Information-sharing to improve learning about community-based management of acute malnutrition (CMAM) and its impact
Nicky Dent, Hedwig Deconinck, Kate Golden, Rebecca Brown, and Anne Walsh Abstract Background. Severe acute malnutrition (SAM) affects 19 million children worldwide annually. The community-based management of acute malnutrition (CMAM) approach was first piloted in 2000. Endorsed by the United Nations in 2007, the approach has been introduced in over 60 countries. Current coverage and quality of services need further strengthening and key stakeholders have expressed the need for improved information-sharing. Objective. To report on an information-sharing initiative that was established to support scale-up of quality services for CMAM by collecting existing technical guidance, evidence, and learning. Methods. Routine website monitoring, country case studies, and surveys were used to assess the profiles of CMAM Forum users and the reach and use of information for improved health outcomes. Results. The number of information products and services and their use have steadily increased. Country case studies have identified ways to adapt information better to the needs of those involved in managing acute malnutrition, particularly at the country level. An urgent need has been identified for more resources in additional languages, especially French and Arabic, and expanded production and use of audiovisual material and social media. Conclusions. Improved information-sharing can have an impact on health outcomes, but further innovation and support are needed to improve access to, and use of, the information.
Nicky Dent, Hedwig Deconinck, and Rebecca Brown are affiliated with the CMAM Forum, Oxford, UK; Kate Golden is affiliated with Concern Worldwide, Dublin, Ireland; Anne Walsh is affiliated with Valid International, Oxford, UK. Please direct queries to the corresponding author: Nicky Dent, CMAM Forum, c/o 35 Leopold Street, Oxford OX4 1TW, UK; e-mail: [email protected] or cmamforum@ gmail.com.
S86
Key words: Community, information-sharing, malnutrition, quality, scale-up
Background Management of acute malnutrition is critical to reducing child mortality, particularly in high-burden areas. In 2013, an estimated 52 million children under 5 years of age were acutely malnourished, including 19 million children with severe acute malnutrition (SAM) [1]. Treatment of SAM was listed in the 2008 and 2013 Lancet Maternal and Child Nutrition Series as a costeffective, high-impact nutrition intervention [1]. Community-based management of acute malnutrition (CMAM) was first piloted in 2000 and endorsed by the United Nations in 2007 [2]. The approach has been introduced in over 60 countries, almost half of which have expanded to countrywide service delivery [3]. CMAM centers on a strategy of active community case-finding of children with SAM for early detection and treatment and maximum coverage. The approach includes an effective treatment protocol provided at decentralized outpatient facilities for the majority of children with SAM who are clinically well enough to be treated at home, and at inpatient facilities for the few children who develop complications. CMAM aims to include management of moderate acute malnutrition (MAM) where appropriate. The rapid expansion of CMAM began in emergency situations and has continued in development contexts, where it is increasingly offered as a routine child health service in high-burden areas. Despite this expansion, fewer than 2 million children under 5 years of age with SAM—or 10% of the global burden—were estimated to have received treatment in 2011, with an increase to 2.6 million in 2012 [3]. By the end of 2012, CMAM was offered in more than 50% of primary healthcare facilities in fewer than one-third of the implementing countries. Scale-up of CMAM is constrained by several factors, including weak health systems and limited funds in low-income countries.
Food and Nutrition Bulletin, vol. 35, no. 2 © 2014 (supplement), The Nevin Scrimshaw International Nutrition Foundation.
S87
Information-sharing and the CMAM Forum
The 2013 Lancet Maternal and Child Nutrition Series [4] stresses that: An enabling environment for nutrition requires empirically sound, timely data about the nature of the problem, evidence for what works and how, good coherence between sectors, good coordination between national and subnational levels, sufficient capacity to build commitment, implementation of programmes at scale, and sustainable public and private means to finance interventions. The Lancet Series also stresses the need for collective action. For scale-up of high-quality CMAM, governments and their partners need to learn from the challenges and successes experienced by others and adapt the CMAM approach and tools to their own contexts. Exchange of information, experience, and evolving best practices among practitioners, policy makers, managers, trainers, researchers, and donors (actors) must keep pace with the demand for, and expansion of, service delivery. As the number of actors involved in CMAM steadily increases, so does the need to consolidate knowledge and tools and continuous learning and to promote collaboration. Improved access to the Internet and web-based resources has meant greater opportunity to reach those at the forefront of managing acute malnutrition. The CMAM Forum was initiated in 2012 as a small pilot initiative to address the critical gap in information related to acute malnutrition by facilitating rapid dissemination of information and synthesis of CMAM experience and best practice. The CMAM Forum is independent and aims to engage actors from multiple sectors, regions, and backgrounds. Its multiagency Steering Committee is made up of 20 representatives of national health ministries, United Nations agencies, nongovernmental organizations (NGOs), and technical advisory bodies. Its structure and website were established with funds and in-kind contributions from a number of organizations.* The second and current phase (January 2013 to December 2014) is funded by the European Commission Humanitarian Aid and Civil Protection and UNICEF. By the end of this phase, the CMAM Forum will have identified a future home for longer-term continuity.
Objectives of the CMAM Forum The CMAM Forum aims to reinforce the current enabling environment for health and nutrition by * Action Contre la Faim–France, UNICEF, Concern Worldwide, Emergency Nutrition Network (ENN), Save the Children-UK, and Valid International.
providing both global and national platforms for information-sharing and consolidation on the management of acute malnutrition. The specific objectives are to: » Ensure that relevant, up-to-date information on acute malnutrition is accessible to key stakeholders based on expressed needs from users; » Produce technical summaries on priority themes related to acute malnutrition; » Synthesize learning on effective ways to disseminate CMAM-related information by conducting case studies in selected countries; » Support CMAM-related advocacy initiatives with evidence-based information.
Methods The CMAM Forum is an open-access website with information compiled from global, regional, and national sources and the latest CMAM information synthesized in the form of technical summaries. These summaries include frequently asked questions, technical updates, and technical briefs on challenging subjects. Experts on specific subjects contribute to the technical summaries, which are edited and disseminated by the CMAM Forum team with the support of the Steering Committee. Monthly resource updates summarize key events, articles, or reports relating to acute malnutrition. Details of ongoing research related to acute malnutrition are regularly compiled to promote complementarity and identify areas for future research. Information services include responding to requests for information, linking members through a messaging system, sharing links with discussion forums and e-learning, announcing meetings and conferences, and their documentation. All information is available via open access, but users who become members receive regular e-mail updates and can contribute to technical summaries. To monitor progress toward achieving its objectives, the CMAM Forum monitors website statistics and surveys members and website users to assess the effectiveness of its information dissemination and use and to identify opportunities to improve its support. Case studies in countries with high burdens of acute malnutrition (India, Kenya, Niger, and Yemen) have included assessments of website usage, e-surveys of members, and national and subnational discussions with key actors. Some case studies include a field visit to a remote location to gauge implementation and information access.
Results and discussion The results of the CMAM Forum’s first 18 months of operation are encouraging. Since 2012, the initiative
S88
N. Dent et al. Members
Resources
35,000
Website visits
1200
30,000
1000
25,000
800 20,000 600 15,000
400
10,000
200 0
Website visits
Members and resources
1400
2012 Q3
2012 Q4
2013 Q1
2013 Q2
2013 Q3
2013 Q4
5,000
FIG. 1. Community-Based Management of Acute Malnutrition (CMAM) Forum quarterly progress (July 2012–December 2013)
has grown steadily in both content and use. By the end of December 2013, the CMAM Forum had over 1,200 members representing 82 countries and had made available almost 1,000 resources on the management of acute malnutrition, including policies, protocols, tools, training materials, articles and research reports, evaluations, advocacy resources, and web-links. Six technical summaries have been completed, including coverage assessment, SAM and infection, estimating caseloads of acute malnutrition, the use of mid-upperarm circumference (MUAC), and mapping of edematous malnutrition, all translated into French. Resource updates are posted monthly and shared with members. Figure 1 shows the evolution of the CMAM Forum website in terms of number of members, resources, and visits per quarter. CMAM Forum members are from national and international NGOs and Red Cross or Red Crescent Societies (49%); the United Nations (16%); academic, training, research, and technical institutions (11%); governments (11%); independent organizations (5%); and other entities (8%). They come from a variety of educational backgrounds, especially nutrition and dietetics, as well as from medicine, nursing, and social and community development. Notably, 76% of the members and 50% of visitors to the website are from low-income countries, where the burden of acute malnutrition is highest. Fifteen percent of CMAM Forum members and website visitors are from francophone countries. Many of these countries, particularly those in the Sahel and in West and Central Africa, face significant undernutrition, but less than 10% of information is available in French. Members have also requested materials in Arabic. Country case studies conducted in collaboration with health policy makers and practitioners have shown that the CMAM Forum information products and services are being put to practical use at the country level. Various actors have used the CMAM Forum’s technical summaries to update national guidelines
or training materials. The actors found the monthly resource updates particularly useful. They also recommended making more audiovisual material available, increasing the use of social media, and strengthening links with other initiatives to prevent and manage acute malnutrition.
Future plans In 2014, the CMAM Forum will continue to collect and upload information on acute malnutrition and produce technical summaries on community engagement, local production of supplementary and therapeutic foods, information and communication technology, integration of CMAM into health services, and the prevention and management of MAM. To enhance collaboration and avoid duplication, the CMAM Forum will link with other nutrition platforms and forums. Website monitoring and member surveys will continue to yield useful information. Two additional country case studies are planned. Based on learning to date, the CMAM Forum will explore ways to engage key actors in high-burden countries more effectively to improve the quality of interventions, staff retention and motivation, peer communication, and linkages with other health and nutrition initiatives. In conclusion, further innovation and support are needed to improve access to, and use of, information on acute malnutrition to have an impact on health outcomes.
Conflicts of interest The authors declare no conflicts of interest.
Information-sharing and the CMAM Forum
Authors’ contributions Nicky Dent and Hedwig Deconinck co-authored the
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article; Kate Golden provided directions on the content and structure of the article; Rebecca Brown and Anne Walsh reviewed the article.
References 1. Black RE, Alderman H, Bhutta ZA, Gillespie S, Haddad L, Horton S, Lartey A, Mannar V, Ruel M, Victora CG, Walker SP, Webb P. Maternal and child nutrition: building momentum for impact. Lancet 2013;382:372–5. doi:10.1016/S0140-6736(13)60988-5. http://www.lancet -journals.com/NutritionSeries/files/assets/common/ downloads/publication.pdf. 2. World Health Organization/United Nations Administrative Committee on Coordination/Subcommittee on Nutrition (ACC/SCN)/UNICEF. Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations
Children’s Fund. Geneva: WHO, 2007. http://www.who. int/nutrition/topics/Statement_community_based_ man_sev_acute_mal_eng.pdf?ua=1 3. UNICEF. Global SAM management update. Summary of findings (September 2013). Nutrition Section, Program Division UNICEF NY 2013. http://www.unscn.org/ layout/modules/news/documents/Global%20SAM%20 Management%20Update.pdf 4. Maternal and Child Nutrition Study Group. Maternal and child nutrition: building momentum for impact. Comment. Lancet 2013;382:4. http://www.lancet -journals.com/NutritionSeries/files/assets/common/ downloads/publication.pdf
FOOD AND NUTRITION BULLETIN
Volume 35, Number 2, June 2014
www.foodandnutritionbulletin.org
SUPPLEMENT
SCALING UP NUTRITION: INTERNATIONAL MALNUTRITION TASK FORCE AND INTERNATIONAL ATOMIC ENERGY AGENCY Guest Editor: Alan A. Jackson
Nicky Dent, Hedwig Deconinck, Kate Golden, Rebecca Brown, and Anne Walsh Abstract Background. Severe acute malnutrition (SAM) affects 19 million children worldwide annually. The community-based management of acute malnutrition (CMAM) approach was first piloted in 2000. Endorsed by the United Nations in 2007, the approach has been introduced in over 60 countries. Current coverage and quality of services need further strengthening and key stakeholders have expressed the need for improved information-sharing. Objective. To report on an information-sharing initiative that was established to support scale-up of quality services for CMAM by collecting existing technical guidance, evidence, and learning. Methods. Routine website monitoring, country case studies, and surveys were used to assess the profiles of CMAM Forum users and the reach and use of information for improved health outcomes. Results. The number of information products and services and their use have steadily increased. Country case studies have identified ways to adapt information better to the needs of those involved in managing acute malnutrition, particularly at the country level. An urgent need has been identified for more resources in additional languages, especially French and Arabic, and expanded production and use of audiovisual material and social media. Conclusions. Improved information-sharing can have an impact on health outcomes, but further innovation and support are needed to improve access to, and use of, the information.
Nicky Dent, Hedwig Deconinck, and Rebecca Brown are affiliated with the CMAM Forum, Oxford, UK; Kate Golden is affiliated with Concern Worldwide, Dublin, Ireland; Anne Walsh is affiliated with Valid International, Oxford, UK. Please direct queries to the corresponding author: Nicky Dent, CMAM Forum, c/o 35 Leopold Street, Oxford OX4 1TW, UK; e-mail: [email protected] or cmamforum@ gmail.com.
S86
Key words: Community, information-sharing, malnutrition, quality, scale-up
Background Management of acute malnutrition is critical to reducing child mortality, particularly in high-burden areas. In 2013, an estimated 52 million children under 5 years of age were acutely malnourished, including 19 million children with severe acute malnutrition (SAM) [1]. Treatment of SAM was listed in the 2008 and 2013 Lancet Maternal and Child Nutrition Series as a costeffective, high-impact nutrition intervention [1]. Community-based management of acute malnutrition (CMAM) was first piloted in 2000 and endorsed by the United Nations in 2007 [2]. The approach has been introduced in over 60 countries, almost half of which have expanded to countrywide service delivery [3]. CMAM centers on a strategy of active community case-finding of children with SAM for early detection and treatment and maximum coverage. The approach includes an effective treatment protocol provided at decentralized outpatient facilities for the majority of children with SAM who are clinically well enough to be treated at home, and at inpatient facilities for the few children who develop complications. CMAM aims to include management of moderate acute malnutrition (MAM) where appropriate. The rapid expansion of CMAM began in emergency situations and has continued in development contexts, where it is increasingly offered as a routine child health service in high-burden areas. Despite this expansion, fewer than 2 million children under 5 years of age with SAM—or 10% of the global burden—were estimated to have received treatment in 2011, with an increase to 2.6 million in 2012 [3]. By the end of 2012, CMAM was offered in more than 50% of primary healthcare facilities in fewer than one-third of the implementing countries. Scale-up of CMAM is constrained by several factors, including weak health systems and limited funds in low-income countries.
Food and Nutrition Bulletin, vol. 35, no. 2 © 2014 (supplement), The Nevin Scrimshaw International Nutrition Foundation.
S87
Information-sharing and the CMAM Forum
The 2013 Lancet Maternal and Child Nutrition Series [4] stresses that: An enabling environment for nutrition requires empirically sound, timely data about the nature of the problem, evidence for what works and how, good coherence between sectors, good coordination between national and subnational levels, sufficient capacity to build commitment, implementation of programmes at scale, and sustainable public and private means to finance interventions. The Lancet Series also stresses the need for collective action. For scale-up of high-quality CMAM, governments and their partners need to learn from the challenges and successes experienced by others and adapt the CMAM approach and tools to their own contexts. Exchange of information, experience, and evolving best practices among practitioners, policy makers, managers, trainers, researchers, and donors (actors) must keep pace with the demand for, and expansion of, service delivery. As the number of actors involved in CMAM steadily increases, so does the need to consolidate knowledge and tools and continuous learning and to promote collaboration. Improved access to the Internet and web-based resources has meant greater opportunity to reach those at the forefront of managing acute malnutrition. The CMAM Forum was initiated in 2012 as a small pilot initiative to address the critical gap in information related to acute malnutrition by facilitating rapid dissemination of information and synthesis of CMAM experience and best practice. The CMAM Forum is independent and aims to engage actors from multiple sectors, regions, and backgrounds. Its multiagency Steering Committee is made up of 20 representatives of national health ministries, United Nations agencies, nongovernmental organizations (NGOs), and technical advisory bodies. Its structure and website were established with funds and in-kind contributions from a number of organizations.* The second and current phase (January 2013 to December 2014) is funded by the European Commission Humanitarian Aid and Civil Protection and UNICEF. By the end of this phase, the CMAM Forum will have identified a future home for longer-term continuity.
Objectives of the CMAM Forum The CMAM Forum aims to reinforce the current enabling environment for health and nutrition by * Action Contre la Faim–France, UNICEF, Concern Worldwide, Emergency Nutrition Network (ENN), Save the Children-UK, and Valid International.
providing both global and national platforms for information-sharing and consolidation on the management of acute malnutrition. The specific objectives are to: » Ensure that relevant, up-to-date information on acute malnutrition is accessible to key stakeholders based on expressed needs from users; » Produce technical summaries on priority themes related to acute malnutrition; » Synthesize learning on effective ways to disseminate CMAM-related information by conducting case studies in selected countries; » Support CMAM-related advocacy initiatives with evidence-based information.
Methods The CMAM Forum is an open-access website with information compiled from global, regional, and national sources and the latest CMAM information synthesized in the form of technical summaries. These summaries include frequently asked questions, technical updates, and technical briefs on challenging subjects. Experts on specific subjects contribute to the technical summaries, which are edited and disseminated by the CMAM Forum team with the support of the Steering Committee. Monthly resource updates summarize key events, articles, or reports relating to acute malnutrition. Details of ongoing research related to acute malnutrition are regularly compiled to promote complementarity and identify areas for future research. Information services include responding to requests for information, linking members through a messaging system, sharing links with discussion forums and e-learning, announcing meetings and conferences, and their documentation. All information is available via open access, but users who become members receive regular e-mail updates and can contribute to technical summaries. To monitor progress toward achieving its objectives, the CMAM Forum monitors website statistics and surveys members and website users to assess the effectiveness of its information dissemination and use and to identify opportunities to improve its support. Case studies in countries with high burdens of acute malnutrition (India, Kenya, Niger, and Yemen) have included assessments of website usage, e-surveys of members, and national and subnational discussions with key actors. Some case studies include a field visit to a remote location to gauge implementation and information access.
Results and discussion The results of the CMAM Forum’s first 18 months of operation are encouraging. Since 2012, the initiative
S88
N. Dent et al. Members
Resources
35,000
Website visits
1200
30,000
1000
25,000
800 20,000 600 15,000
400
10,000
200 0
Website visits
Members and resources
1400
2012 Q3
2012 Q4
2013 Q1
2013 Q2
2013 Q3
2013 Q4
5,000
FIG. 1. Community-Based Management of Acute Malnutrition (CMAM) Forum quarterly progress (July 2012–December 2013)
has grown steadily in both content and use. By the end of December 2013, the CMAM Forum had over 1,200 members representing 82 countries and had made available almost 1,000 resources on the management of acute malnutrition, including policies, protocols, tools, training materials, articles and research reports, evaluations, advocacy resources, and web-links. Six technical summaries have been completed, including coverage assessment, SAM and infection, estimating caseloads of acute malnutrition, the use of mid-upperarm circumference (MUAC), and mapping of edematous malnutrition, all translated into French. Resource updates are posted monthly and shared with members. Figure 1 shows the evolution of the CMAM Forum website in terms of number of members, resources, and visits per quarter. CMAM Forum members are from national and international NGOs and Red Cross or Red Crescent Societies (49%); the United Nations (16%); academic, training, research, and technical institutions (11%); governments (11%); independent organizations (5%); and other entities (8%). They come from a variety of educational backgrounds, especially nutrition and dietetics, as well as from medicine, nursing, and social and community development. Notably, 76% of the members and 50% of visitors to the website are from low-income countries, where the burden of acute malnutrition is highest. Fifteen percent of CMAM Forum members and website visitors are from francophone countries. Many of these countries, particularly those in the Sahel and in West and Central Africa, face significant undernutrition, but less than 10% of information is available in French. Members have also requested materials in Arabic. Country case studies conducted in collaboration with health policy makers and practitioners have shown that the CMAM Forum information products and services are being put to practical use at the country level. Various actors have used the CMAM Forum’s technical summaries to update national guidelines
or training materials. The actors found the monthly resource updates particularly useful. They also recommended making more audiovisual material available, increasing the use of social media, and strengthening links with other initiatives to prevent and manage acute malnutrition.
Future plans In 2014, the CMAM Forum will continue to collect and upload information on acute malnutrition and produce technical summaries on community engagement, local production of supplementary and therapeutic foods, information and communication technology, integration of CMAM into health services, and the prevention and management of MAM. To enhance collaboration and avoid duplication, the CMAM Forum will link with other nutrition platforms and forums. Website monitoring and member surveys will continue to yield useful information. Two additional country case studies are planned. Based on learning to date, the CMAM Forum will explore ways to engage key actors in high-burden countries more effectively to improve the quality of interventions, staff retention and motivation, peer communication, and linkages with other health and nutrition initiatives. In conclusion, further innovation and support are needed to improve access to, and use of, information on acute malnutrition to have an impact on health outcomes.
Conflicts of interest The authors declare no conflicts of interest.
Information-sharing and the CMAM Forum
Authors’ contributions Nicky Dent and Hedwig Deconinck co-authored the
S89
article; Kate Golden provided directions on the content and structure of the article; Rebecca Brown and Anne Walsh reviewed the article.
References 1. Black RE, Alderman H, Bhutta ZA, Gillespie S, Haddad L, Horton S, Lartey A, Mannar V, Ruel M, Victora CG, Walker SP, Webb P. Maternal and child nutrition: building momentum for impact. Lancet 2013;382:372–5. doi:10.1016/S0140-6736(13)60988-5. http://www.lancet -journals.com/NutritionSeries/files/assets/common/ downloads/publication.pdf. 2. World Health Organization/United Nations Administrative Committee on Coordination/Subcommittee on Nutrition (ACC/SCN)/UNICEF. Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations
Children’s Fund. Geneva: WHO, 2007. http://www.who. int/nutrition/topics/Statement_community_based_ man_sev_acute_mal_eng.pdf?ua=1 3. UNICEF. Global SAM management update. Summary of findings (September 2013). Nutrition Section, Program Division UNICEF NY 2013. http://www.unscn.org/ layout/modules/news/documents/Global%20SAM%20 Management%20Update.pdf 4. Maternal and Child Nutrition Study Group. Maternal and child nutrition: building momentum for impact. Comment. Lancet 2013;382:4. http://www.lancet -journals.com/NutritionSeries/files/assets/common/ downloads/publication.pdf
FOOD AND NUTRITION BULLETIN
Volume 35, Number 2, June 2014
www.foodandnutritionbulletin.org
SUPPLEMENT
SCALING UP NUTRITION: INTERNATIONAL MALNUTRITION TASK FORCE AND INTERNATIONAL ATOMIC ENERGY AGENCY Guest Editor: Alan A. Jackson
