Figures & Tables
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Flow Diagram of Selection Process
Tables
Reference Objective Thematic Category and Platform Design, Training, and Remuneration Key Findings Alé et al. 201611 To compare the efficacy and cost-effectiveness of maternal measurement of child MUAC and edema with CHW measurement (Niger) Caregiver detection, CHW diagnosis (Community platform, rural) Design: Intervention efficacy study with 2 experimental groups comparing the performance of 12,893 mothers with 36 CHWs
Training and remuneration: 30-minute group training plus follow-up individual training for mothers, 6 hours theoretical and 2 hours practical training for CHWs. CHWs were part of established national network and may have been volunteers (payment unknown).Mothers' MUAC measurements were in agreement with those of health workers more frequently than those made by CHWs (risk ratio 1.88, P<.0001).
Case detection was earlier in the mothers' group (median MUAC of cases 1.6 mm higher than CHW group), with fewer children requiring inpatient care relative to the CHW group.Alvarez-Moran et al. 201719 To assess CHW capacity to evaluate, classify, and treat uncomplicated cases of SAM, and to appropriately refer complicated cases, as part of an integrated iCCM package (Mali) CHW diagnosis and treatment, Integration
(iCCM/community platform, rural)Design: Cross-sectional observational study (no comparison group) of 17 CHWs assessing 125 children
Training and remuneration: CHWs had a median of 6 months of job training; no additional training for this study. CHWs were part of Mali's established network and received a salary according to national regulations.CHWs assessed MUAC correctly in 97% of children, assessed edema correctly in 78%, administered medical treatment correctly in 75% of SAM cases, and managed RUTF supplies correctly in 100% of cases. Amthor et al. 200922 To describe a rapidly adapted home-based SAM therapy approach in which village health aids diagnosed and treated SAM (MUAC and/or edema) in the context of a food crisis with inadequate health system support (Malawi) CHW diagnosis and treatment
(Emergency community platform, rural)Design: Retrospective descriptive study of the clinical outcomes of 826 children with SAM who received treatment at home from village health aids
Training and remuneration: 5 hours of training plus 5 days job shadowing a nurse. Village health aids were part of an established network; payment unknown.Recovery rates of children with SAM treated by village health aids were high (94%), without any intervention by medical professionals aside from training. quality of care. Blackwell et al. 201510 To determine whether minimally trained mothers could identify children with SAM, using either arm and without measuring the specific midpoint (Niger) Caregiver detection
(Community platform, rural)Design: Nonrandomized non-blinded evaluation study of 2 experimental groups (103 mother-child pairs using simplified protocol and CHWs using standard protocol)
Training: Intended to be 5 minutes with each individual, was instead done communally. CHWs were part of a nationally established network and may have been volunteers (unknown).Mothers' ability to classify GAM and SAM had high sensitivity (>90% of GAM and >73% of SAM cases correctly identified as such) and high specificity (>80% of GAM and >98% of non-cases correctly identified as such). The simplified protocol (either arm and visual ascertainment of midpoint) performed as well as the standard protocol. Grant et al. 201812 To test the sensitivity of 3 MUAC classification devices when used by caregivers/mothers (Kenya) Caregiver detection
(Community platform, rural)Design: Prospective nonrandomized clinical diagnostic trial comparing the performance of 3 “Click-MUAC” devices and an MUAC insertion tape across 21 health facilities and 1,040 mother-child pairs
Training and remuneration: NAAll devices yielded high sensitivity (>93%) for detecting SAM. Sensitivity for SAM was highest (100%) with the standard MUAC insertion tapes. Specificity was also high for all devices (>96%), with no significant differences observed between the insertion tape and the “Click-MUAC” devices. Linneman et al. 200723 To assess clinical outcomes of children with acute malnutrition receiving home-based RUTF therapy from community health aids in an operational setting (Malawi) CHW diagnosis and treatment
(Community platform, rural)Design: Observational study of 3 intervention groups with varying levels of decision-making and SAM treatment authority given to community health aids (12 health centers, >3,000 children with acute malnutrition)
Training and remuneration: 1 month plus 4 days job shadowing a nurse. Community health aids were part of an established network; payment unknown.SAM cases who received treatment from community health aids had the same rate of recovery (90%) as those treated by medical professionals (87%). Note that community health aids appear to have delivered some of the care under supervision in clinic settings. Maust et al. 201527 To evaluate an integrated MAM/SAM program in terms of coverage, number of children treated, and recovery of children (Sierra Leone) Integration
(Integrated CMAM platform, rural)Design: Cluster randomized controlled trial with an intervention group (integrated protocol using MUAC for admissions and discharge, RUTF used for MAM and SAM) and a control (standard protocol using W/H Z, RUTF for SAM, and FBFs for MAM)
Training and remuneration: NACoverage of the integrated program was higher (71% compared with 55% using standard protocol), and recovery rates were comparable (83% vs. 79%). Nyirandutiye et al. 201128 To evaluate integration of MUAC screening into National Nutrition Week activities (Mali) Integration
(National Nutrition event platform, rural)Design: Cross-sectional survey of health centers (2) and interviews with health center staff (45), CHWs (17), and caregivers (1543)
Training and remuneration: MUAC training was incorporated into event training; CHWs were unpaid volunteers.Integrating MUAC screening into other activities led to a greater proportion of kids screened (52% of eligible children) than via community screening (5%) or via health center screening (22%), and was viewed as beneficial by caregivers and health care providers. Screening rates were low in clinics, even where staff had been trained in the CMAM protocol. Puett et al. 201220 To assess the quality of CHW care of uncomplicated SAM cases, including technical competence and acceptability, as part of an iCCM health platform (Bangladesh) CHW diagnosis and treatment,
Integration
(iCCM/community platform, rural)Design: Observational cohort study of 55 CHWs who provided SAM care, and focus group discussions with 29 caregivers whose children received SAM care from CHWs
Training and remuneration: 2 days plus monthly refresher trainings. CHWs were part of an established network and received payment.Trained and supervised CHWs delivered high-quality care to uncomplicated SAM cases; they correctly assessed MUAC and advised caregivers of children with SAM appropriately (90% of cases were managed error-free). Antibiotics correctly administered in 90% of pertinent cases. See also Puett et al. 201321 and Sadler et al. 2011.25 Puett et al. 201321 To assess the cost-effectiveness of SAM management (diagnosis and treatment) by CHWs as part of a community nutrition program, compared with inpatient treatment (Bangladesh) CHW diagnosis and treatment,
Integration
(iCCM/community platform, rural)Design: Nonrandomized intervention study of 724 SAM cases treated by CHWs in the community and 633 SAM cases treated as inpatients
Training and remuneration: 2 days plus monthly refresher trainings, CHWs were part of an established network and received payment.CHWs delivered the full spectrum of SAM identification and treatment at a lower overall program cost than inpatient treatment. Supervision was the greatest expense in the CHW group (40% of total, compared with 28% of total budget in inpatient group). See also Puett et al. 201220 and Sadler et al. 2011.25 Rogers et al. 201724 To assess the quality of care for uncomplicated SAM by female health workers (Pakistan) CHW diagnosis and treatment,
Integration
(iCCM/community platform, rural)Training: Observational cross-sectional study of 17 female health workers providing care for 61 cases of uncomplicated SAM
Training and remuneration: 3 days plus a refresher 3–6 months later. CHWs were part of an existing network and received salaries according to national regulations. They did not receive additional pay for the added SAM care responsibilities.MUAC and edema were correctly measured for 57% and 88% of children, respectively. 68% of cases received correct medical and nutrition treatment, but only 4% also received key nutritional counseling messages. Abbreviations: CHW, community health worker; CMAM, community-based management of acute malnutrition; FBF, fortified blended flour; GAM, global acute malnutrition; iCCM, integrated community case management; MAM, moderate acute malnutrition; MUAC, mid-upper arm circumference; NA, not available; RUTF, ready-to-use therapeutic food; SAM, severe acute malnutrition; W/H Z, weight-for-height z score.
Reference Organizational Source and Setting Thematic Category Type of Document Objective of Document ACF 201742 Action Against Hunger (DRC, Kenya) Caregiver detection, CHW diagnosis Description of program/materials To describe a simplified, standardized MUAC bracelet under development for testing in the DRC and Kenya. Bailey 201826 Multiagency (Chad, Kenya, Yemen, Pakistan, Jordan) Integration Pilot study (results not yet published) To summarize the protocol being used by the ComPAS study. The ComPAS study, currently underway as of the writing of this article, aims to integrate the treatment of MAM and uncomplicated SAM by using one product (RUTF) in doses that correspond to growth at each stage of treatment, and using MUAC and edema as the only metrics for admission, monitoring, and discharge. CMN 201534 Coverage Monitoring Network (no specific setting) Integration Advocacy To advocate for the integration of MUAC into other health and nutrition activities, including vaccination campaigns, well-baby clinics, and water and sanitation programs. Emary 201718 World Vision (Mauritania) Caregiver detection Description of program/materials To describe qualitative and quantitative tools developed for training and monitoring “Mother-Led MUAC” programs in Mauritania. Friedman and Wolfheim 201435 Multiagency (no specific setting) CHW diagnosis and treatment Description of program/materials To identify and describe models for how CHWs currently incorporate SAM screening, referrals, and treatment into their work. While there is evidence supporting CHW capacity to conduct all SAM-related activities, there are outstanding questions regarding the conditions that foster success, as well as the optimal mix of iCCM and nutrition-related responsibilities. ALIMA 201715 ALIMA (Niger, Burkina Faso, Mali, Chad) Caregiver detection Description of program/materials To describe the expansion of “Family MUAC” concepts in Burkina Faso, Chad, Mali, and other locations. MSF 201743 Médecins Sans Frontières (no specific setting) Caregiver detection, CHW diagnosis and treatment Pilot study To report on lab testing of an alternative MUAC strap for use with adult and child populations. Initial testing of the strap using a standardization process (not on humans, but on differently sized cylinders) showed it to be more accurate and have a higher sensitivity than the standard UNICEF strap. The next step is to test the straps on children in a field setting. Sadler et al. 201125 Save the Children/Feinstein International Center (Bangladesh) CHW diagnosis and treatment Research study To report outcomes of SAM cases receiving CHW care in Bangladesh (some results also published, see Puett et al. 201220 and Puett et al. 201321). Coverage, weight gain, and recovery were high (89%, 6.7 g/kg/day, and 92%, respectively). The use of multiple pathways to care within the CHW model—use of MUAC, monthly growth monitoring sessions, home visits to sick children, and use of a “watch list” to monitor sick children—facilitated high coverage of screening and diagnosis. See also Puett et al. 201220 and Puett et al. 2013.21 Sayadi 201617 CMAM Forum (multiple settings) Caregiver detection Description of program/materials To connect agencies interested in adopting “Mother-Led MUAC” programs (Action Against Hunger, Médecins Sans Frontières, GOAL, Concern, World Vision, International Red Cross, International Medical Corps, and Cooperazione Internazionale). Sessions 201716 Action Against Hunger (India, Mauritania) Caregiver detection Pilot study To describe 2 pilot studies of the “MUAC Mothers” approach. In India in 2015, 61 caregivers were trained to measure MUAC and given information about how to proceed if they classified their child as having MAM or SAM. Seven months after training, approximately 20 were using the tapes actively; the remaining 41 had misplaced, forgotten how to use the tapes, or not participated in measuring. In Mauritania in 2016, CHWs provided training for more than 6,000 mothers on MUAC use, screening for edema, and what to do if a child got a red, yellow, or green reading. Tesfai 201514 International Rescue Committee (multiple settings) CHW diagnosis and treatment Description of program/materials To describe tools to enable low-literacy CHWs to diagnose and treat uncomplicated SAM. Piloted tools include use of MUAC-only for admission and monitoring, the use of visual materials (color-coded RUTF dosage charts, scales that indicate RUTF dose, and use of icons to facilitate registration and monitoring), and alignment with iCCM vocabulary and tasks. Field tests have been conducted in Chad, India, Mali, and South Sudan. Abbreviations: CHW, community health worker; CMAM, community-based management of acute malnutrition; ComPAS, Combined Protocol for Acute Malnutrition Study; DRC, Democratic Republic of the Congo; iCCM, integrated community case management; MAM, moderate acute malnutrition; MUAC, mid-upper arm circumference; NA, not available; RUTF, ready-to-use therapeutic food; SAM, severe acute malnutrition; UNICEF, United Nations Children's Fund.
