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Objective: To understand factors affecting the compliance of malnourished,

Background: Severe acute malnutrition (SAM) is currently defined by the WHO as either a low mid-upper arm circumference (i.e. MUAC <115 mm), a low weight-for-height z-score (i.e. WHZ <− 3), or bilateral pitting oedema. MUAC and WHZ do not always identify the same children as having SAM. This has generated broad debate, as illustrated by the recent article by Grellety & Golden (BMC Nutr. 2016;2:10). Discussion: Regional variations in the proportion of children selected by each index seem mostly related to differences in body shape, including stuntedness. However, the practical implications of these variations in relation to nutritional status and also to outcome are not clear. All studies that have examined the relationship between anthropometry and mortality in representative population samples in Africa and in Asia have consistently showed that MUAC is more sensitive at high specificity levels than WHZ for identifying children at high risk of death. Children identified as SAM cases by low MUAC gain both weight and MUAC in response to treatment. The widespread use of MUAC has brought enormous benefits in terms of the coverage and efficiency of programs. As a large high-risk group responding to treatment, children with low MUAC should be regarded as a public health priority independently of their WHZ. Conclusion: While a better understanding of the mechanism behind the discrepancy between MUAC and WHZ is desirable, research in this area should not delay the implementation of programs aiming at effectively reducing malnutrition-related deaths by prioritising the detection and treatment of children with low MUAC.

ObjectiveThis paper reviews coverage data from programmes treating severe acute malnutrition (SAM) collected between July 2012 and June 2013.DesignThis is a descriptive study of coverage levels and barriers to coverage collected by coverage assessments of community-based SAM treatment programmes in 21 countries that were supported by the Coverage Monitoring Network. Data from 44 coverage assessments are reviewed.SettingThese assessments analyse malnourished populations from 6 to 59 months old to understand the accessibility and coverage of services for treatment of acute malnutrition. The majority of assessments are from sub-Saharan Africa.ResultsMost of the programmes (33 of 44) failed to meet context-specific internationally agreed minimum standards for coverage. The mean level of estimated coverage achieved by the programmes in this analysis was 38.3%. The most frequently reported barriers to access were lack of awareness of malnutrition, lack of awareness of the programme, high opportunity costs, inter-programme interface problems, and previous rejection.ConclusionsThis study shows that coverage of CMAM is lower than previous analyses of early CTC programmes; therefore reducing programme impact. Barriers to access need to be addressed in order to start improving coverage by paying greater attention to certain activities such as community sensitisation. As barriers are interconnected focusing on specific activities, such as decentralising services to satellite sites, is likely to increase significantly utilisation of nutrition services. Programmes need to ensure that barriers are continuously monitored to ensure timely removal and increased coverage.

Objective: To understand and compare the primary barriers households face when accessing treatment for cases of childhood severe acute malnutrition (SAM) in different cultural settings with different types of implementing agencies. Design: The study presents a comparative qualitative analysis of two SAM treatment services, selected to include: (i) one programme implemented by a nongovernmental organization and one by a Ministry of Health; and (ii) programmes considered to be successful, defined as either coverage level achieved or extent of integration within government infrastructure. Results from individual interviews and group discussions were recorded and analysed for themes in barriers to access. Setting: Sindh Province, Pakistan; Tigray Region, Ethiopia. Subjects: Beneficiary communities and staff of SAM treatment services in two countries. Results: Common barriers were related to distance, high opportunity costs, knowledge of services, knowledge of malnutrition and child's refusal of ready-touse foods. While community sensitization mechanisms were generally strong in these well-performing programmes, in remote areas with less programme exposure, beneficiaries experienced barriers to remaining in the programme until their children recovered. Conclusions: Households experienced a number of barriers when accessing SAM treatment services. Integration of SAM treatment with other community-based interventions, as the UN recommends, can improve access to life-saving services. Efforts to integrate SAM treatment into national health systems should not neglect the community component of health systems and dedicated funding for the community component is needed to ensure access. Further research and policy efforts should investigate feasible mechanisms to effectively reduce barriers to access and ensure equitable service delivery.