Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic

Abstract

The COVID-19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community-based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid-upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow-up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well-accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID-19 disruptions; however, challenges included long-term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme.Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi-year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences.

Outcomes after Acute Malnutrition Program Adaptations to COVID-19, Uganda, Ethiopia, and Somalia

“…Recovery rates were anticipated to deteriorate in programs that decreased the frequency of follow-up visits because the interval between nutritional and medical assessments would be longer, although > 1 study has shown that reduced frequency of follow-up visits does not necessarily reduce treatment efficacy ( 20 ). Furthermore, sharing of rations among siblings, such that the malnourished child receives less than the intended amount, is a known outcome of providing supplementary rations through CMAM programs ( 21 , 22 ), and anecdotal evidence in multiple contexts reported that when larger portions were distributed to cover longer time intervals between facility visits, sharing and selling of rations increased ( 13 ), potentially lowering the caloric intake of the child. However, recovery rates across the entire observational period in all countries were well within the global CMAM threshold of >75% recovered recommended by Sphere, a global reference of minimum humanitarian standards ( 23 ).…”

“…Analyses included facility-level (outpatient community clinics) indicators of enrollment and treatment outcomes for all 3 countries and child-level indicators for Somalia ( Table 1 ). Program coordinators in each country provided information on the timing and type of protocol adaptations through a separate online survey conducted in July 2020 ( 13 , 18 ).…”

“…Given the urgency posed by the COVID-19 pandemic, the adaptations were implemented by CMAM programs despite limited evidence regarding effectiveness ( 13 – 17 ). To provide information for CMAM programming, we evaluated changes in enrollment and treatment outcome indicators corresponding with implementation of program adaptations for COVID-19.…”

Impacts of the COVID-19 Pandemic on Agri-Food Systems in West Africa

“…Other studies are rather global, dealing with countries from different continents; for instance, Wrabel et al [78] document the operational experiences and lessons learned by nutrition practitioners dealing with the screening of acute malnutrition and its treatment during the COVID-19 pandemic in 17 developing countries from Africa (viz., Democratic Republic of Congo, Ethiopia, Nigeria, Kenya, Malawi, Somalia, South Sudan, Tanzania, and Uganda) and Asia (viz. Bangladesh, India, Jordan, Myanmar, Nepal, Pakistan, Philippines, and Yemen).…”

Family MUAC supported by a two-way SMS platform for identifying children with wasting: the Mama Aweza randomised controlled trial

“…Training caregivers to monitor their child's MUAC and seek care if they identify wasting is increasingly being used to expand malnutrition screening. 8 , 9 , 10 , 11 , 12 Research in West Africa has suggested that these “Family MUAC” programs may lead to the earlier identification of wasted children compared with community health worker facilitated screening. 8 , 9 However, there is minimal evidence regarding methods to support caregivers to sustain Family MUAC measurements and to access care if their measurement indicates childhood wasting.…”