Introduction for project staff:Mother-led MUAC

August 2016

Screening and diagnosis of malnutrition by mothers

…to reduce mortality and morbidity related to malnutrition

For CHW and Mother trainingPlastic bags filled with soilMUAC tapes

Justification Context Training for mothers Planning the training Example of group training for Mother-led

MUAC

Justification: Studies have shown that…

Mothers can classify their children according to the colour of the tape in the same way as Community Health Workers (according to a pilot study undertaken in Niger)

The precision of the method is not affected by the choice of arm (left or right), nor by the way the midpoint is chosen (by eye or by measurement)

Mothers / caregivers who have been trained have shown they are equally as capable of taking the MUAC and identifying oedema as health workers

SAM is detected earlier by mothers and less hospitalisation is necessary for children screened by their mothers

Screening costs are considerably reduced by working with mothers compared to a Community Health Worker based strategy

The feasibility of training mothers to screen their children for malnutrition has been studied by other organisations since 2011

Mothers are trained how to use the MUAC tape to measure the Mid-Upper Arm Circumference (MUAC) and to identify oedema

Context

Context

Address 2 recurring problems of nutritional programmes : Late diagnosis of malnourished children Coverage less than 50%

Put mothers at the centre of screening strategy Recognise they can most quickly detect the first signs of malnutrition in

their children and they want to improve their health

→ training family members improves coverage considerably and encourages early detection which reduces the risk of death and medical complications

Screening by Community Health Workers is the norm

→ Children are screened

less than once a month → Mothers are less involved and less aware of malnutrition

Why the Mid-Upper Arm Circumference (MUAC)?

The Mid-Upper Arm Circumference is a better predictor of mortality for children aged 6 to 59 months than the weight for height ratio, particularly if it is used regularly

The MUAC is simple to understand and to use Regular screening in the community has shown that

earlier detection occurs thereby reducing the risk of mortality and morbidity

Training for mothers Those to be trained:

Mothers of children aged 6 to 59 months Anyone who looks after children e.g. grandparents, uncles,

aunts Young mothers and pregnant women Any interested person e.g. adolescents Husbands, fathers

Trainers: CHW or former CHW Health promoters Nutrition assistants Nurses

The Community Health Workers continue to play an important role in the community. It seems more

appropriate to train them to instruct mothers than to screen

children themselves.

Training for mothers Objectives:

Train mothers in screening techniques After a practical demonstration in how to use the

MUAC tape and identify oedema, the mothers practice

Content: Short presentation describing malnutrition, how to

diagnose and treat (using videos, drawings, pictures)

Demonstration and practice of screening techniquesKey Messages are simple, clear and in the local language

Training for mothers The training location:

Individual or group training in all health centres (easy to integrate into pre-existing programmes)

Cascade training for the community at the health centre and for the health centre at the hospital – reinforcing key messages and actions Community level: mass training campaign with group

training in the villages and individual training in homes [2 weeks], training incorporated into screening campaigns (vaccination, malaria…), identify lead mothers to train small groups

Health Centre level: training during triage/in the waiting area, after triage for cases who don’t need any treatment, during cooking demonstrations, health promotion activities, after exiting the programme

Hospital level: during hospitalisation as soon as the child has stabilised, individual training on exit

Media: training via radio or video

Monitoring and evaluation

Evaluating the effectiveness of the training and the screening capability of mothers: Random tests in homes several weeks after the initial

training by a supervisor + refresher session if 25% of results are unsatisfactory

Compare the colour reported by the mother on arrival at the health centre or hospital and the measurement taken by a health professional (supervisor should record the percentage which ‘correlate’ and organise refresher sessions, if <90%)

Supervisor must monitor the median on admission to the programme (close to 115 and 125mm?)

Reminders about screening: media (radio…), text message, public criers, women’s meetings, posters in the health centre

Preparation

Planning the training

Define the coverage area ______________________________________________________________________________________________ ____________________ When a Mother-led MUAC programme is set up for the first time in a community it is important to cover the whole of the health catchment area in order to optimise the impact of the programme. To do this the population of the area needs to be defined and its density evaluated :

Have an exhaustive list of villages in the catchment area and a recent census

Identify focal points in the villages who will be responsible for training and monitoring mothers

Identify the circumstances for training (where, when, how etc.)

Determine the means of circulating messages so that screening activities can take place regularly (reminders via announcements on the radio, text message, social networks, public criers, cooking clubs, posters etc.)

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Planning the training Define the human resources needed for the mass training campaign ______________________________________________________________________________________________ ____________________ The number of trainers depends on the population density. According to Alima’s experience to cover a health catchment area (Mirriah district in Niger 2013) :

Reckon on 1 trainer per 50 / 60 people per day in a rural area (or 100 / 120 people with a team of 2 trainers)

In more densely populated areas reckon on 1 trainer per 100 / 120 people per day (or 200 / 240 with a team of 2 trainers)

Allow half a day per village, unless the villages are very close

If possible plan the training for market day

Allow 1 or 2 days for extra visits to villages to train mothers who weren’t able to attend the initial training

2

Planning the training

Draw up the budget __________________________________________________________________________________________________________________ The experience of ALIMA in Niger shows that the Mother-led MUAC approach, from mass training through to monitoring and evaluation, costs approximately $1 per child per year. Although overall this type of programme costs less than a Community Health Worker (CHW) based strategy, it requires a greater initial outlay. The cost breakdown is as follows :

$5000 : Initial training of trainers and mass training campaign 75% : Per diems for 16 trainers (training and 2 week campaign) 10% : Transport for trainers (fuel, drivers etc.) 15% : Supervision and evaluation costs for the initial training

$2000 : One off supervision of community leaders and per diem for the district

supervisor (1 supervisor per 16 trainers) $1750 : MUAC tapes estimated at 0.14$ per tape / tapes distributed to 12,900

mothers and family members

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Planning the training Prepare for the trainers ______________________________________________________________________________________________ ____________________ To organise the training of trainers you need to :

Calculate the number of MUAC needed per trainer

Provide all the training materials to each trainer (picture box, oedema demonstration bag, key messages, attendance sheets to record the number of participants, and MUAC tapes to distribute)

Draw up a timetable starting with the pre-training visit (to explain the aim of the training to community leaders and to optimise the number of mothers available on the day of the training), through to the post training monitoring visits (to train the mothers who were absent on the day of the training and to check the quality of the training)

Plan the transport and fix the daily rate of pay Prepare the photos and drawings for the presentation

To lead the group sessions in the village the trainers must :

Limit the number of participants to 20 / 25 mothers and family members Reckon on 20-30 minutes for each session Allow a little extra time for individual supervision

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Planning the training Lead a training session ______________________________________________________________________________________________ ____________________ The group sessions comprise presentations and practical demonstrations. The key messages must be clear and simple and in the local language. A typical programme for a 20 / 30 minute session contains the following elements :

Welcome to mothers and explanation of the aims of Mother-led MUAC

Definition of malnutrition

What is the difference between wasting and oedematous malnutrition

How to recognise the first signs of malnutrition

What are the advantages of Mother-led MUAC

How to use the MUAC (followed by a practical demonstration)

When to use the MUAC and check for oedema

Thanks to mothers for their participation

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Planning the training

Follow up of mothers __________________________________________________________________________________________________________________ Monitoring and evaluation of the effectiveness of the training is as important as the training itself. ALIMA’s experience shows that monitoring at the health centre can include the following questions during triage :

Have you already been trained on measuring the MUAC ?

If yes, did you check your child’s MUAC / for oedema before coming to the health centre ?

If yes, record the colour of the MUAC and the presence / absence of oedema reported by the mother and have the measurement checked by a health worker. If there is a discrepancy, the health worker can do a practical demonstration with the mother

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Example of training for a group of mothers1. Welcome the mothers and explain the aims of Mother-led MUAC2. What is malnutrition ?3. How do you recognise the first signs of malnutrition?4. What is the difference between wasting and oedematous malnutrition?5. What are the advantages of Mother-led MUAC ?6. How to check the MUAC in 3 steps7. What to do depending on the colour of your child’s MUAC 8. How to detect oedema in 2 steps9. When to measure the MUAC and check for oedema10. It is important to remind mothers : they can always go to the health

centre or the hospital if they think their child is sick irrespective of the MUAC

Thank you!