A Community-based Approach to Combating Malnutrition: What It Looks Like and How to Evaluate It
In a world of increasing rates of obesity, it is sometimes hard to remember that another type of malnutrition—undernutrition—remains a major contributor to mortality. Although all ages may be affected by malnutrition, children are most vulnerable to death and long-term disabilities caused by this disease. As such, treating and preventing undernutrition in children contribute to the achievement of Millennium Development Goals 1: Eradicate extreme poverty and hunger, and 4: Reduce child mortality.
In the MVP Potou Village Cluster in Senegal, community leaders and site team coordinators are tackling the burden of childhood malnutrition by addressing many of the social and environmental factors that eventually lead to poor health: minimally productive agriculture, poverty, gender inequality, and sanitation. However, despite significant gains in food security and social equality, one out of every nine children under five years old remains acutely malnourished.
One program that has been shown to effectively treat a large number of malnourished children is the Community-based Management of Acute Malnutrition (CMAM). CMAM was derived from treating large, famished populations during emergencies at the site of refuge. In the past, severely malnourished individuals would have had to travel great distances to a functioning clinic or hospital care, and the numbers of patients requiring the labor-intensive treatment would have overwhelmed hospitals. Once the community-based approach was proven to be as effective, if not more effective than sending patients to the hospital, specific guidelines and training manuals, promoted by the WHO and UNICEF, were developed to train healthcare workers around the world.
The bedrock of CMAM is the Community Health Worker (CHW), who administers screening campaigns, provides clinical referrals for severe acute malnutrition (SAM), treats moderate acute malnutrition (MAM) and organizes community gatherings to provide nutritional education. Instead of waiting for sick patients to become “sick enough” to go to the hospital, CMAM gives CHWs the responsibilities of identifying high-risk cases before they become severely malnourished and caring for those who are already severely malnourished, under the supervision of a local nurse or other qualified healthcare professional. The CMAM program is presided over by a medical physician; however, CMAM decentralizes the direct care of malnourished children so that local resources can be used more efficiently and effectively.
As a health intern with the Millennium Villages Project in West Africa, I designed a tool to evaluate the progress of CMAM in the MVP Cluster in Senegal, and completed a pilot-test during the program’s initiation in the cluster’s primary research zone. The resulting survey was a combination of questions for CMAM personnel and patients, and a checklist of observations intended to efficiently provide enough evidence to determine areas of improvement. The expected outcome was a report on the current state of CMAM in Potou, with recommendations for improved program implementation.
Once there were enough patients enrolled in the CMAM program, I took my survey to the field, and in three days completed eight interviews with mothers in their homes, one interview with the presiding pharmacist, and one interview with a CHW who was providing direct care for cases of MAM.
Separated by stretches of sandy terrain and cactus patches, travel between villages is either done by horse cart, a well-equipped SUV, or by foot. Since the women of Potou typically go by foot, I chose to hire a horse cart to get a better understanding of their paths. Traveling without the benefit of an SUV provided a wealth of information on the actual circumstances imposed on sick patients trying to seek medical care.
The nearest medical doctor is in Louga, about 35 kilometers away. This distance would be a breeze in a car, but no one owns a car, and so traveling to the district hospital requires hitching rides or paying for a spot in overcrowded vans. Thus, when a program like CMAM can be executed properly, treating patients closer to their homes saves precious time and reduces their risk of injury from road accidents. However, as I learned while traveling from village to village, even a five-kilometer distance can take over one-hour travel time by horse cart due to the difficult terrain. Walking takes even more time, which can become problematic in the evening hours when women have to return home in the dark.
Meeting with mothers and asking them about their experiences with CMAM and their use of a Ready-to-use Food Therapy (RUFT), known as PlumpyNut, was more reassuring. Although the findings are preliminary, all mothers and caretakers expressed great relief in the effectiveness of the product, and appreciated the accessibility of care. Mothers also had great facility in understanding basic nutritional concepts, such as the importance of including specific foods in their diets and their child’s supplementary diets.
While speaking with mothers about feeding practices, as well as observing and taking notes on the home environment, I was able to recognize a number of potentially positive and negative behavioral influences. For example, the cultural practice of eating together, around one bowl promotes greater intake of food. Individuals that typically eat less will eat more when they are surrounded by others who are consuming. However, the practice of saving the tastier morsels, which are typically the more nutritious components of a dish, for the head of the household, usually the father, may preclude optimal nutritional intake for those children who are most vulnerable to malnutrition.
Gathering this insight can be used to help tweak the CMAM program so that it meets the needs of the local community. To continue with the example above, should future studies demonstrate that fathers really are hindering the recovery of their child by eating the best part of the meal, community health workers could try to lead a discussion with local leaders and fathers on the benefits of feeding their children specific foods.
CMAM activity reflects the greater strategy behind MVP in that it is based on a continuous and evolving conversation between technical experts, program administrators and local constituents. Therefore, an evaluation of CMAM should utilize this same strategy, which, essentially, provides more useful feedback for maintenance of the new program. And if this program can be well maintained, then the cluster site will be one step closer to achieving MDG’s 1 and 4.
All photographs were taken in the rural district of Leona, Senegal by Angelie Singh with subjects’ permission.