Acute malnutrition in children under five remains a critical challenge, exacerbated by the COVID-19 pandemic. Estimates indicate that up to 9.3 million more children will suffer from acute malnutrition by 2022. However, standard community-based management of acute malnutrition (CMAM) program models require proximity between health workers and patients, which may increase COVID-19 transmission risk. Furthermore, children must undergo frequent check-ups, a challenge under movement restrictions.
Following guidance from nutrition coordinating bodies, organizations and governments adapted their standard CMAM protocols to continue nutrition service delivery while reducing COVID-19 transmission risks. These adaptations include changes to community-based screening methods; modified admission and discharge criteria; reduced frequency with which children return to health facilities for follow-up visits; modified dosage of therapeutic foods; and shifts in where and how treatment is provided. Many of these, often referred to as ‘simplified approaches’ to the current CMAM model, have been piloted or trialed previously. Still, questions remain regarding feasibility, effectiveness, and cost and operational implications.
The mass rollout of these adaptations as the pandemic escalated in early 2020 presented a unique opportunity to examine them at an unprecedented scale. Therefore, Action Against Hunger USA, in collaboration with the United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), and the US Centers for Disease Control (CDC), carried out a mixed methods study between July 2020 and May 2021. This study sought to achieve two primary objectives:
(1) to document operational adaptations to CMAM programs prior to and during COVID-19; and
(2) to identify and document lessons learned and operational implications from adaptations.
The findings presented in this report aim to both contribute to decision-making as the pandemic continues and to the simplified approaches evidence base by highlighting operational experiences and lessons learned. The report discusses takeaways consistent across adaptations and delineates lessons learned for five common adaptations: Family MUAC; modified admission and discharge criteria; reduced frequency of follow-up visits; modified dosage of therapeutic foods; and providing treatment when facilities were inaccessible.
The study comprised two stages. First, a screening survey was circulated among nutrition coordination mechanisms and non-governmental organizations (NGOs) to document which implementing organizations were applying COVID-related CMAM adaptations and where. Surveys were collected between July 2020 and January 2021, with a follow-up survey circulated to identify updates in May 2021. Results were published in a live map on the State of Acute Malnutrition website. Second, the research team conducted semi-structured interviews with practitioners. These interviews probed the following themes related to program adaptations during the pandemic: decision-making actors, processes, and factors; operational considerations; and strengths, challenges, and lessons learned, including perceived impacts on program performance. Interviews were recorded and transcribed, and analyzed using thematic analysis.
Overall, respondents submitted surveys representing 75 countries in North America, South America, Asia, and Africa. These responses included those of 19 organizations running programs in 28 countries, and UNICEF’s guidelines in 70 countries. Respondents reported implementing CMAM adaptations during the pandemic in 69 countries. Overall, the most common adaptations were Family MUAC and reduced frequency of follow-up visits. Seven partners working in 13 countries responded to the follow-up survey; most reported no changes. Within the second stage, the research team conducted 43 interviews with 46 individuals representing 19 organizations working in 20 countries. The sections below summarize the key findings and lessons learned from interviewees across adaptations and for each adaptation individually.
Cross-Cutting Themes: Decision-Making, Rollout, and Logistics
Overall, interviewees reported that decision-making about adaptations was a multi-step process, most often led by Ministries of Health in collaboration with the Nutrition Cluster, UNICEF, WFP, other coordination and working groups, and implementing partners. Governments and organizations largely used cascaded approaches to inform stakeholders about protocol adaptations. Gathering restrictions and lockdowns drove innovation and flexibility in how orientation and training were provided, with virtual trainings and meetings increasing. Many organizations pre-positioned supplies to mitigate anticipated supply chain ruptures; however, several COVID-related factors exacerbated shortages and stockouts.
Under the Family MUAC approach, caregivers are trained to take their children’s mid-upper arm circumference (MUAC) to identify and refer acute malnutrition earlier. Though many trials and pilots took place pre-pandemic, Family MUAC was scaled up during the pandemic to supplement or replace restricted or suspended community-based screening. Caregiver training typically followed a cascade approach, using virtual and socially distanced trainings wherever possible. However, training was often hindered by a lack of official guidelines and training materials and MUAC tape shortages. The approach enabled continued screening, though caregiver measurement accuracy varied widely. Some caregivers were initially reluctant to take the measurements, while some tensions arose over reallocating community worker responsibilities when shifting screening to caregivers. Despite these challenges, the approach was well accepted among staff and caregivers. Most interviewees indicated they would continue Family MUAC post-pandemic.
Modified Admission and Discharge Criteria
To minimize contact between staff and patients, many interviewees reported suspending weight and height measurements during the pandemic, requiring the suspension of weight-for-height Z-score (WHZ) as an admission criterion. While sometimes contentious, this adaptation reduced contact between staff and patients and streamlined caregivers’ and patients’ time at facilities, with both staff and caregivers relieved by reduced contact. Furthermore, using MUAC and edema only simplified staff training, and increased caregiver understanding of program protocols. However, some respondents were concerned that not using WHZ would exclude children needing care, mirroring global conversations about optimal admission criteria.
A few interviewees also noted implementing an expanded MUAC threshold for admission alongside the suspension of WHZ to continue treating children who may have otherwise been excluded. Decision-making bodies typically analyzed existing program data to identify optimal thresholds to balance treatment of atrisk children with the realities of resources and supply limitations associated with a sudden change in protocols, given that caseloads most often increased when thresholds expanded. Most interviewees indicated that they anticipated returning to standard criteria once transmission risks were lessened.
Reduced Frequency of Follow-up Visits
Reducing the frequency of follow-up visits was one of the most reported adaptations. Interviewees said this enabled crowd control and social distancing at facilities and alleviated caregivers’ burden to travel under movement restrictions. While caregivers appreciated less frequent travel, in some contexts they struggled to store and dose the increased rations distributed at each visit. Interviewees also reported increased sharing and sale of the larger rations due to increased household economic insecurity. Some staff were also concerned that children’s health could deteriorate rapidly without prompt intervention from frequent visits. Once again, interviewees noted that they would likely increase visit frequency when the pandemic lessened.
Modified Dosage of Therapeutic Foods
In response to suspended weight measurements, interviewees modified the dosage calculation for therapeutic food given to enrolled children, including either a universal dosage for all children with severe acute malnutrition or case-specific dosage. This adaptation enabled service continuity despite suspended weight measurements. It also streamlined service provision, since staff could quickly and easily prepare rations ahead of time, and simplified staff training and stock management and forecasting. Some caregivers were dissatisfied with the modified dosage, though this may stem from household food insecurity rather than the adaptation itself. Finally, interviewees expressed concern about negative impacts on children’s progress, leaving them likely to revert to standard dosage protocols post-pandemic.
Treatment When Health Facilities are Inaccessible
Given access challenges during the pandemic, some organizations changed how and where follow-up visits took place, including treatment at household level and conducting phone visits during total lockdowns, enabling continued service provision. The division of responsibilities between staff and community workers varied. Transportation and last mile service delivery were common logistical challenges for home visits, while low-cost unlimited data plans enabled phone visits. Across all adaptations, consultation time increased significantly. However, interviewees reported difficulties identifying deterioration through phone visits. These adaptations were highly responsive to local conditions, and largely reverted once lockdowns abated.
As the pandemic continues, so will nutrition programs continue to innovate and adapt. This study illuminated several lessons learned from the complex adjustments undertaken to continue life-saving services and minimize transmission risk during the pandemic. Common best practices included ensuring adaptation buyin among multiple stakeholders at all levels, and rolling out adaptations through multiple sources, such as facilities, community groups, home visits, and phone calls. Common challenges included reduced health seeking behaviors; continuing service provision and trainings despite movement and gathering restrictions; and limited standardized monitoring systems and adaptation-specific indicators. Moving forward, program design should increase sensitization on early identification and treatment of acute malnutrition as well as assuage caregiver concerns about viral transmission; and capitalize on opportunities for virtual trainings to reduce associated costs and increase access. The global nutrition community must also collectively develop tools and indicators specific to each adaptation to capture impacts and compare effects across contexts.