studies, the same
the CHW diagnosis is SAM, nor do they classify a observation can be made concerning the ability of
child as SAM when the CHW diagnosis is normal mothers measuring MUAC (see table 2.)

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TABLE 2. Results on the quality of detection (operational findings)

Operational findings Country Results on Quality of detection (sensitivity, correct measurements)

Cameroon, Chad, Mothers/parents correctly using MUAC: Cameroon 2019 (72.7%),

LQAS survey_CRF_2016
Niger, Mauritania Chad 2020 (59%), Niger 2019 (57,1%), Mauritania 2019 (50%)

Multicountry project_GOAL Ethiopia, Malawi, 86% of self-referrals to Health Facilities were recorded as correct
(2018) South Sudan admissions (79% Malawi, 80% S.S. and 100% Ethiopia)

87% of the mothers have correctly identified acute malnutrition

UNICEF_Evaluation_2018 Madagascar
(MAM+SAM)

Project_COOPI_2018 RDC 97% of referral by MUAC mothers were admitted in health centers

SLEAC survey and impact

60% of mothers made a correct MUAC measurement
study of Mother-MUAC_ Senegal
5 months after the first training
ACF_2016

93% of mothers made a correct MUAC measurement

Final report_ACF_2018 Senegal
6 months after the first training

MUAC measurements that were validated as correct

UNICEF_Case-study_2020 Zimbabwe
were 80% (CI 69% -100%)

However, two main limitations have been reported that mothers are in a better position to detect
by available evidence (qualitative and quantitative potential cases of a deadly condition with
data): rapid onset and resolution in either death or
The capacity of caregivers seems to decrease spontaneous recovery), and yet, fewer children
several months after the last training, meaning were admitted to the treatment program for
that refreshments/trainings should be regularly edema (47.19%). Based on Hamer et al (2004),
done and in a sustainable manner. ACF in Matam Ale explains this result by suggesting that in
recommended to conduct the training each 6 settings where there is a low prevalence of
month “for the mothers to remember how to edema, it can be difficult (even for health staff)
measure MUAC. to reliably identify edematous malnutrition and
Caregivers seem to have less ability to detect therefore recommends that ability of mothers to
edema, especially in area where there is a low detect edema should be further studied in an area
prevalence of edema (Ale et al, 2016) of high prevalence.

Ability over time In Senegal, results of the interviews from

Data provided by the CRF (Niger-Cameroon-Chad- keypersons involved in the MUAC-mother pilot
Mauritania) show that the sensitivity of MUAC project (staff from ACF) also raise this concern
measurements made by caregivers may decrease of reduced ability of detecting edema while
over time, as time passes from the last training indicating that mothers can detect SAM and
or refreshment. After 1 year, only half of mothers MAM using MUAC but not edema2.
can take correct MUAC measurements.

Detection of edema
In Niger, Ale et al (2016) showed that more
children were referred for edema in the Mothers
Zone compared to the CHWs zone (suggesting

2. Enquête SLEAC du programme PECMAS et étude sur l’impact du projet pilote « PB Mamans », ACF Lort-Philips et al, November 2016. Projet Renforcement de la lutte contre la malnutrition aigüe sévère et de sa prise 8
en charge au Sénégal par une approche multisectorielle et intégrée dans la région de Matam, Sénégal.
 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

B2. Quality of detection: MUAC measurement Main results on Quality

(either arm visual mid-point) of detection

In the standard protocol for measuring MUAC Ability of caregivers. Based on operational
to screen for acute malnutrition, a health care findings and peer-reviewed studies, it is
provider bends the child’s left arm to locate and clear that caregivers can correctly take
mark the midpoint. Then the arm is relaxed straight, MUAC measurements.
the MUAC tape is wrapped around the midpoint,
and the circumference of the arm is recorded to Detection of edema. In setting with low
the nearest 1 millimeter (De Onis, 2004). Another prevalence of edema, ability of caregivers
MUAC protocol recommends using either arm and to detect edema seems to be lower and
a visual ascertainment of midpoint to measure yet aligned with the “global ability”
MUAC (ALIMA, Guidelines for training of trainers, (CHWs, health workers) of detecting
2016) to simplify measurements. edema in these settings.

Blackwell et al (2015) have showed that this MUAC measurement protocol: the
protocol (either arm and visual ascertainment MUAC protocol (either arm and visual
of midpoint) performed as well as the standard ascertainment of midpoint) used by
protocol. Accuracy was not influenced by which some implementers performed as well
arm (right or left) was measured nor by how the as the standard protocol for MUAC
mid-point of the upper arm was determined (by- measurement
eye or by measurement), providing evidence that
could simplify training while maintaining accuracy
and precision Recommendations

Other published evidence stated that this Recommendation: Conduct regular

way of measuring could simplify training of assessment of ability of caregivers and/
mothers/caregivers while maintaining accuracy or integrate (refresher) trainings in the
and precision (Ale et al, 2016) and may hold health system platform as the ability of
additional potential in increasing effectiveness caregivers tends to decrease over time
of community/caregiver MUAC use in different after the last training.
contexts (Bliss et al, 2018).
Recommendation: Further studies are
needed to assess the ability of caregivers
in areas where edema is highly prevalent
(Ale et al, 2016) and/or improve trainings
related to the specific detection of
edema for both health staff and mothers/
caregivers in low-prevalence settings.

Recommendation: The “simplified”

MUAC protocol (either arm and visual
ascertainment of midpoint) should be
used in all Family-MUAC strategies, as it
doesn’t influence accuracy of measures
and as it can greatly simplify trainings.

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B3. Timing of detection and quality of treatment: However, most of the peer-reviewed studies
Early detection and fewer hospitalizations (4/6) rather suggest and/or presuppose that
the approach leads to an earlier detection. Only
One of the expected outcomes of this approach one (Ale et al, 2016) includes results showing
is an earlier detection and treatment seeking with an effective earlier detection. It showed higher
an expected lower rate of hospitalization and median MUAC measurements at admission (for
reduction of cost per case treated. children referred by mothers compared to children
In terms of timing of detection, there are promising referred by CHWs) and a lower requirement for
results on an earlier detection among operational inpatient care among children admitted upon
findings and peer-reviewed studies. referral of mothers (see table 3).

TABLE 3. Results on the timing of detection and quality of treatment: early detection and hospitalizations
(published peer-reviewed studies)

Quality of
Article Early detection Fewer Hopitalizations
evidence

Proved. In the Mothers Zone, there was earlier Proved. Consistent with earlier detection
detection of cases, with median MUAC at and treatment seeking, children
admission for those enrolled by MUAC <115 mm admitted in the Mothers Zone were
estimated to be 1.6 mm higher using a smoothed less likely to require inpatient care
Ale et al, bootstrap procedure than children in the CHWs Zone, both
Strong3
2016 (Niger) at admission and during treatment,
This study demonstrates that earlier detection of with the most pronounced difference
SAM can be achieved by training mothers to classify at admission for those enrolled by
the nutritional status of their children by regular MUAC < 115 mm (risk ratio = 0.09 [95 %
MUAC screenings CI 0.03; 0.25], p < 0.0001)

Assumptions (No results/indicators).

In the background, the author states
Assumptions (No results/indicators). In the
that the rationale for teaching mothers
discussion, the author is advocating for the use of
to perform MUAC is to achieve an early
the Family-MUAC as the tipping point in scaling up
Blackwell, diagnosis of SAM, which will result
CMAM programmes thanks to repeated screening
2015 (Niger) in lowering the proportion of children
with MUAC,that will increase the likelihood of early
requiring expensive in-patient care for
diagnosis, even if the initial screen classified the
SAM with complications (as shown
child incorrectly.
in a study from Bangladesh (Sadler,
2011;Puett, 2013)

Suggested: the author found evidence that

Bliss et al, caregivers are able to use MUAC to detect SAM in
No mention
2018 their children with minimal risk and many potential
benefits to early case detection and coverage

Suggested. In the discussion, the author suggest

that under OptiMA and compard to the study of
Maust et al (2015) in Sierra Leone, the OptiMA Assumptions (No results/indicators).
programme might have achieved achieved good No Other studies found that identification
Daures et
coverage and caught most children early in the and treatment of children earlier in
al, 2020
wasting process as only 16 % of children treated the wasting process led to fewer
(Burkina
were admitted with MUAC < 115mm or oedema, hospitalisations and that inpatient care
Faso)
while 84 % were admitted with MUAC between 115 was shown to be twice as costly as
and 124 mm, whereas the proportion of children in outpatient SAM management.
each category in the Sierra Leone study was 30 and
70 % (Maust et al, 2015).

Assumptions (No results/indicators). In the Assumptions (No results/indicators).

background, the author is presenting the advantages In the background, the author is stating
of an early diagnosis of a SAM case in decreasing that an early diagnosis of a SAM case
mortality and morbidity related to malnutrition, would reduce per-case treatment costs
Grant, 2018
reducing per-case treatment costs thanks to shorter thanks to shorter treatment times and
(Kenya)
treatment times and lowering the numbers of lower the numbers of children requiring
children requiring expensive in-patient care for SAM expensive in-patient care for SAM (based
(based on published evidence in the context of on published evidence in the context of
Bangladesh: Sadler, 2011; Puett, 2013) Bangladesh: Sadler, 2011; Puett, 2013)

3. Strong = evidence extracted from a peer-reviewed article; medium = evidence extracted from a case-study including a relative important set of data; weak = case-study or policy brief with little/absent data or opinions
of experts including no data (Classification developed by author) 10
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Ale et al (2016) showed that children in the As stated by some partners, it can be difficult to
Mothers Zone were admitted at an earlier stage prove an early detection/impact on hospitalization
of SAM and required fewer hospitalizations4 through operational research or implementation of
Daures et al (2020) suggested that under a Family-MUAC project. Probably because there is
OptiMA and compared to the study of Maust et a need for a “standard” and feasible indicator to
al (2015) in Sierra Leone, the OptiMA programme be able to assess these outcomes. The indicator
might have caught most children early in the “Median MUAC at admission for children referred
wasting process as there is a smaller proportion through mothers” seems to be the most reliable
of SAM children (16% vs 30 % in Maust et al, to assess an early detection when compared
2015) to another source of referral and/or zone and/
Both Grant (2018) and Blackwell (2015) are or periods of time since the beginning of a
stating that an early admission would lead to projects (the comparison with another screening
an increased effectiveness (shorter treatment mechanism/standard protocol may however be
time) and cost-effectiveness (lower the number the most striking evidence to support advocacy).
of inpatient care) based on published results in
Bangladesh (Sadler et al, 2011; Puett et al, 2013). In Kenya, ACF suggests that Family-MUAC may
have also led to earlier detection of MAM, as the
What are the operational findings in terms average MUAC on admission to MAM treatment
of early detection and lower requirement for increased at the end of data collection when
inpatient care at admissions and/or during compared to the start of data collection. In the
treatment? same country, Concern Worldwide used the same
indicator in time to prove an earlier detection.
Out of the current evidence including operational In the DRC, COOPI used the frequency of
findings (20 documents: 10 case-studies, 5 screenings as a proxy of an early detection,
final report/evaluation, 3 coverage surveys, 3 suggesting that the higher frequency of screening
capitalization reports), only 4 document a potential made by mothers (four times a month) will
early detection as an outcome of the Family- therefore allow an earlier detection compared to
MUAC approach, and 2 document a potential the “standard” detection (once a month) made by
decrease in hospitalizations. CHWs.

TABLE 4. Results on the timing of detection and quality of treatment: early detection and hospitalizations
(operational findings)

Operational findings Early detection Fewer Hopitalizations

Assumptions (No results/indicators). In the

Suggested: Median MUAC at background, the author is stating that an early
SLEAC survey and
admission = 111 with a high diagnosis of a SAM case would reduce per-case
impact study of
proportion of children admitted treatment costs thanks to shorter treatment
Mother-MUAC_
with MUAC 110-114mm. The times and lower the numbers of children requiring
ACF_2016_Senegal
author suggested that this expensive in-patient care for SAM (based on
(Matam)
constitute an early detection published evidence in the context of Bangladesh:
Sadler, 2011; Puett, 2013)

Suggested: Results indicate that

the use of the simplified tape
may have also led to earlier No significant change in admissions but in
Case-study_ACF
detection of MAM, as the comparison to the previous year, admissions
Kenya (Isiolo County,
average MUAC on admission to reduced slightly, and this could indicate that fewer Medium
2017) linked to Grant
MAM treatment was increased children are becoming malnourished as their
et al (2018)
at the end of data collection, as mothers are monitoring their state of malnutrition
compared to the start of data
collection.

4. Ale et al (2016), Niger: Although it is likely that screening by mothers contributed to the observed difference in proportion of hospitalized cases in the two zones, this is not certain as hospital referrals depend on
many factors (e.g. clinicians’ level of training and/or experience).
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Operational findings Early detection Fewer Hopitalizations

Suggested: The higher frequency

of screening by mothers (88% Assumptions: By taking MUAC measurements at
of children admitted through least four times per month, MUAC mothers improve
referral by mothers were nutrition surveillance and the early detection of
Case-study_COOPI
screened at least 4 times per malnourished children. The earlier the detection,
(DRC)_2018
month) compared to CHWs (once the shorter and more efficient the treatment, which
a month) allows the author to therefore reduces the risk of medical complications
conclude that there is an early and mortality.
detection of cases of malnutrition.

Proved: There was an

improvement on the Median
MUAC at admission for both OTP
Final report_Concern
and SFP Programs from 11.0cm
Worlwide_2020_ Medium
and 12.0cm during the baseline to
Kenya
11.4cm and 12.2cm respectively,
observed during the end line
assessment.

B4. Quality of treatment: average length of stay is little evidence related to a shorter stay and/
and recovery or an impact on recovery, and/or there is almost
no comparison between the average time to
Apart from an expected decrease of children recovery for children admitted by Family-MUAC
needing inpatient care, the quality of treatment and average from another source of referral.
associated to the approach has been assessed by However, Daures et al, 2020 showed for the first
the comparison of the average length of stay of time that children of a caretaker who received
children admitted through the referral of caregivers MUAC training were more likely to recover,
compared to another source of referrals. A case- which could be explained by a better care-
study from COOPI in DRC (2018) suggests, that seeking behaviour resulting from such trainings.
“the earlier the detection, the shorter and more Operational experiences of COOPI in DRC
efficient the treatment, which therefore reduces revealed a shorter stay of children referred by
the risk of medical complications and mortality”. MUAC mothers (32 days vs 41 days) compared to
children referred by CHWs.
Among all studies/operational findings, there

TABLE 5. Results on the timing of detection and quality of treatment: early detection and hospitalizations
(published peer-reviewed studies)

Quality of
Study Quality of treatment (Average length of stay and recovery)
evidence

No possible comparison due to presence of MAM treatment

Program lengths of stay were expected to be shorter in the Mothers Zone but
comparison was not possible because the therapeutic supplementary feeding
Ale et al, 2016
programs (i.e. programs treating MAM) in the zones were operating at different levels
(Niger)
of capacity, causing children to be retained in the therapeutic feeding program longer
in the Mothers Zone than in the CHWs Zone.

No comparison between average length of stay and source of referral. Average

time to recovery: 5.8 weeks (all children); 8.1 (<115 and edema)
Positive association between being MUAC-trained and recovery. Child of a
Daures et al, 2020
caretaker who received MUAC training (adjusted hazard ratio 1·09; 95 % CI 1·01, Strong5
(Burkina Faso)
1·19) were more likely to recover. It is the first time that a positive association is
demonstrated between training mother to use MUAC bracelet and recovery, likely
due to a better care-seeking behaviour resulting from such trainings

5. Strong = evidence extracted from a peer-reviewed article; medium = evidence extracted from a case-study including a relative important set of data; weak = case-study or policy brief with little/absent data or opinions
of experts including no data
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Quality of
Study Quality of treatment (Average length of stay and recovery)
evidence

Operational findings

Shorter stay for children referred by MUAC mothers. With regards to the recovery
of children screened and admitted by CHWs and MUAC mothers:
COOPI (DRC) Medium
• The average length of stay of the children referred by CHWs was 41 days
• The average length of stay of the children referred by MUAC mothers was 32 days

ACF Senegal (Matam

No comparison. Average time to recovery: 6 weeks (2016)
region, SLEAC)

GOAL (Ethiopia- No significant results (Ethiopia) or absence of data (Malawi/S.Sudan) on average length
Malawi-S.Sudan) of stay or weight gain

Main results on timing of Recommendations

detection and quality of
treatment Recommendation:
Further studies are needed to assess the
Early detection effectiveness of this approach in terms
and fewer hospitalizations of quality of treatment (earlier/shorter)
Although it is mainly presupposed or in different settings and by comparison
suggested by implementers/researchers with standard protocol or referral by
that the Family-MUAC approach leads another source (CHWs).
to an earlier detection, one study (Ale
et al, 2016) showed an effective earlier Recommendation:
detection and fewer admissions to Implementers should include standard
hospitals in Niger. Results are promising and feasible indicators in their M&E
but further evidence/documentation is strategy to enable implementers to
needed in different contexts. further assess this part and make
comparisons possible between different
Shorter stay and recovery contexts (See section on M&E)
There is little evidence on the fact that a
Family-MUAC approach can improve the
quality of treatment by reducing time
needed for it and by fasting recovery.
But one study (Daures et al, 2020)
showed for the first time that children of
a caretaker who received MUAC training
were more likely to recover, which could
be explained by a better care-seeking
behavior resulting from such trainings.
In the DRC, COOPI found a shorter stay
for children admitted through mother’s
referral, compared to CHWs (32 vs 41
days)

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B5. Coverage These may also be the reasons why implementers

are using (and testing) various indicators - and
Coverage assessments consistently show not sharing the same standard indicators – and
program coverage for CMAM services to be lower sometimes struggling to try to assess the impact
than expected and failing to meet context-specific of the Family-MUAC on coverage of CMAM
internationally agreed minimum standards services.
for coverage (50% or under in rural settings),
meaning high-risk cases are not being diagnosed However, based on available evidence,
and children are not accessing the essential life- an examination of all indicators used by
saving treatment they need. implementers/researchers to assess coverage
was conducted and their reliability/limitations
In most community settings, either community were also assessed. Below are the 2 main types
health workers periodically, or opportunistically of indicators related to coverage observed within
measure/check children for acute malnutrition in the available evidence:
the communities where they work or periodic Indicators related to the coverage of community
mass screenings occur. Opportunistic screening screening/coverage of MUAC utilization
by health workers is known to have very limited (frequency of screening by mothers; % children
coverage and mass screenings happen so admitted to malnutrition treatment upon referral
periodically that again, many cases will be missed of mothers; % of caregivers who have been using
between cycles. MUAC over the last 4 weeks)
Indicators related to the coverage of
By including caregivers in the detection of programme: proportion of children aged
malnutrition, the Family MUAC approach is between 6 and 59 months with MUAC < 115
perceived to have the potential to increase mm or bilateral oedema at the time of a survey
coverage of CMAM programs. who are effectively supported in an appropriate
nutrition program (indicators used for SLEAC/
Regarding evidence on the impact of the Family- SQUEAC surveys); variation in admission to
MUAC approach, the word “coverage” remains a services (routine programme data)
broad term which covers very different indicators
depending on what is attempted to be assessed by Coverage of community screening
implementers/researchers (screening, coverage
of CMAM services…). At the same time, it seems According to the evidence, the Family-MUAC
difficult to assess the real impact of this approach approach can lead to an improved coverage
on coverage as there are other permanent of screening. This improvement has been
factors which can explain variations of coverage demonstrated by an increase in the frequency
(presence of other actors/programmes, external of community screening in different contexts.
events, difference in terms of RH capacities, Operational findings suggest and prove that
geographic distance…). Therefore, it may be screening within households is more likely to be
difficult to clearly assess the impact of the Family- repeated several times a month (ALIMA, COOPI).
MUAC approach on coverage, independently Moreover, when caregivers are in charge, the
from other factors, and this could explain why the valuable time of CHW’s can be put towards
impact on coverage is still not clear for this home- covering other geographic areas and therefore
based screening (Bliss et al, 2018; CORTASAM, improve the coverage of screening (GOAL,
landscapes analysis, 2020). COOPI).

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Frequency of screening. Some implementers Operational findings include data on the frequency
have demonstrated an increased frequency of screening by mothers among operational
of screening when done by caregivers which findings. Multiples experiences of ACF in Senegal,
then indicates an improved coverage of ALIMA in Burkina Faso and the CRF multi-country
screening. According to the available evidence, scope in Niger-Chad-Mauritania-Cameroon,
an “increase” can be defined by comparing data provide an interesting overview of this indicator.
with data from another screening mechanism A vast majority of caregivers are reported to
(CHWs) but is mainly based on the fact that a take MUAC measurements several times a
caregivers is expected to screen their child at month (see table 6).
least once a week (as recommended by several
implementers in training guides/see part C.2).

TABLE 6. Operational findings related to frequency of screening by mothers (improved coverage of

community screening)

Operational findings Frequency of screening by mothers (coverage of MUAC utilization)

Children are screened by mothers at least four times a month instead of once a month
by the CHWs. COOPI concludes that because mothers of malnourished children are taking
COOPI (DRC) care of the screening and follow-up of the children in their village, this allows CHWs to
screen in other villages, and to come back only to follow up with the children detected by the
mothers

ACF Senegal (Matam

89.8% of mothers are taking MUAC measurement once a week
region) SLEAC 2016

ACF Senegal (Louga

93.2% of households have taken MUAC measurement at least once a week (61.5% have
region) Capitalization
taken measurement once a week)
report 2018

CRF_LQAS survey_
90.4% (Cameroon); 68.3% (Chad); 53.7% (Niger); 20% (Mauritania) have taken MUAC
Cameroon-Chad-Niger-
measurements in the past four weeks
Mauritania_2016

ALIMA_Capitalization
91% of mothers have taken MUAC measurements at least every two weeks
report_Burkina Faso_2016

But it is also important to consider the mothers stopped at the end of the project in the
sustainability of MUAC utilization: there may absence of partners. The same challenge appears
be a decrease of MUAC utilization overtime if with an ACF’s pilot in India which revealed that
no support is provided. Data from CRF showed only 30% of mothers trained to use MUAC tapes
that the ability of mothers using MUAC would measured their children in the 7 months following
decrease as the months pass following the most training.
recent training (see part B.1).
Regarding frequency of MUAC utilization, it Children admitted to malnutrition treatment
seems to follow the same pattern. For instance, by referral of mothers (self-referral by mothers)
the low proportion of mothers who took MUAC Theoretically, this indicator can inform on the
measurements (20%) in the past month (April effectiveness of the Family-MUAC approach,
2019) in Mauritania could be (partially) explained showing that there is an important proportion of
by the fact that there have been 10 to 14 months children arriving and being admitted at the health
since the initial training, with no follow-ups. centers by referral of their mothers who detected
The case-study of COOPI in DRC mentioned a potential malnutrition at home.
challenge linked to sustainability: the screening by
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Table 7 shows that the proportion of children admitted by reference of mothers is quite low, less than
40% and always lower than the proportion referred by CHWs (DRC, Senegal, Mali, Burkina Faso…).

Some implementers (CRF, ALIMA) have investigated why and found that mothers were screening but
then went to CHW to confirm the screening (to save time and money before going to the health center).
If confirmed by the CHW and once they arrived at the health centers, mothers were telling the health
center staffs they were referred by the CHW.

TABLE 7. Evidence on children admitted by referral of mothers

Study Admissions referred by mothers

12·9 % of all admissions are referred by mothers vs 39.3% by CHWs. ALIMA explains
Daures et al, 2020 that this low proportion is likely due to an underestimation because many mothers sought
(Burkina Faso) confirmation from a Community Health Worker (CHW) after using MUAC at home and then
reported being referred by a CHW at admission.

Operational findings

ACF Senegal (Matam

Less than 10%* of all admissions are referred my mothers vs 14% by CHWs
region) SLEAC 2016

ALIMA Mirriah Niger 2017 71% of all admissions are referred by mothers

COOPI (DRC) 37.8% of all admissions are referred by mothers vs 62.2% referred by CHWS

GOAL (Ethiopia-Malawi-S. GOAL provides data on numbers of children U5 presenting at OTP/TSFP as nutrition self-
Sudan) referals but no estimation of the proportion of these children to total admissions

IRC Preliminary results

24% of all admission are referred by mothers vs 45% by CHWs
ComPAS Mali (Nara) 2020

Save, 2017, Niger, Diffa 34% of SAM children admitted to CREN in Maradi and Zinder are referred by mothers

*this very low proportion can be linked to the fact that the data on admission were collected from January to September 2016, but the mother-MUAC program started only in
May 2016. The survey took place in November 2016.

So, in practice, this indicator seems to and 59 months with MUAC < 115 mm or bilateral
underestimate the true level of screenings oedema at the time of a survey who are effectively
being done at home. supported in an appropriate nutrition program
Also, as the Family-MUAC approach is relatively (point coverage/period coverage estimators).
recent and/or not yet scaled-up and/or integrated Results obtained from SLEAC/SQUEAC surveys
in the health system, it may take time to adopt are generally used to assess the level of coverage
this new behavior (make MUAC measurement) of a CMAM programme, and therefore evaluate
and observe tangible results in the proportion of its overall performance.
children admitted by reference of mothers and
results on coverage, in general. Coverage estimated by SLEAC/SQUEAC surveys
There are two different estimators of coverage
Coverage of programme (point coverage and period coverage) using
Regarding assessment of CMAM coverage, current coverage assessment methods: point
SLEAC/SQUEAC surveys can provide information coverage and period coverage.
on the proportion of children aged between 6

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Point coverage reflects the ability of a program measure of overall program performance and which
to find and recruit cases. The point coverage should be used in preference to use either the point
estimator does not account for recovering cases or period coverage estimators. (Balegamire et al,
and so does not directly reflect the program’s 2015) to overcome the mutual limits of the two
ability to retain cases from admission to cure, usual estimators. This new indicator has been used
unlike a period coverage estimator but it tends by ACF in Senegal and Concern Worldwide in Kenya.
to overestimate program performance because Based on available evidence extracted from
the denominator does not include recovering SLEAC or SQUEAC surveys, no significant
cases that are not in the program. A new single impact on coverage has been demonstrated
coverage estimator has been proposed which is a for the Family-MUAC approach.

TABLE 8. Evidence related to program coverage

Study Results from SQUEAC/SLEAC surveys on coverage

Coverage was assessed several times (x4) based on a SQUEAC method with a point
coverage estimator. Point coverage was similar in both zones at the end of the study
Ale et al, 2016 (Niger)_
(35.14 % Mothers Zone vs 32.35 % CHWs Zone, difference 2.78 %, [95 % CI −16.34 %;
SQUEAC method
21.90 %], p = 0.9484, Yates corrected chi-square test. = mothers are not inferior to CHWs in
terms of coverage

Operational findings

ACF-CRF Cameroon
Coverage increased from 31.2% to 44.7% in Tokombere but decreased in Roua from 51.5%
(Tokombere and Roua
à 29.7%. But coverage still under 50% and no mention of a significative difference. Single
Health districts, 2020)
coverage estimator.
SQUEAC survey

ACF Kenya (Isiolo County,

No significant impact on coverage (no data/information on coverage estimators used)
2017)

ACF Senegal (Matam No significant impact on coverage (46.6% in 2016 vs 48.5% in 2014) Coverage was
region) SLEAC 2016 assessed based on a SLEAC method with a single coverage estimator

Concern Worldwide Kenya

No significant impact on coverage (Single coverage estimator. 52.6% in Outpatient
(Tana River County, 2019)
therapeutic care (OTP) at baseline and 53.7% at end line.)
SQUEAC Survey

IRC Preliminary results No significant impact on coverage (50.1% in February 2019 vs 56.1% in February 2020).
ComPAS Mali (Nara) Coverage was assessed twice based on a SQUEAC survey but no information yet on
2020_SQUEAC surveys coverage estimator used

Operational findings did not identify a As Ale et al (2016) did in Niger, it could be more
significant impact on coverage in areas where relevant to make comparisons in terms of
the approach has been implemented. As coverage with another screening mechanism,
stated in the introduction of this section, it may so that to demonstrate that coverage in zones
be difficult (or less relevant) to clearly assess the where mothers are screening can be similar
only impact of the Family-MUAC approach on (superior or at least non-inferior) to coverage
coverage, independently from other factors. This where CHWs/others are screening. In Niger,
could explain why the impact on coverage is still this ALIMA’s study showed that coverage can
not clear among the available evidence for this be similar whether it is a zone where mothers
home-based screening. are screening or where CHWs are in charge.

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Including comparison with other standard indicators. Based on ALIMA, ACF and CRF’s
mechanisms will allow more relevant comparisons experiences and reflections, the indicators
and would be a more striking piece of evidence to below can be used to assess the coverage (and
support advocacy and scale-up of this approach. effectiveness) of the Family-MUAC approach:
% of mothers trained to use MUAC (to assess
Variation in admission to services potential coverage of screening)
% of functioning MUAC bracelet in the home (to
Variation in admission to therapeutic services has assess coverage of utilization)
also been considered by some implementers as % of correct utilization of the MUAC (to assess
an indicator to assess the impact of the Family- sustainability of the training)
MUAC approach on coverage of program. % of MUAC utilization in the last 4 weeks (to
Here again, it is well known that there can be a assess sustainability of the approach)
lot of factors to “explain” a variation in admissions CRF is using all these indicators during LQAS
to therapeutic services (seasons, external event, community surveys to regularly monitor the
presence of new programmes…) so this indicator, effectiveness of the approach and prioritize
could not really be considered as a reliable indicator. refreshments or MUAC replenishment depending
By looking at the total percentage of admissions on these results.
to CMAM services, GOAL saw that the Family- Coverage surveys remain essential to inform and
MUAC approach was a significant contributor address barriers to health access.
to the caseload in both Malawi and South
Sudan, both of which were previously relying on Coverage should be assessed in terms of
traditional, relatively low resource methods of case comparison with other screening/standard
identification, through community health workers mechanisms.
(CHWs), either by active case finding or periodic Comparing effectiveness of different approaches
mass-screenings. In Malawi and South Sudan, can help support advocacy and better inform on
the average increase in admissions to therapeutic how the Family-MUAC approach can reach better
care services was 43%, over and above the results or at least non-inferior ones.
normal methods employed, which is seen as
an enormous increase in case identification for Using different indicators to assess coverage
GOAL. In Matam, ACF used these admission data does not help to give a clear overview of
but observed no significant change. the impact on coverage, nor does it enable
comparison across contexts
Why is the impact of coverage unclear or not Implementers/researchers are using different
significant? indicators to assess coverage depending on
what part of a program is being assessed by
Here we compiled the 2 main reasons which can implementers/researchers (screening, overall
explain why the impact on coverage appears not program…) and depending on their initial
to be clear and what could be done to overcome objectives (show the ability of mothers to screen
this issue. compared to CHWs, demonstrate an improved
frequency of screening by mothers…). This may
Coverage estimators used in SLEAC/SQUEAC explain why the word “coverage” remains a broad
survey may be to broad to clearly assess term which encompasses very different indicators
the impact on coverage for this approach. It within the available evidence.
may be more relevant to assess the impact
on the coverage of screening to inform on However, it seems important to have standard
effectiveness of the Family-MUAC approach. and feasible indicators to be able to monitor and/
Estimators assessing the coverage of screening or assess the coverage and effectivity of the
can be reached by using relevant and reliable approach, on a regular basis and across contexts.
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Main results on coverage Recommendations

Coverage of community screening Recommendation: coverage of the Family-

According to the evidence, the Family-MUAC MUAC approach can be well assessed by
approach can lead to an improved coverage directly assessing the specific coverage of
of screening. A vast majority of mothers are screening (Frequency of screening)
reported to take MUAC measurements several Recommendation: Conduct regular assessment
times a month. of ability of mothers and/or integrate (refresh)
trainings in the health system platform as both
Coverage of CMAM programs the ability of mothers and MUAC utilization
Some indicators used to assess impact on tend to decrease over time
coverage “children admitted to malnutrition
treatment by referral of mothers” (1), variation
Recommendation: These indicators could be
in admission to therapeutic services (2),
systematically used to assess coverage (see
coverage estimators used in SLEAC/SQUEAC
M&E part)
surveys (3) may not be properly adjusted to
this approach, as they can underestimate the % of mothers trained to use MUAC (to assess
real coverage by mothers (1) or are difficult to potential coverage of screening)
link with the sole impact of the approach (2-3). % of functioning MUAC bracelet in the home
However, it seems important to have standard (to assess coverage of utilization)
and feasible indicators to be able to monitor % of correct utilization of the MUAC (to assess
and/or assess the coverage and effectivity sustainability of the training)
of the approach, on a regular basis and % of MUAC utilization in the last 4 weeks (to
throughout contexts. assess sustainability of the approach)

Comparing coverage between the Family- Recommendation: Assess coverage while

MUAC approach and another standard
enabling comparisons with comparable
mechanism such as CHW screening can
standard/mechanism (CHW screening) in the
produce more striking evidence to support
same geographical area over the same period.
advocacy and scale-up of the approach.

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B6. Cost-effectiveness Faso, the main difference is explained by the monthly

(modest) cash incentives generally allocated to
Globally, it is well known that if a child with wasting is CHWs.
detected and admitted early in the disease episode,
this can decrease mortality and morbidity related ALIMA provides the most developed information
to malnutrition, reduce per-case treatment costs on costs and their variations related to the Family-
thanks to shorter treatment times and lower MUAC approach, based on an efficacy and cost
the numbers of children requiring expensive in- analysis of each screening strategy (CHW/caregiver)
patient care for SAM with medical complications conducted in Niger and a capitalization report
(Sadler et al, 2011; Puett et al, 2013;). developed in Burkina Faso.
As such the cost-effectiveness of the Family-MUAC
approach could be assessed by demonstrating its Variation of costs over time
effectiveness in terms of early detection, shorter According to ALIMA, training mothers required
treatment times and lower need for inpatient care higher initial up-front costs, but overall costs for the
(see results above). There is still little evidence year are then much lower.
on the cost-effectiveness of this approach as
effectiveness on quality of treatment (earlier/ Variation of cost with strategies used for training
shorter) would need to be further studied in The cost per trainee can significantly vary depending
different contexts. on the chosen strategy used for training: mass-
Regarding costs, cost-comparisons between the campaign, routine training or household visit (ALIMA,
Family-MUAC approach and existing screening Burkina Faso, 2016). Training integrated in the care
mechanisms for active case finding, such as CHWs, pathway and mass-campaign provide significant
were examined. Below is a summary of the main lower costs (around $0.65) than household visit
data which can be collected on costs related to the ($4.83) according to ALIMA’s experience in Burkina
Family-MUAC approach among current evidence. Faso. Households visits were found to be inefficient
regarding costs.
Costing The cost-effectiveness of the approach is however
Despite different tools, approaches and calculations also conditioned by the ability of mothers to make
to estimate and compare costs, it appears that correct MUAC measurements in a sustainable
a caregiver-based strategy is less costly than a manner as it seems to decrease over time (see B.1),
screening strategy based on CHWs (GOAL, ALIMA). pointing out the need to refresh trainings and/or to
identify sustainable training such as an integrated
Why? Regarding ALIMA’s experience in Burkina training in the care pathway.

Main results on Recommendations

cost-effectiveness
Recommendation: More evidence is required on cost-
There is a limited evidence on effectiveness including comparisons with standard protocols/
cost-effectiveness of the Family- CHW screening in different contexts. Impact on the quality of
MUAC approach. Regarding treatment and on coverage should be also better defined in
cost, despite an initial higher several contexts to support evidence on cost-effectiveness.
investment for training, the Cost-effectiveness is a crucial tool to enable scale-up and
approach seems cheaper than integration of this approach into the health system.
a CHW’s screening approach,
but the cost-effectiveness Recommendation: An integrated training routine seems more
of the approach also mainly cost-effective and adapted to the need for a continuous learning,
depends on the sustainability considering the decreasing ability of mothers in measuring
of the training. MUAC and using MUAC, if no refreshment is made (see B1).
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C. Implementation and related recommendations In which contexts the Family-MUAC approach

has been implemented?
C1. Contexts
This has been mainly implemented in rural areas
Family MUAC fits within existing normative of Sub-Saharan Africa. One pilot including a
guidance on how to manage Acute Malnutrition. simplified protocol (treatment) and a screening at
WHO guidelines state the following with regards household level is currently ongoing in an urban
to the involvement of community members in the area (OptiMA Bamako, ALIMA).
screening of children:
“In order to achieve early identification of children According to the available evidence and
with severe acute malnutrition in the community, implementers, the selected areas for implementing
trained community health workers and the approach are mainly areas with existing low
community members should measure the mid- coverage of routine community screening/low
upper arm circumference of infants and children program coverage, areas where malnutrition
who are 6–59 months of age and examine them poses a high risk of death or illness (high
for bilateral pitting edema.” burden of malnutrition/wasting) and areas
where an earlier detection of malnutrition
Therefore, training families/community members could improve the situation for children.
how to screen by MUAC is already endorsed by Addressing the low coverage of CMAM programs
normative guidance. and aiming at an earlier detection are the 2 main
objectives of the Family-MUAC approach quoted
At a global level, this approach has been officially by implementers.
endorsed by the Council of Research and Technical Below are some contexts in which the approach
Advice on Acute Malnutrition (CORTASAM), has been implemented, according to the
who have published a systematic review description of contexts made by implementers
recommending this approach at community level6. (when stated in documents).

From a regional perspective, multiple countries

in the Sahel have already adapted their protocols
to include community member training on MUAC
to facilitate early detection and treatment. In
Mali, a revision of the protocol in 2017 resulted in
community members being cited as instrumental
in the detection process, with mothers being
specifically identified as important targets for
training. In Mauritania, the approach has also
been integrated into national policy, with over
18,000 family members having received training.
Likewise, the national policy in Niger endorses
this approach. Finally, in Burkina Faso the
Nutrition Division has standardized the approach
by annexing it into national protocols to ensure
the approach can be delivered at scale.

6. The Council of Research and Technical Advice on Acute Malnutrition. Recommendations on the use of Mid-Upper-Arm-Circumference (MUAC) in the community: A statement from the Council of Research and Technical
Advice on Acute Malnutrition (CORTASAM). No Wasted Lives; 2018
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C2. Trainings Entry points. The identification of Entry point (s)

is a core-step of the Family-MUAC approach to
There is no one-size-fits-all approach to integrate the approach into existing community
teaching caregivers how to use and interpret a mechanism so as to ensure both sustainability
MUAC tape or check for edema. and a context-specific implementation. This
identification will depend on the context, the
During a workshop on the Family-MUAC approach resources and the target. SCI has deepened the
held in Dakar, April 18th 2019 (UNICEF, SCI, CRF, reflection on what entry points should be selected
ALIMA, MSF and Action Against Hunger), one according to these 3 points.
conversation debated whether it is preferable
to identify one approach for MUAC training First, it is important to consider what is already
which is adhered to by all partners. Whilst one existing in the country/locality and to be aware
standardized approach may help coordination, of the MoH recommendations (regarding the
a singular approach may be too restrictive given coordination of the Family-MUAC approach and
different ways of working of partners, and the MUAC as an admission criteria). Using lessons
different community platforms that exist. It was learned will help facilitate the implementation and
determined that a minimum set of criteria could coordination.
be a useful approach to ensure coordination at
country level. Several implementers are recommending
engaging community leaders for the success of
These minimum standards should include the this approach for them to support the adoption
following considerations: desired outcomes, cost- of Family MUAC. ACF also recommends
effectiveness, communications and messaging, developing a SBCC strategy which will reinforce
integration and data collection. the effectiveness of the Family-MUAC approach,
especially if members of the family others than
The minimum standards should be based on mothers are included.
lessons learned from existing implementation in
country and developed in a collaborative manner Then, the selection of entry points should
amongst all implementing partners under the depend on the context (what are the existing
guidance of the Ministry of Health, Direction of community mechanisms) but also resources. High
Nutrition. Furthermore, consideration should be number of entry points implies a higher number of
given to existing community health platforms and women and therefore higher resources required
community groups. Priority should be given to for training and monitoring.
identifying and reinforcing the capacity of these
existing community mechanisms, and to integrate Lastly, selection of targets will also depend on the
MUAC training using these entry points rather context, the objectives and the resources (mothers
than creating new parallel groups specifically for 6-59 months, mothers of SAM children, women
this activity. These are the reasons why there of reproductive age, soon-to-be-mothers, fathers,
are a variety of approaches developed by other members of the family…). For example,
implementers according to the context (entry depending on resources and objectives, the
points, situation) and their way of working. approach can prioritize children at risk of relapsing
and emphasizing the need for early detection and
It is however important to co-design referral and select a CMAM entry point such as
the approach in coordination with other OTP and TSFP platforms (SCI). In case Family-
implementers and by using lessons learned MUAC is first introduced to a community, ALIMA
in the country. Selection of entry points will recommends covering an entire health area to
depend on the context, the objectives and the help ensure maximum impact.
resources of the implementer.
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Below is a list of pros and cons to consider GRAPH 6. 12 recommended steps for a Family-
while developing the approach (developed by MUAC training
Save the Children International WCARO): 1. Welcome mother/caregivers
Higher coverage vs lower quality if limited
2. The objectives
resources (low monitoring capacities) of the training
3. What is malnutrition
Multiplying entry points for a stronger impact vs 4. How to recognize
dividing/scattering your resources the early signs of
malnutrition 5. What is the difference
Focusing on reducing relapse and late referral between wasting and
edematous malnutrition?
(Targeting the most vulnerable (malnourished 6. Advantages of Family-
Children/Children at risk of malnutrition) vs MUAC: early detection
can reduce the risk of 7. How to check MUAC
Prevention (all children) death or the need for in three steps (followed
a lenghty hospital stay by practical
(most effective message demonstration with three
About key messaging as specified by ALIMA) mother-child pairs)

Implementers stated during the Dakar workshop

8. What to do if the color 9. How to check for
on Family-MUAC that a standardized approach to of your child’s MUAC is: edema in two steps
Family-MUAC would facilitate coordination but could red/yellow/green (followed by a practical
demonstration with
be less relevant regarding the importance of being three mother-child pairs)
10. When to check MUAC
context-specific (adaptation to existing community
and check for edema?
platforms, context and cultural appropriateness…). 11. Important to remind
mothers that you can
But it was also recommended to conduct a review of ALWAYS visit the health
center or hospital
key messaging given in trainings to move towards a
semi-standardization of the approach and therefore 12. Thank mothers/cargivers for their participation

improve the quality of trainings.

By conducting this review of key-messaging About tools

in trainings, it appears that there is already As the approach is mainly implemented in areas
a semi-standardization of the training, as the where participants are low literate/non-literate,
content and structure of reviewed trainings it is important to adapt tools to the context.
are nearly the same for implementers (CRF, Messages should be clear and simple and must
GOAL, World Vision and ALIMA). The training be communicating while using “attractive” tools
guides developed by implementers are based on such as videos, pictures and drawings to support
the training guide developed by ALIMA (which the content of the training.
is the most complete) including all steps of the Below are some recommendations about
training from the identification of the coverage what tools should be used and how.
area to the monitoring tools.
Use videos, pictures and drawings.
Graph 6 is a review of key messaging given In order to maximize the impact, it is highly
in trainings (available evidence from GOAL, recommended to use pictured tools which are
CRF, ALIMA and World Vision) which can be considered relevant low-literacy tools regarding
summarized in 12 essential and recommended steps. the context of implementation of the approach.
Regarding the part on the advantages of Family-
MUAC, ALIMA recommends highlighting the fact Use simple and clear messages in the local
that early detection can reduce the risk of death language
or the need for a lengthy hospital stay for children. ALIMA has also found that that key messages need
This statement has been particularly effective to be as simple and clear as possible in the local
(ALIMA). If no nutrition services are available for language to ensure a right assimilation of the training.
MAM children in the area, nutritional education
should be provided.
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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

GRAPH7. UNICEF (new) MUAC insertion tape

Use a MUAC insertion tape like for persons who are not used to seeing or
A study in Kenya (Grant et al, 2018/ACF) has tested checking for them, especially in settings where
three simple MUAC classification devices to there is a low prevalence of edema (Ale et al,
determine whether they improved the sensitivity 2016). Therefore, the training on detecting edema
of mothers/caregivers at detecting acute should be emphasized and supported with visual/
malnutrition. The sensitivity of mother/caregiver practical tools.
classifications was high for all devices (>93%
for severe acute malnutrition (SAM), defined by Repeat messages (refresher trainings)
MUAC < 115 mm) but the MUAC insertion tape Lastly, it is important to consider that making
performed best. This could be due to the use of MUAC measurements at the household level is
an improved MUAC tape design which has several a new behavior for mothers/caregivers. Even
new design features compared to the standard if mothers/caregivers understand well the
UNICEF MUAC* tape such as three slots (which advantages of screening their child’s nutritional
stabilize the measurement) and a wider band. status, this requires changing/adopting new
behaviors and this generally takes time. That’s
*During COVID-19 context, UNICEF Supply why refresher trainings and/or integrated trainings
has recently revised their MUAC templates to in the health system are needed to ensure the
include 3 slots and images on the back to improve sustainability of the training outcomes. So, this is
sensitivity and use of the tape. an important point to consider while developing
a Family-MUAC approach: one training won’t be
Use bags filled with clay/soil enough. Messages must be repeated and that’s
To demonstrate how to check for bi-lateral pitting also the reason why ACF has recommended to
edema, ALIMA and other implementers are using jointly develop a SBCC strategy to the approach
a plastic bag filled with clay (or soil). This can in order to facilitate behavior change/adoption and
greatly help understand what an edema looks ensure the sustainability of trainings.
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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

GRAPH 8. Summary on tools

Use videos, pictures and

drawings in support

Use as simple and clear

as possible messages in
the local language

Use plastic bags filled with

soil/clay to demonstrate
how to check edema

Use color-coded MUAC tapes

ALIMA, Mother-MUAC Guidelines for trainings of trainers

Compared sensitivity/specificity of MUAC devices used by mothers Sensitivity Specificity

(published results) to SAM to SAM
The MUAC
CLICK-MUAC 96,1% 98,8%
Grant, 2018 insertion tape
MUAC insertion tape (uniMUAC) 100% 98,8% performs best
MUAC tape (color-coded and numbered but other devices
Blackwell, 2015 (Niger) >73% >98% perform well
mid-upper arm circumference tapes)

About current training issues But as stated above (in About tools), it is quite
The main issue regarding training is sustainability “normal” that current trainings are non-sustainable
which depends on entry points selected and/ because a new behavior for mothers/caregivers
or the integration of the training into the health (take MUAC measurements) cannot be adopted
system. in one step, especially if they don’t perceive it
as an immediate benefit to their children. That’s
The results of this rapid review showed the why this is highly recommended to integrate
decreasing ability of mothers taking MUAC trainings in the health system (and ideally into
measurements over time after the last training/ national protocols) and/or to make refreshers
refresher (see part B.1). Prior to the workshop in trainings (which may be more expensive) to
Dakar, a questionnaire was shared amongst field ensure caregivers/mothers can receive regular
actors from different NGOs (CRF, ACF, Save the and systematic trainings on MUAC. Repetition
Children) implementing the approach in different of messages can help assimilation and therefore
countries (Mauritania, Niger, Senegal, Mali, behavior change. To support the sustainable
Burkina Faso) to gain a better understanding of adoption of taking MUAC measurements, a SBCC
the lessons learnt (good practices, bottlenecks) approach should also be jointly developed to
in implementing and scaling-up the approach. the approach. See part C.3 to assess whether a
“Poor training and difficulties in monitoring refresher training is needed.
& evaluation” were identified as a barrier to
implementation and scaling-up. They stated that
current trainings are non-sustainable and that
there are high requirements for retraining.

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Main results on trainings Recommendations

There is no one-size-fits-all approach to Recommendation: Use existing community

teaching mothers how to use and interpret mechanisms to integrate Family-MUAC
a MUAC tape or check for edema, but the trainings to ensure sustainability and
strategy of the Family-MUAC approach has use lessons learned from existing
to be context-specific: existing models and implementation in the country
entry points should be considered.
Recommendation: Select your entry points
The identification of the Entry point (s) is according to your objectives, your resources
a core-step of the Family-MUAC approach and the context
to integrate the approach into existing
community mechanism so that to ensure Recommendation:
both sustainability and a context-specific Use cascade-training and a short duration
implementation. Use the 12 essential and recommended
steps for key-messaging of the training
There is already a semi-standardization of Use “attractive” tools (videos, pictures,
the training, as the content and structure of drawings) and simple words in local
existing trainings are nearly the same for language
implementers (CRF, GOAL, World Vision and
ALIMA) and based on ALIMA’s work. Recommendation: Develop a SBCC strategy
to ensure the sustainability of the approach
Consider MUAC measurement as a new (motivation of mothers/caregivers to make
behavior for mothers/caregivers for which MUAC measurements, support from other
the advantages have to be repeated to members in the family)
ensure the sustainability of the approach
Recommendation: Define an M&E strategy
There are a set of common indicators to clearly integrating standardized indicators
measure the outputs of training, currently outcomes for training (see C.3 on M&E)
used by most of the implementers (see C.3
on M&E)

C3. M&E tool There is no standardized set of indicators and

organizations use different tools and measure
Monitoring and follow-up actions are as activities in a variety of different ways, which tend
important as the training itself. The M&E part to be linked to internal monitoring and evaluation
of the Family-MUAC approach is crucial to systems as well as donor reporting requirements.
ensure the effectiveness and the sustainability However, it seems possible to gather a
of the approach. minimal set of reliable, feasible and standard
indicators.
During the workshop held in Dakar, “difficulties
in M&E” were also identified as a barrier for Why is it important to use standard indicators?
implementation and scaling-up, because there are
no harmonized tools and an inadequate budget It appears as a need for ensuring more coordination
for M&E compared to targeting/training. And yet, between implementers at the national level, a
M&E will ensure the sustainability of the training harmonization of the approach but also a way to
over time.
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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

further assess the effectiveness of the approach At the household level, a community screening
in different contexts, as there remain gaps for card (monitoring by mothers over months
some outcomes (early detection, impact on supervised by a CHW) is currently used by ACF,
treatment…). which enables to collect information on what is
happening at the household level (frequency
A minimal set of indicators can be defined and of screening and child’s nutritional status over
adjusted to the context (according to the selected months). ACF is also using a reference sheet (to be
entry points) and resources. Optional indicators filled by a CHW before referring a child screened
can be added. There are 2 levels to monitor the by mothers for confirmation and admission at the
Family-MUAC approach (community level and health center). To help monitor the performance
health facility level) but also additional indicators of screening, a feedback sheet (filled at the health
(to assess sustainability and effectiveness). center level after referral) is then used to monitor
children eventually admitted for SAM or MAM.
M&E at the community level Including a M&E mechanism at the household
level should however consider whether this
At the community level, the M&E mechanism task-shifting would not overburden the mother/
will collect data to monitor trainings (number of caregiver who already has a “new” behavior to
caregivers trained, number of MUAC distributed). adopt (i.e. taking MUAC measurement).
Special attention will be given to gender (men/
women) and location (name of villages, health Below is a graph including a proposed set
centers) in collection of data. of indicators for M&E and some guidance
at community level, based on the review of
Generally, implementers are using trainers (mainly tools used by implementers and their related
CHWs) to complete training forms. efficacy to monitor the approach.

GOAL has developed M&E tools for monitoring at

the community levels (training forms) which can
be adapted and consulted here.

GRAPH 9. Proposed set of data collection and indicators for M&E at the community level

M&E at Community Level (Data collection)

#Mothers with #Mothers with child TOOLS

Planning child 6-59 months 6-59 months to be
in the community trained in the community
(estimation) (prevision)
Training forms (initial/summary/
refresher) to be completed by
#Mothers with #Other CHWs, recos, Health Promoters,
Targeting #MUAC
children 6-59 participants Nutrition Assistants, Nurses…
distributed
months trained trained (H/F)

#Training Referral sheet (filled

Training #Refreshers training sessions
sessions by CHW) and feedback
sheet (filled by HC)
M&E at Community Level (Outcome Indicators)

Performance
%Mothers trained taking accurate MUAC CHWs are mainly
of initial
measurement (monthly basis) used as trainers and
training-refresher
are recommended to
be used as supervisors
to support mothers/
Performance of %Mothers trained in the community monitor the approach
targeting (monthly basis)

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Some remarks M&E at the health facility

2 main outcome indicators can be used at the At the health facility level, the M&E mechanism
community level to assess performance of the will collect data to monitor the performance of
initial training/refresher) and the performance of the approach mainly in terms of screening, but
targeting (in yellow on graph 8). performance of training can also be included
at this level (ALIMA). Data collection is managed
But the indicator “Percentage of mothers trained by health staffs.
in the community” assessing the performance of
targeting may be optional as implementers are The main outcome indicator collected at this level
generally only considering the number of mothers is the “Percentage of self-referrals presenting at
trained in the community. However, a percentage the health facility which are accurate (Agreement/
could help assess the coverage of the training in Quality)”. It enables to assess the ability of
the community. mothers to detect malnutrition and therefore the
performance of screening and training.
Due to their competencies, it is recommended to
use CHWs as supervisors to monitor the approach Below is a graph including a proposed set
and support motivation and understanding of of indicators for M&E and some guidance at
mothers at the community-level. health facility level, based on the review of
tools used by implementers and their related
Task-shifting a part of the monitoring at the efficacy to monitor the approach.
household level should consider whether this
could be an overload for mothers/caregivers.

GRAPH 10. Proposed set of data collection and indicators for M&E at the health facility level

M&E at Community Level (Data collection)

#Self-referrals to TOOLS
Health Facilities by #Self-referred
Monitoring
mothers bringing children admitted
of screening
their children after
screening at home Data collection forms
(Family-MUAC weekly register)
at health center to be
Monitoring #Mothers trained completed by health staff
of training to use MUAC in A monthly register can be used to
catchment areas summarize the weekly register and
be reported to the NGO for M&E

Feedback sheet for children

referred by mothers to inform
M&E at Community Level (Outcome Indicators) on admissions (filled at HC,
returned at HH)

Performance of % of self-referrals presenting

screening at the health facility which are accurate
Performance of screening
(Agreement/Quality)
and training should also be
assessed by community surveys
(6-12 months after the initial
Performance of %Mothers trained to use MUAC
screening)
training in catchment areas

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Some remarks changes over time in terms of effectiveness (see

Graph 11). Moreover, this assessment can help
The indicator directly related to the performance reorient the communication on the approach and
of training “Percentage of Mothers trained to use identify need for refreshers training and/or need for
MUAC in catchment areas (out of mothers coming resupply. This should be done 6 to 12 months after
to HC)” can also be more widely assessed at the the initial training in order to be able to observe a
community level during community surveys (see minimal change in time but less than 12 months to
next part). avoid long time without MUAC and/or low reduced
According to operational experiences, the screening coverage in the community.
data on self-referral may undercount the true Community surveys such as LQAS surveys are
screenings being done by mothers, mainly well-recommended to provide an overview of the
explained by the fact that mothers are confirming state of the learning outcomes in the community
their first screening with CHW before going to the and can be used as a consistent tool to prioritize
health center and then are declaring to the health refresher trainings and resupply in areas where a
staff that they were referred by a CHW. This is low coverage of this indicators has been observed.
a very important point to monitor (verify) and to Moreover, qualitative studies can be used as
mention during the training of mothers (mothers a complement to identify how the key-actors
should mention “self-referral” anytime they did involved in the approach are perceiving and using
screen first). it but also to further assess barriers and boosters
(what works and what doesn’t) in that context.
Additional M&E to assess sustainability This can both help improve/adapt the approach and
of the approach contribute to the documentation regarding this
approach in different contexts.
As the ability of mothers to take MUAC
measurements seems to decrease over time after Below is a graph including a proposed set of
the last training/refresher (see B.1), it is important indicators to assess the sustainability of the
to monitor the overall sustainability of the approach. approach in the community (and at health
4 main indicators regularly used by facilities), based on the review of tools used
implementers (ACF, CRF…) seem to be the by implementers and their related efficacy to
most appropriate to assess how the approach monitor/evaluate the approach.

GRAPH 11. Proposed set of indicators for M&E to assess sustainability of the approach

Additional M&E to assess sustainability of the approach

TOOLS
% Households with presence %Mothers/Parents
of MUAC for screening 6-59 using MUAC
Spot-checks in randomly selected
months children correctly
households several weeks after the
Sustainability initial training in a given village
of the approach
%Mothers/
%Mothers/Parents having a
Parents Use quantitative community
good knowledge of key-
who have used surveys (LQAS for ex.) to assess the
messaging provided during
MUAC during sustainability of the approach. Also
initial training
the last 4 weeks to identify needs for resupply

Knowledge/Perception/
Adhesion of the approach by Use qualitative community
mothers and key-actors in surveys (interview with
Perception of implementation key-actors: mothers, health
the approach staff…) to identify barriers and
Booster/Barriers in boosters in the perception and
implementation of the approach implementation of the approach
(mothers & key-actors)

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Additional M&E to assess the effectiveness of What is important to support advocacy and scale-
the approach up of the approach is to document comparisons
between the Family-approach and other screening
Eventually, as Family-MUAC remains a new mechanisms.
approach, increased evidence is needed to assess Based on the previous parts of this review (see
the effectiveness of the approach in different B.3/B.5/B.6), below is a minimal set of indictors
contexts. M&E should be also used to help which can be used to assess the main expected
support the advocacy to scale-up these programs outcomes of effectiveness for this approach
at a country-level. Implementers should consider (Graph 12).
including at least indicators on early detection.

GRAPH 12. Proposed set of indicators for M&E to assess the effectiveness of the approach

Additional M&E to assess effectiveness of the approach

Median MUAC at admission TOOLS

comparison vs CHWs* or in time
(between the start and the end
of the project)
Early
detection Use coverage surveys
(SLEAC/SQUEAC) to
Length of treatment (days) assess coverage, barriers
comparison vs CHWs and boosters

Point coverage/Period coverage/

Coverage Single estimator coverage
(coverage comparisons vs CHWs* To support advocacy for the
or comparison in time) scale up of this initiative
in country program and
its prospective inclusion
in national guidelines, it is
Cost-Effectiveness useful for the country team
Cost- Cost Comparison Family comparison with to collect following additional
effectiveness MUAC versus CHW areas where only information on effectiveness:
CHWs are screening cost-effectiveness + coverage
(include indicators + treatment (early detection +
on early detection shorter stay)
*most relevant comparison
+ treatment +
coverage + costs

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Some remarks
Lastly, cost-effectiveness of the approach has
According to the evidence review, the indicator also to been compared to other models and
“Median MUAC at admission” is a relevant should include the indicators which enable the
indicator when compared to another source of approach to be cost-effective (early detection/
referral (CHW) to assess whether the approach quality of treatment/coverage).
leads to an early detection of malnutrition. It can
also be compared in time between start and end When to find out if a refresher training is
of the project, but this would be more striking in needed
terms of advocacy (and more relevant in terms of
research) to compare outcomes from 2 different Defining when refreshers are needed is
screening mechanisms. to be included in the M&E strategy since
the beginning of the project. There are no
If possible, to further the comparison with guidelines or standards existing but ALIMA
CHWs, the length of treatment between self- has communicated on indicators and possible
referred children and children referred by CHWs thresholds used to decide when to conduct
should be investigated. refresher trainings. These thresholds must be
adapted to the context and the possibilities of the
Regarding coverage, as it remains difficult to implementer.
explain a variation in terms of coverage (several This monitoring for refresher need should be done
others external factors/ See B.5), a comparison of at the community level (community surveys) and
coverage between areas covered by CHWs and at the health facility level.
other covered by mothers would also be a more
relevant approach to prove effectiveness correctly
and support advocacy.

GRAPH 13. When to conduct a refresher course

When to conduct a refresher training (Examples from ALIMA in Niger)

%Mothers having a MUAC

bracelet at home If 25% of households did not
have a MUAC tape or did not
use it correctly: conduct repeat
%Mothers/Parents using training sessions
Define a MUAC correctly
strategy and
thresholds to
%Mothers trained to use
decide when If less than 50% of mothers
MUAC when coming in
refresher arriving at health centers
target “acute malnutrition
courses are are not trained, organize
treatment service”
needed refresher courses
catchment areas

% Self-referrals admitted If agreement drops below

which are accurate 90% organize refresher
(agreement) courses

Based on the results of the workshops regarding training and related issues and based on the
results of the rapid review on effectiveness of the approach and its implementation, some
minimum standards (summary of part II) have been developed and gathered in the graph below
to support a more effective implementation (Graph 14).

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 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

GRAPH 14. Minimum standards for designing the Family-MUAC approach

Co-designing the Family- Training of mothers

Training of trainers M&E
MUAC approach

Identify entry points = existing Integrate MUAC Include all mothers

community mechanisms to 6-59 months Define an M&E
training using existing
integrate Family MUAC and strategy using
entry points
oedema assessment training standard/feasible
Other members of the family indicators for M&E
rather than creating new parallel
for sustainability (adolescent at community and
groups specifically for this Use Cascade trainings girls, fathers, grandparents, health facility level
activity
soon-to-be mothers…
Optimal duration:
Use lessons learned from
20-30 min Use effectiveness
existing implementation Training content: simple key indicators to support
in the country messaging in local language, advocacy and
At Community
discussion, explanation, scaling-up
Coordinate with implementing Level pratical demonstration
partners under the guidance of CHW, community
MoH/Cluster relays/ At Health Define a strategy for
volunteers… facilities At At Health
refreshers course
Or mass training Center Community facilities
Engage community leaders/ campaigns managers, Level Center Triage
(thresholds/trainer)
stakeholders for the success of (groups) … HH visits waiting area
the Family-MUAC Or attached to Mass training Discharge from
other campaigns campaigns treatment
(groups) With other
Include CHWs in
Develop a SBCC strategy to Or attached health promotion supervision of
enhance the effectiveness of the Distribution of MUAC at to other activities caregivers to ensure
household PB approach the same time campaigns Routine activity their adhesion

Initiate/continue discussions with the MoH for the integration of the household PB approach in the
community-based screening system and in the national protocol to ensure sustainability

Main results on M&E Recommendations

Monitoring and follow-up actions are as Recommendation: Define a M&E strategy at

important as the training itself. Continuous the community and health center level while
monitoring is very key throughout the considering the proposed set of indicators
program period in order to realize an impact. to facilitate harmonization, coordination
The design of the M&E part is crucial to and documentation of the approach at
ensure the harmonization, the effectiveness country and global level.
and the sustainability of the approach
Recommendation: Define a strategy for
There is no standardized set of indicators/ refresher courses to ensure a long-term
tools used by organization, but it seems sustainability of the approach (community
possible to gather a minimal set of reliable, surveys/M&E at HC) + adopt a SBCC
feasible and standard indicators for which strategy.
reliability has been assessed.
Recommendation: Use indicators of
M&E should be used to verify the effectiveness (early detection/treatment/
sustainability of the approach over time coverage) and comparisons with other
standard mechanisms to support advocacy
M&E should be used to increase evidence and scaling-up of the approach.
on effectiveness of the approach in different
contexts 32
 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

C.4. Main challenges in implementation and This requires that the approach (and the means
related recommendations to adequately conduct it) needs to be included
in national training plans, acute malnutrition
Implementations is always facing challenges treatment guidance and community health
but what are the main recurring challenges strategies. The lack of ownership and commitment
for the implementation of the Family-MUAC of health actors and the system constitutes a
approach? barrier to implementation and scale-up (Family-
MUAC workshop report, Dakar) and this reveals
1. Projects can encounter delays in the the limited integration of Family-MUAC into the
procurement of the MUAC tapes health system. And yet, the sustainability of the
Ensure sufficient stock of MUAC tapes for approach mainly depends on its integration into
initial training and resupply the health system to avoid a mechanism which
Many implementers have experienced a delay in would be in competition with existing systems,
MUAC tape procurement. For instance, in Kenya, especially in terms of M&E.
Concern Worldwide (Tana River) encountered a
delay in procurement of these tapes for close to 4. CHWs could have the perception that this
3 months which then subsequently contributing approach is in competition with their work
to delay in the implementation of pilot activities Include CHWs as trainers and supervisors,
as nothing could go on as scheduled without the consider coupling Family-MUAC with ICCM+
MUAC tapes. Once the tapes were received, This challenge indicates again the importance to
refresher trainings were undertaken for the CHVs integrate this approach into the health system. As
and the mothers. Moreover, regarding the need of stated previously, CHWs should be involved as
refresher courses, a stock for resupply should be trainers for mothers and as supervisor to monitor
considered before starting the project. the approach. However, it has been reported
that some CHWs could complain about having
2. Distance to health facilities for self-referrals an increased workload with supervision without
There is need for consideration of CHWs to financial compensation. A poor adhesion of
manage uncomplicated acute malnutrition CHW could highly compromise the effectiveness
at community level while shifting the task of of the approach. Engagement of CHW is
screening for acute malnutrition to families therefore a crucial point of the approach. Ideally,
Distance to health facilities is a recurrent barrier coupling Family-MUAC with ICCM + SAM at the
to accessing services. Despite the mothers community-level could tempered this perception
measuring their children, referral to the facility for and overall increase effectiveness of the approach
treatment remains a challenge due to distance. (main barrier = distance).
Actors of the Family-MUAC approach will
encounter the same barriers for access to health 5. Undercounting of self-referral due to seeking
and services, except if this approach is coupled of confirmation of screening with CHW before
with other another simplified approach such as going to the health center
the managing of uncomplicated cases of SAM at Raise awareness on that point during training
the community -level by CHWs which will then with mothers
overcome the most common barrier to health ALIMA highlighted the potential undercounting
access (distance). generating by this indicator which is the main
indicator to assess the fact that mothers are
3. There is a poor integration into the health screening their children, coming to the health
system facility and measuring MUAC well (agreement).
Include the approach into national training To overcome this issue, this message should be
plans and/or national community health and emphasized during the training for both CHWs
nutrition protocols and mothers/caregivers (first screening = self-
referral even if the CHW is confirming). 33
 RAPID REVIEW: SCREENING OF ACUTE MALNUTRITION BY THE FAMILY AT COMMUNITY LEVEL

Summary of recommendations

Integration into the health system and into the context

Advocate for integration of the Family-MUAC approach into the health system/national
protocols to ensure the sustainability of the approach
The ability/motivation of mothers as well as MUAC utilization tend to decrease over time after the last training/
refresher course (may be reduced by half after one year). Taking MUAC measurement should be considered as a
new behavior which cannot be adopted at once.

Identify and use existing community mechanisms (entry points) to integrate Family-MUAC
trainings, use lessons learned from existing implementation in the country and coordinate with
MoH/partners to ensure sustainability of the approach
Identify and use existing community mechanisms (entry points) to integrate Family-MUAC trainings, use lessons
learned from existing implementation in the country and coordinate with MoH/partners to ensure sustainability of
the approach.
Priority should be given to what is existing (existing community health platform, others operational experiences of
implementers and lessons learned) to ensure a context-specific and sustainable implementation.

Implement the Family-MUAC approach in areas with high burden of malnutrition, with a
(minimal) presence of CMAM services displaying a low coverage and late presentation of
children affected by malnutrition.
It appears relevant to implement the approach in geographical areas where the population are already accustomed
to nutrition programs as the Family-MUAC approach can be viewed as a complementary approach to improve
coverage and performance of existing services.

Harmonize and conduct simplified trainings

Use the 12 essential and recommended steps for the training

Implement cascade-training and a short duration (20-30min)
Preferentially use a MUAC insertion tape
Include “attractive” tools adapted to low-literacy context (videos, pictures, drawings)
Choose simple and clear words in local language
Consider using either arm and visual ascertainment of midpoint to for MUAC measurement
It doesn’t influence accuracy of measures and as it can greatly simplify trainings (Blackwell et al, 2015)
Strengthen capacity of health staff, CHWs and mothers for detection of edema
Detection of edema has been identified as a potential limitation for screening by mothers but can also concern
health staff in setting with low prevalence (Ale et al, 2016).
Develop a SBCC strategy to ensure the sustainability of the approach
This can help support the motivation of mothers/caregivers to adopt and take MUAC measurements and can also
involve other members in the family, community.

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Design a M&E strategy to ensure sustainability of the approach

Define a strategy for refresher courses to ensure a long-term sustainability of the approach
(community surveys/M&E at health center and at community level)
As taking MUAC measurement is a new behavior to adopt, assessment of the sustainability of training and
refreshers are needed to avoid a decrease in ability/motivation of mothers and MUAC utilization.
The M&E strategy should include indicators to assess the sustainability of the approach such as:

% of mothers trained to use MUAC (to assess potential coverage of screening)

% of functioning MUAC bracelet in the home (to assess coverage of utilization)
% of correct utilization of the MUAC (to assess sustainability of the training)
% of MUAC utilization in the last 4 weeks (to assess sustainability of the approach)
Community surveys 6 to 12 months after the initial training, regular random checks in the community and
qualitative studies (perceptions/boosters/barriers) should be used to monitor sustainability and reorient strategy if
needed.

Define a M&E strategy at the community and health center level, considering the proposed
set of indicators to facilitate harmonization, coordination and documentation of the approach at
country and global level.
According to the context and resources, select indicators belonging to a set of harmonized, standard and feasible
indicators. These indicators are based on results from the evidence review (use and limitations noticed by
implementers)

At the community level:

%Mothers trained taking accurate MUAC measurements
%Mothers trained in the community
Achievements related to trainings (including gender/location/initial training or refresher)

At the health center level:

%Self-referrals presenting at the health facility which are accurate (agreement/quality)
%Mothers trained to use MUAC in catchment areas

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Design a M&E strategy to further assess effectiveness of the approach in different contexts

Use indicators of effectiveness (early detection/quality of treatment/coverage) and

comparisons with other standard mechanisms to support advocacy and scaling-up of the
approach
It is possible and recommended to use standard and feasible indicators to harmonize collection of data and be able
to collect more evidence (which is needed) on the effectiveness of the approach in different contexts.
One effective way to support scaling-up of this approach is to make comparisons between outcomes of the
Family-MUAC approach with outcomes from other screening mechanism, and preferentially CHWs screening.
This can be striking evidence to use for advocacy and therefore scaling-up.

Early detection/Quality of treatment:

Compare median MUAC at admission (children referred through mothers/caregivers vs children referred through CHWs)
Compare number of days of treatment (children referred through mothers/caregivers vs children referred through CHWs)
Compare need for inpatient care (children referred through mothers/caregivers vs children referred through CHWs)

Coverage:
Assess coverage of screening (frequency of screening)
Compare impact on CMAM coverage between areas where mothers are screening and areas where CHWs only
are screening

Cost effectiveness:
Compare costs between comparable screenings mechanisms (mothers/caregivers vs CHWs)
Conduct cost-effectiveness analysis including indicators on early detection + quality of treatment + coverage

Conduct further studies to complement evidence on effectiveness of the approach

(especially on cost-effectiveness)

More evidence is required on cost-effectiveness including comparisons with standard protocols

and/or other screening mechanism (preferentially CHW screening) in different contexts. Impact
on the quality of treatment and on coverage should be also better defined in several contexts to
support evidence on cost-effectiveness. (M&E can help build the evidence on effectiveness)
Cost-effectiveness is a crucial tool to enable scale-up and integration of this approach into the health system.

Further studies are needed to assess the ability of mothers in high-prevalence settings
(Ale et al, 2016)

Consider improving effectiveness of the Family-MUAC approach by coupling with

ICCM + SAM at the community-level

There is need for consideration of CHWs to manage uncomplicated acute malnutrition at

community level while shifting the task of screening for acute malnutrition to families
Despite the mothers measuring their children at the household level, referral to the facility for treatment remains
a challenge due to distance. Actors of the Family-MUAC approach will encounter the same barriers for access
to health and services, except if this approach is coupled with other another simplified approach such as the
managing of uncomplicated cases of SAM at the community -level by CHWs which will then overcome the most
common barrier to health access (distance).

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