Background

Nutrition is the intake of food considered in relation to the bodys dietary needs. Good nutrition: an adequate, well balanced diet combined with regular physical activity, is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity (WHO, 2015).

Globally, under nutrition which refers to both: protein energy malnutrition and micronutrient deficiency, is the cause of around 3.1 million child deaths annually in low and middle-income countries (Black et al, 2013).

When nutritional reserves are depleted or nutrient intake is inadequate to meet the bodys daily metabolic needs a state of under nutrition develops. Nutrient deficiency may stem from inadequate ingestion, impaired digestion or absorption, dysfunctional metabolic processing, or increased excretion of essential nutrients. Infants, children, pregnant females, individuals with low incomes, hospitalized persons, and older adults are at the greatest risk of becoming undernourished. Undernourishment may result in impaired growth and development, lowered resistance to infection, poor wound healing, and poor clinical outcome from disease or trauma with increased morbidity and mortality (Mahan et al, 2012). The long-term energy and nutrient depletion of eating disorders and the resulting malnutrition can have lasting effects on growth (More, 2013).

Malnourished children, particularly those with severe acute malnutrition, have higher risk of death from common childhood illness such as diarrhoea, pneumonia, and malaria. Nutrition-related factors contribute to about 45% of deaths in children under 5 years of age (WHO, 2016).

Since the 1950s the case-fatality rates in hospitals treating sever acute malnutrition (SAM) remained unchanged in developing countries (onaverage 20–30%). In 1992, this failure to translate scientific knowledge of what is needed to treat malnutrition in to effective large-scale interventions(Collinset al, 2007).Important achievements have been observed in the management of acute malnutrition over the last decade, particularly in the development of ready-to-use therapeutic foods (RUTF). The use of RUTF has facilitated decentralized ambulatory management of acute malnutrition and has promoted a community approach called community-based management of acute malnutrition (CMAM) (Kouam  et al, 2014).

Community based Management of Acute Malnutrition (CMAM) is an innovative approach for managing acute malnutrition in children within the community. CMAM results in early detection of cases of acute malnutrition, expanded access to treatment in decentralized sites, greater community involvement and support, and extended coverage. A comprehensive CMAM approach consists of community outreach, Outpatient Care management of severe acute malnutrition (SAM) without medical complications, Inpatient Care management of SAM with medical complications, and management of moderate acute malnutrition (MAM) (FANTA, 2011).

The community-based management of severe acute malnutrition is an attempt to achieve sustainable impacts at a population level by taking the socioeconomic realities into account, balancing the potentially conflicting demands and ethics of clinical and public health(Collins  et al, 2007).

The approach of community-based involves timely detection of active case finding in the community, Community health workers or volunteers can easily identify the children affected by acute malnutrition using simple colored plastic strips that are designed to measure mid-upper arm circumference (MUAC) and another sign can be recognized through  nutritional oedema of the feet. Once children are identified as suffering from acute malnutrition, they need to be seen by a health worker who has the skills to fully assess them following the Integrated Management of Childhood Illness (IMCI) approach. The health worker should then determine whether they can be treated in the community through the provision of treatment for those without medical complications with ready-to-use therapeutic foods (RUTF) or other nutrient-dense foods at home, or whether referral to inpatient care is required. RUTF have a similar nutrient composition to F100, which is the therapeutic diet used in hospital settings. But unlike F100, RUTF are not water-based, meaning that bacteria cannot grow in them. Therefore, these foods can be used safely at home without refrigeration and even in areas where hygiene conditions are not optimal.Early detection, coupled with decentralized treatment, reduced and prevent of hundreds of thousands of deaths. Evidence shows that about 80 percent of children with severe acute malnutrition who have been identified through active case finding, or through sensitizing and mobilizing communities to access, decentralized services themselves, can be treated at home (WHO, WFP, UNSSC and UNICEF, 2007).

 Justification

Rural Kassala locality is the second area in the Eastern Sudan states, implemented CMAM, after the pilot conducted in North Delta locality. Two coverage surveys were conducted, to investigate the number of children with severe acute malnutrition who were being reached by the program. The data which used are routine program data (such as admissions over time, MUAC on admission, proportion of discharges of defaulters, non-response and cures, length of stay and location of admissions) and qualitative data collected from beneficiary careers, program delivery staff and various community members (including traditional healers, TBAs, Imams and school-teachers) from which to make an estimate of program coverage (UNICEF, 2011). The role of community outreach workers / volunteers were not assessed, therefore this drew the researcher attention to assess the volunteers

 General objective

To evaluate the effectiveness of community outreach workers / volunteers in improving and increasing the coverage of the CMAM program, in Rural Kassala locality, Kassala state.

 Specific objectives

·          To assess the community outreach workers / volunteers performance, on the identification of cases, Health /Nutrition education, follow up home visit, and trace defaulters.

·          To identify the linkage between the community outreach workers/volunteers and the center running the therapeutic feeding.

Methodology

Study design

This study is a community based - cross sectional study targeting the communities covered by CMAM program in Rural Kassala locality, Kassala state.

Study area

The study carried out in the rural Kassala locality, villages covered by CMAM program.  The rural Kassala locality was established and set its boundary on the year 2007. It is approximately 3,650 square kilometers with a population figure of 156 thousand. The locality has consisted of 56 villages/communities, from which 21 communities were covered by CMAM program.

Study population

The populations of the study are of two types: community outreach workers / volunteers who are part of the CMAM program and households who inhabit in Rural Kassala locality and have children under five, in the period October 2016 – February 2017.

Sample size

Sample size was calculated using SMART software, (ENA SMART software (July 2015) version). A total children (6-59months) of 24,246was used for the sampling frame with an expected 18.7% prevalence of malnutrition (MUAC, S3M 2013, for Rural Kassala),a precision of 4.5% was used, with a design effect of 1.5.  The average household size was six people (taken from MICS 2014). The proportion of under five year olds was taken as 17%, the MoH guideline. A 1% contingency was included in case of non-response or invalid data. This gave a sample size of 288 children (6 -59 months). (See Appendix 2)

Selection of households

Upon reaching the selected village, went to the center of the village. At the center of the village a pen was spun and walked to the edge of the village in the direction shown by the pen, counting the houses along this line. The first house was selected randomly by drawing a number, from 1 to the total houses counted, blindly; the number picked became the first household and thereafter of 5 household intervals used. If a household with no children 6 -59 months, household with the nearest door was selected until all the samples completed.

The study included 200 households with 309 children 6 - 59 months. There was slight increase on the number of children 6 -59 months from the original sample this was due to the number of children 6 -59 months at last house found to be more than needed, so included all.

For the community outreach workers / volunteers, all volunteers were included (n=62).

Data collection

Primary data collection: The data have been collected using a structured questionnaire that developed by the researcher containing closed and open ended questions to the household with children 6 -59 months and community outreach worker / volunteers (See appendix 1).

The questionnaires of the household consisted of information about household demographic characterizes, knowledge of the CMAM program and the role of the community volunteer. Beside that other informations collected related to the nutritional status of their children and whether he/she registered in the nutrition program or not. MUAC and bilateral edema used as anthropometric assessment.

The questions of the community outreach worker / volunteer, inquire about the role of the volunteer, coverage areas, a way of taking the MUAC measurement and its linkage with the program and the nutrition worker and the problem facing to do their jobs.

Pilot was conducted in areas not to be included in the study, sample of 10 households and 5 community volunteers in Kassala town centers, no major problem found then used as a final questionnaire to collect the informations.

 Results

Data for Household interviewed

A total of 200 households were included for the study, the results show that (96.5%) of the household are headed by males and (3.5%) were female headed. Almost half of the mothers, 45% in the present study were at age group of 24-28 years, and one quarter of age group of 31-36 years. Regarding family size, 55% of the households had a family size around 3-5 persons, and 42% had 6-8 persons and only 3% were more than 8 persons. As for the presence of children under 5 per household, 60% of the households had only 1 child age under 5 years and one quarter had 2 children under five years.  The Educational level of the mothers /caregiver was reported as 40% were illiterate, 30 % had with primary level of education and only 1% had a secondary level of education.

Table (2) reveals that 94.5% were well knowledgeable of the Nutrition Therapeutic feeding programme at the centres and only5.5% were not knowledgeable about this program .The majority of the household (99%) well oriented by the presence of community outreach worker / volunteers in the community. The result also demonstrates 97% of the community outreach worker / volunteers were from the community.

Last visits and activities undertaken by community outreach workers / volunteers were shown in table (3). Less than half of the study households 43.9% were visited by the community outreach workers / volunteers within last week from the date of the interview, and a quarter of the sample 24.7% and 23.7% were visited on the same week and before one month from the date of interview respectively, and only 1% from the total interviewed household mentioned that never visited by the community outreach workers / volunteers. The activity of MUAC measurement was undertaken by the community outreach workers / volunteers as mentioned by 73% of household, 13.7% of households were visited by community outreach workers / volunteer to follow up children on nutrition programme and the rest 13.3% raised their awareness by either health and nutrition or IYCF information.

To view Table 1, Click below
Table 1: Demographic data of household.


Table 2: Knowledge of Nutrition program and volunteers.

To view Table 3, Click below
Table 3: Last time visits and activities undertaken by volunteers.

 Under five children Data

Regarding socio-demographic data, gender distribution among the selected children, table (4) shows that 53.4% of the children were males, while 46.6% were females. Their age group was classified as follows 25.9% of the children were in the age group ( 6-17 months) , 23% in the age group  (18 - 29 months), 26.9% in the age group  (30-41 months), 19.7%  in the age group  (42 - 53 months) and 4.5 % at age group ( 54 - 59 months ).


Table 4: Age and sex of children under 5 years.

A total of 309 children of age from 6 – 59 months have their MUAC checked and bilateral oedema to find out their nutritional status table (5). Based on MUAC cutoff 1.6% was found to be severely wasted and 15.5% was moderately wasted, with no case report with oedema.

Table 5: Prevalence of acute malnutrition based on MUAC cut off and/or oedema.

Table 6 the distribution of the sample by sex shows no significant differences was found in the number of boys and girls, P = 0.603 showing that boys and girls were equally represented. Also, there were no significant differences in the prevalence of acute malnutrition between boys and girls (p=0.477).

Table 6: Distribution of age with sex and prevalence of acute malnutrition.

 Data for community outreach workers / volunteers interviewed Table (8) results shows that (72.6%) of the community outreach workers / volunteers were female and 27.4 were male. One third of the community outreach workers / volunteers, 35.5% in the present study were at age group of 34-41years, 27.4% at age group of 26 – 33 years, and a reasonable % 12.9% were at the age over 50 years. Regarding family size, 62.9% of the community outreach workers / volunteers had a family size around 6-8 persons, and 29% had 3-5 persons and only 8.1% were more than 9 persons. As for the presence of children under 5, 58.1% of volunteers did not have children under 5 years and only 3.2% of them had 2 children under five years.   The education level of the volunteers community outreach workers / volunteers was reported as 37.1% were illiterate, 30.6% had a primary level of education, 22.6% had educated through Khalwa and only 6.5% and 3.2% had a secondary level of education and university respectively.

 Table (9) reveals that 53.2% worked as community outreach workers / volunteer between 3-5 years and 21% worked as community outreach workers / volunteer more than 5 years. Regarding working days per week, 53.2% were working 2 days per week and 30.6% of the community outreach workers / volunteer worked 3 days per week. For the community outreach workers / volunteer worked in the  same community,100% of them knew each other .The result demonstrates that 90.3% of the community outreach workers / volunteer  had a specific area to  be covered .

Table (10) showed that the community outreach workers / volunteers 87.1% was trained on basic CMAM training and almost all 98.4% were receiving  Food for Work as an incentive.

 Table (11) reveals that, 90.3% of the community outreach workers / volunteers knew well their role inside the community and only 9.7% did not know their role,  100% of community outreach workers / volunteers had used MUAC measurement to identify malnourished children and 12.9% beside the MUAC also had used bilateral edema for checking malnutrition. From the total interviewed community outreach workers / volunteers 90.3% had demonstrated the correct way of measuring MUAC.

 In table (12) the issue of mothers refusal was reflected, 88.7% of the mothers were referred to the centers / nutrition program without any objection, where some (11.3%) cases refused to refer, from them refused cases, 14.3% were not convinced and 85.7% of them convinced by the medicals assistance and key person from family.

 Table (13) shows that, only 79% of the community outreach worker / volunteers did their work based on their role at the CMAM guideline, 91.9% of the community outreach worker / volunteers had good linkage with the feeding program and 85.5% of the community outreach worker / volunteers reported the cases identified as malnourished to the staff at the center. Of the community outreach worker / volunteers 79% discussed their monthly achieved activities with the nutrition program staff and 21% demonstrated that they did not discuss their monthly achievement and report.              

 Discussion

This study was conducted to investigate the effectiveness of the community outreach workers/ volunteers on increase in the coverage of community based management of acute malnutrition program in Rural Kassala locality, Kassala state, Sudan. The study covered 21 communities with feeding centers. Data was collected from the community outreach workers/ volunteers total of 62, with an average of 3 volunteers for each center. A total of 200 households were sampled for the community data. The result showed that, a total of 1091 people living in these households, at an average family size of 5.5 persons, this corresponding to the Sudan MICS (2014) the average of household size were found to be 5.9 persons. The nutritional status was identified for 309 children less than five years.

Regarding head of household (96.5%) of the household headed by males since in Sudan generally and the rural areas specifically men had authority  to make all of the decisions of the aspect of life,  that include not limited to the health, education and even the voluntary work.

Concerning mothers / caregivers education levels, education is one of the most important resources that enable women to provide appropriate care for their children, which is an important determinant of childrens growth and development. In the present study majority of the sample was illiterate or participated in informal education, need nutrition and health educator to support them in increase their awareness of child care, improving their nutrition and health of the pregnant women and their outcome, support on identification of their childs nutritional status, beside spread the information about the feeding and health services at the community.

The study reveals that, 99% of the entire community knew the availability of the community outreach workers / volunteers with the community. Volunteers are usually local and therefore familiar with the area, its population and customs, and also well known by the community members.

The results indicated that 75.2% of the interviewed households were reached by the community outreach worker / volunteers within last month and 73% of them were screened by MUAC, this is a good indicator for the active case finding and early identification of malnourished cases. This similar to the report conducted by Collins et al (2007), who stated that in order to be able to provide the largest possible proportion of the acutely malnourished population with access to care, a program needs to be very effective at identifying people who need care andadmitting them to the program. To reduce the barriers to access, screening must take place in thecommunity using a simple, low cost method that is easy for community-based volunteers to use and isaccepted as fair and transparent by the population.

 The coverage of feeding program was calculated using the point coverage estimate and the result showed how well the program was doing at the time of the study. A point coverage calculation used the formula as follows: the cases identify as malnourished and found to be attending SFP or OTP divided by the total cases identified as malnourished times 100, the coverage of the program estimated by 64.2%.This stipulates therapeutic feeding programs coverage standards of 50% for rural populations, 75% of urban populations and 90% of the camp populations as a key indicator of programperformance (SPHERE, 2004). Regarding the effectiveness of the identification of cases and referring them to the nutritional feeding program, the result showed that 67.7% of the cases attending the feeding program were referred by the community outreach worker/volunteers. In line with, Collins et al (2007) state that, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. Wherever possible, programs build on local capacity and existing structures and systems, helping to equip communities to deal with future periods of vulnerability.

The majority of the volunteers were females, this is referred to the concept of the Eastern Sudan culture and traditions, for easily enters to the household for case finding, passing the nutrition and health information to the mothers and caregivers. The result showed that 58.1% of the community outreach workers / volunteers did not have children, which allowed them to work with the community.All the volunteers used MUAC for case identification;MUAC is a more sensitive indicator of mortality risk associated withmalnutrition than weight for height. It is therefore a better measure for the identification of children most in need of treatment, 9.7% of the community outreach workers / volunteers had taken MUAC measurement wrongly which needs more training(Unicef,21014)..As state by  Maleta. and Amadi, (2014) traditionally, therapeutic feeding programs use weight-for-height percentage of median (WHM) and/orthe presence of bilateral pitting oedema as admission criteria whilst at the same time screening in thecommunity using Mid Upper Arm Circumference (MUAC). The community outreach workers / volunteers 78%knew their roles in the community. As state in Sudan CMAM manual, community outreach is essential to make sure that undernourished children are detected early and referred for treatment, raises awareness of the aims of services and builds support. Moreover, it strengthens the communitys awareness of causes, signs and treatment of SAM, and promotes health and nutrition behavior change.

On the questions of challenge and the issue faced their volunteers work, 30% asked for a salary and 24% mentioned that the community is confused about the admission criteria for each program. Puett, and Guerrero, (2014).stated there are two major challenges facing volunteer-based case finding systems. These are choosing volunteers who are representative of their communities and secondly motivating volunteers to perform their roles.

Concerning the linkage of volunteers with the feeding program, 91.9% of the volunteers had good linkage through reporting and discussing their monthly performance with the nutrition staff at the main feeding center. In general, this indicates the good relationship between the main feeding centers and volunteers, which emphasizes the   regular detecting of malnourished cases, besides the updating of the situation of the entire community.

Conclusions

-          The community outreach workers / volunteers found to 72.6% were female, from them 35.5% at age group of 34-41years.

-          The entire community knew the availability of the community outreach workers / volunteers within the community.

-          Active case finding and early identification of malnourished cases 75.2% of the households were reached by the community outreach worker / volunteers within last month and 73% of them were screened by MUAC.

-          The coverage of the program estimated to be 64.2%, which is above the Sphere minimum standards of 50% (for rural programs).

-          A good relationship between the main feeding centers and volunteers, which emphasizes the   regular detecting of malnourished cases, besides the updating of the situation of the entire community.

Recommendation

-          This study was done in one locality in Rural Kassala locality, so the findings may not represent other localities implementing same feeding program. Similar study being recommended to be conducted targeting all localities.

-          Strengthen the role of community outreach /volunteers at the community level, through training, follow up and motivation.

-          On Job training, to ensure the properly taking of the measurement of MUAC.

 References

1.            Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, et al. Maternal and Child Nutrition 1, Maternal and child under nutrition and overweight in low-income and middle-income countries (2013) Lancet 382: 427-451. https://doi.org/10.1016/S0140-6736(13)60937-X

2.            Mahan LK and Escott-Stump S.  Krauses Food and Nutrition therapy, edition 12th, Publisher Saunders Elsevier, London UK.

3.            Collins S, Dent N, Binns P, Bahwere P, Sadler K et al. Management of severe acute malnutrition (2007) Lancet 368: 1992-2000. https://doi.org/10.1016/S0140-6736(06)69443-9

4.            Kouam CE. Delisle H, Ebbing HJ, Israel AD, Salpéteur C, et al. Perspectives for integration into the local health system of community-based management of acute malnutrition in children under 5 years: A qualitative study in Bangladesh (2014) Nutr J 13: 22. https://doi.org/10.1186/1475-2891-13-22

5.            Food and Nutrition Technical Assistance II Project (FANTA-2) (2011).

6.            Federal Ministry of Health of Sudan. Report of a Multi Indicator Cluster d (MICS) (2014) Survey in Sudan, Sudan

7.            Maleta K and Amadi B. Community-based management of acute malnutrition (CMAM) in sub-Saharan Africa: Case studies from Ghana, Malawi, and Zambia (2014) Food Nutrition Bulletin 35: 2. https://doi.org/10.1177/15648265140352S105

Keywords

Community; CMAM;  Acute Malnutrition; Severe Malnutrition.