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Evaluation Methods for Community Management of Acute Malnutrition Coverage

Good nutrition is essential for the human body to grow and develop as it should. Under-nutrition is one of the most serious, yet least addressed, development challenges in the world today, affecting a quarter of the world’s population. This why evaluation methods are important for countries facing these developmental challenges.

Deficiencies of iron, vitamin A and zinc are ranked among the World Health Organization’s (WHO) top 10 leading causes of death through disease in developing countries. (World Food Program 2016)

World Food Programme (WFP) defines malnutrition as “a state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance process such as growth, pregnancy, lactation, physical work and resisting and recovering.” (WFP & CDC 2005) In countries where malnutrition is one of the main contributing factors to the high mortality rates among children. This means that a large proportion of the next generation cannot live up to its full physical and mental potential.

CMAM Evaluation Method

Since 2007, the Community-Based Management of Acute Malnutrition (CMAM) has expanded to more than 55 countries. The CMAM method promotes use of ready-to-use therapeutic food (RUTF). This new model requires direct assessment and monitoring of coverage. Key determinants of impact are the degree to which interventions treat people early and the ability to spread treatment to as many affected persons as possible. (Myatt, et al., 2012)
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Reaching out at scale to all the vulnerable groups with essential nutrition services remains a challenge. (Lutter, et al., 2011) Many factors contribute to the delays in reaching scalability of CMAM – inadequate human resources, poor nutrition knowledge and health systems’ capacity to manage a nutrition program, high workloads and etc., result in low coverage of nutrition services. In countries like Sierra Leone and Uganda, childhood illnesses, insufficient service coverage, quality and demand for health services (exacerbated by the recent Ebola outbreak), and poor sanitation remain a major cause of child under-nutrition. (Lutter, et al., 2011; West, Saint, & Arnim, 2014, UGANDA REFERENCE)


Measuring and Interpreting Malnutrition

In 2005, World Food Program (WFP) and the Centers for Disease Control and Prevention (CDC) published Measuring and Interpreting Malnutrition and Mortality, which offers indices and other guiding information about how to identify and measure malnutrition program coverage. This tool also includes a randomization table, health surveys, and index z-score charts. Since the publication of this tool, recognized survey methods have emerged and been tested by the Coverage Monitoring Network. The methodological choices that evaluators make is generally varied and based the desired outcome.
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Indices for malnutrition include:



Anthropomorphic Indices

  1. Height for age
  2. Weight for age
  3. Weight for height

Other Indices

  1. Anemia: Hemoglobin
  2. Vitamin A Deficiency: Night Blindness and/or Serum Retinol
  3. Iodine Deficiency: Urinary Iodine

Complications – Edema (page 18)

When determining how well a program covers, or meets the needs of a malnourished population, the two indicators of low coverage stand out. They are “length of stay at admission” and “rate of default, i.e. people who do not return for follow up care, or failures who don’t go for care when referred.  Furthermore, as more information is learned, researchers continue to refine available models and adjust for contextual experiences.

Four of the primary coverage survey types include:


Coverage Survey Types

1) Centric Systems Area Sampling (CSAS), which is a resource intensive coverage survey that provides strong spatial resolution of surveys. Outputs include overall coverage estimate, local coverage, and ranked barriers.

2) Simple Spatial Survey Method (S3M), which designed for wide area coverage, is a Simple Spatial Survey, providing a simple assessment “general survey method” used to survey and map coverage and prevalence. It is not designed to cover three program levels or to determine levels of accessibility and utilization. Outputs include coverage map, overall estimate of coverage and ranked barriers.

3) Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage (SLEAC), a rapid low-cost survey using spatial sample similar to CSAS, requiring small sample sizes. Outputs include overall coverage classification, local coverage classifications with coverage map and wide area “estimates”, as well as ranked list of barriers.

4)  Semi-Quantitative Evaluation of Access and Coverage (SQUEC), a method of evaluating effectiveness, coverage, and ability to meet need. Provides overall coverage estimate and rich information on barriers and boosters to coverage. Outputs include mapping of coverage using “risk map” approach, estimation of coverage using Bayesian techniques, concept map of barriers and boosters to coverage.

These methods are important because, as research is showing, their use on a regular basis is improving CMAM coverage to 75% to 80%. (Myers, et al).

Technological Solutions to Tracking and Monitoring CMAM Programs

In today’s age, we can now use geographic positioning systems and telephone technology to map hard to reach communities, like villages in rural areas. Information systems should always be designed in such a way that data can be aggregated, reported, and integrated into local level systems.

Statistical Software

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For evaluation purposes, you can use statistical software, such as Epi Info™ or the newly developed Nutrisurvey, as they automatically calculate the nutritional indices.


(World Food Program 2016)

Clinical Presentation and Management of Severe Ebola Virus DiseaseAnn Am Thorac Soc1191341-1350

Maternal and child nutrition in Sub-Saharan Africa: challenges2008105-108LegonNutrition Society

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Reducing the Burden of Anemia in Infants and Young Children in Malaria-Endemic Countries of Africa: From Evidence to Action2004 Am. J. Trop. Med. Hyg71Supplement 225-34

2011Undernutrition, Poor Feeding Practices, and Low Coverage of Key Nutrition InterventionsOnlineAmerican Academy of Pediatrics

UNDP2011Human Development Report: Sustainability and Equity: A better Future for AllUNDP

Mark Myatt, Alison Norris, Saul Guerrero and Ernest Guevarra, (Report from Coverage Monitoring)

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