RecommendedCitati

on:FoodandNutr
iti
onTechni
cal
Assi
stanceI
IIPr
oject(
FANTA).2018.Tr
aini
ng
GuideforCommunit
y-BasedManagementofAcut
eMalnut
ri
ti
on(CMAM) .Washi
ngt
on, DC:FHI
360/FANTA.
Sept
ember2018
Thetrai
ningmat eri
alsaremadepossi
blebythegeneroussupportoft heAmer i
canpeoplethroughthe
supportoftheOf f
iceofMater
nalandChil
dHeal t
handNut r
it
ion,Bureauf orGl
obalHeal
th,U.S.Agencyfor
Int
ernati
onalDevelopment(USAI
D)andUSAI D/BotswanaundertermsofCooper ati
veAgreementNo.AI D-
OAA-A-12-00005,throught
heFoodandNut r
iti
onTechnical
AssistanceIIIProj
ect(
FANTA) ,
managedby
FHI360.
Thecont
entsar
etheresponsi
bil
i
tyofFHI360anddonotnecessar
il
yref
lectt
hev
iewsofUSAI
Dort
he
Uni
tedSt
atesGover
nment .
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

ACKNOWLEDGEMENTS
Thedev el
opmentoftheor
iginal2008Traini
ngGuideforCommuni ty-
BasedManagementofAcuteMalnut
ri
tion
(CMAM)andt he2018revi
sionwer etheproductofcol
labor
ationbetweenmanydif
fer
entpeopl
eand
organi
sati
ons,al
lofwhom contri
butedgreatl
ytothefi
nalproduct
.Wewoul dl
iket
oacknowledgethecont
ribut
ion
ofthefoll
owi
ngpeopleandor gani
sati
ons:
Dev
elopmentoft
heOr
igi
nal2008Tr
aini
ngGui
def
orCMAM
Wewoul dli
ket othankHedwi gDeconinck,Kr
istenCashin,
andJoanWhel an(FoodandNut ri
tionTechnical
Assist
ancePr oj
ect[FANTA])
; Val
eri
eGat chel
l(ConcernWorldwi
de);TanyaKhara(UNICEF);AnneWal sh(Vali
d
Int
ernati
onal)
;ChantalGegout(WorldHealthOrganisat
ion[WHO]);
andMar garetFer
ri
s-Morris,Car
oli
neGr obl
er-
Tanner,JamieLee,andMar yanneStone-Jiménez(i
ndependentconsult
ants)f
orthei
rvaluablecontr
ibuti
onsas
authorsofvari
oussectionsofthemodul es.
Wewoul dli
ket othankCar oli
neAblaandEuny ongChung( U.S.AgencyforInter
nati
onalDev elopment[USAID]);
MohamedAy oya,LeahRi chardson,MahendraShet h,Adr
ianaZar r
ell
i
,andot her
s(UNICEF) ;
Andr eBri
end( WHO) ;
MikeNeequay e(GhanaHeal t
hSer v
ice)
;Marie-SophieSimon( Acti
onAgainstHunger);NickyDent ,
KateGol den,
LyndaKi ess,andot hers(ConcernWor l
dwide),KathrynBoll
es(Sav et
heChildren);
MesfinTekl u(Worl
dVi si
on
Int
ernati
onal);FredGr ant(for
mer l
yFANTA) ;SandraRemancus( FANTA);TulaMichael
idesandRenat aSei del(FHI
360);andJosephSomuahAkuamoahandShei khShahedRahman( i
ndependentconsult
ant s)fort
echnicalinput
s
andreviewt hatstrengthenedt hedocument.
2018Rev
isi
onoft
heTr
aini
ngGui
def
orCMAM
Wewoul dliketothankAli
ceNkor oi
,RebeccaEgan,andSandraRemancus(FANTA);AmandaYour chuck
(f
ormerlyFANTA) ;Mari
eMcGr ath(EmergencyNutr
iti
onNetwork);
andMaryLung’ahoandMar yanneSt one-
Ji
ménez( independentconsul
tants)f
orthei
rval
uablecontr
ibut
ionsint
herevi
sionofvar
ioussectionsoft he
modules.
Wewoul dli
ketothankLi ndyFenlason,Timot hyQui ck,Eri
nBoy d,SoniaWal i
a,JudyCanahuat i
,andElizabet
h
Bontrager(USAID);
ZitaWei sePr i
nzo(WHO) ;DoloresRi o(UNI CEF); AndreBri
end(Universi
tyofCopenhagenand
Univ
er si
tyofTamper e);Catheri
neAdu- Asare( GhanaHeal thSer v
ice);SaulGuerr
ero,GraceFunnell
,andot hers
(Act
ionAgai nstHunger )
;KateGolden,Nat al
ieSessi ons,andot hers(ConcernWor l
dwide);SusanButlerandNi cky
Connel l
(SavetheChildren);Col
leenEmar y(Wor ldVi si
onInt ernati
onal);SuzanneBri
nkmann( I
nter
national
Medical Corp[I
MC]);JeanetteBaileyandBet hanyMar r
on( InternationalRescueCommi t
tee[I
MC] )
;andKev in
Phelan( Al
li
anceforInternat
ionalMedicalAct i
on[ ALIMA] )
.
Wewoul dal
sol i
ketot hankthefoll
owingmember soft heManagementofAt-r
iskMothersandI nf
ant
sUnder6
Mont hs(MAMI )SpecialInter
estGroup:MarkoKeracandLoui seDay(LondonSchoolofHygiene&Tropical
Medicine),
JayBer kel
y( KEMRI /
WellcomeTrust);
Hat t
yBarthorp(
GOAL) ;
Kati
eBeck(Partner
si nHeal
th)
; I
ndi
TrehanandKi r
ril
ydePol nay(MédecinsSansFronti
èrs[MSF]);Ni
gel
Rolli
ns(WHO);andMi j
a-TesseVerv
ers(U.S.
CentersforDi
seaseCont r
olandPrevent
ion[CDC]).
Forherwor
kedi
ti
ngt
her
evi
sedt
rai
ningmat
eri
als,
wewoul
dli
ket
oacknowl
edgePam Sut
ton(
FANTA)
.
Wealsowouldl
i
ketothankallt
heagenciesthathavei
mplementedcommunit
y-basedt
herapeuti
ccare(
CTC)and
CMAM progr
ammesandt hathavedi
rect
lyandindir
ect
lycont
ri
butedtot
heexperi
enceandlearni
ngtodatef
rom
whi
chthesemodul
eshavebeendeveloped.

i
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

PREFACE
In2017,theWorldHealthOr ganisati
on(WHO) ,UnitedNati
onsChi l
dren’
sFund(UNICEF),andtheWor ld
Bankestimatedthatwasting,af orm ofacut
emal nutri
ti
on,affectstheli
vesofapproxi
mat el
y50.5milli
on
chi
ldr
enunder5y ear
sofagegl oball
y.Mostofthesechi l
drenliveinSouthAsiaandSub-SaharanAfrica.
Malnutr
it
ionisamaj orpubli
cheal thconcernandt heunder l
yi
ngcauseofdeat hsinchil
drenunder5y ears
ofage;chil
drenwithacutemal nutri
ti
onar eal
sothr eetoninetimesmor eli
kel
ytodi et
hanwel l
-nour
ished
chi
l en1.
dr
Toaddr essthehi ghr atesofacut emalnutr
it
ion,communi t
y-basedmanagementofacut emal nutr
it
ion
(CMAM) ,
whi chev olv
edf rom theCommuni t
y-BasedTher apeuticCar e(CTC)approach, wasdev el
opedin
20012.Theappr oachai mst oreachthemaxi mum numberofchi ldrenwi t
hacutemal nutri
tionandt o
ensurequal i
ty,access, andcov eragebyall
owingamaj ori
tyofchi l
drentobet r
eatedatmany
decentral
isedout patientcaresites.Inmanycount ri
es,CMAM wasi ntr
oducedasanemer gency
i
nterventi
on, butitisnowi ncreasinglybei
ngintegratedintoroutinehealthser
v i
cedeliveryandscal edup
asanessent ialsoluti
onf orthemanagementofacut emal nutr
iti
on.Ov er70countri
esar ecur rentl
y
3
i
mpl ement i
ngCMAM, wit
hmanyoft hem i
ntegrati
ngt hemanagementofsev ereacutemal nutri
ti
on(SAM)
i
ntogov ernmentpol i
cies.
TheCMAM appr oachconsistsoffourmai ncomponents:communityoutr
each,out
pat
ientcaref
ort
he
managementofSAM wi t
houtmedi calcompli
cati
ons,i
npati
entcar
ef ort
hemanagementofSAM wi t
h
medicalcompl
i
cations,andpr ogr
ammesf orthemanagementofmoder ateacutemal
nutri
ti
on(MAM),
suchasasuppl
ement aryfeedi
ngprogramme( SFP).

TheScopeoft
heTr
aini
ngGui
def
orCMAM
Thistraini
nggui defocusesont hemanagementofSAM i nchildren6–59mont hsofageandt akesi nto
accountemer gingev idenceont hemanagementofMAM andt he“managementofat -r
iskmot her sand
4
i
nfantsunder6mont hsofage( MAMI )”.Thetraini
nggui deisdesignedt oi ncreasepar t
ici
pant s’
knowledgeofandbui l
dpr acti
cal ski
ll
st oimplementCMAM i nemer gencyandnon- emer gencyset t
ings.
Thegui decompl ementst heWHOgui deli
nesandpr otocolsforthemanagementofacut emalnut rit
ionand
theWHOt rainingmodul esf orinpat i
entmanagementofsev erelymal nourishedchildren5.Thegui deis
i
ntendedt obeadapt edtot hel ocal contexttoensuret hatnati
onal guidel
inesandpr otocolsfort he
managementofacut emal nutri
tionandl ocalmodel sandmat eri
alsar econsidered.Not ethatwhi le
nati
onal guidelinesmustber espect ed,thisguiderefl
ectsev i
dence- basedgui danceand/ orcur rentbest
pract
ices,unlessot herwisest ated.

1
Coll
insetal .2006.Managementofsev er eacutemal nut r
iti
oninchi ldren.TheLancet .368:1992- 2000.  
2
Col l
i
ns, S.2004.“ Communi ty
-BasedTher apeut i
cCar e:ANewPar adi gm f orSelect i
v eFeedingi nNut r
iti
onal Cri
sis.”Humani t
ar i
an
PracticeNet wor kPaper48.Ov erseasDev elopmentI nst i
tute(ODI ).
3
UNICEF.2014.Nut r
idash2013:Gl obalRepor tont hePi lotYear .NewYor k:UNI CEF.Av ail
ableat :
https:
/ /unicef eapronutri
tionwashtoolkit
.fi
les.wor dpress.com/ 2017/09/ uni cef-gl
obal -nutri
dash- report-2013.pdf.
4
In2017, t
hist erm wasr edefi
nedf rom ‘managementofacut emal nut ri
ti
oni ni nfantsunder6mont hs’to‘managementofat -risk
mot hersandi nfantsunder6mont hs’ t
or eflectthepr ofil
eoft hemot her -
infantpai rbeingident if
ied, t
heirassociatedr i
sks,and
consequent l
y,thewi derscopeofi ntervent i
onsneededt ocat erfororsuppor tthem; theseincl udebutar enotli
mi tedtonut r
it
ion.
5
Thet rainingmodul esar e:
WHO.2013.Updat esont heManagementofSever eAcut eMal nutri
tioni nI nfantsandChi l
dren.Geneva:WHO.
WHO.2012.Techni calNot eonSuppl ement aryFoodsf ortheManagementofModer ateAcut eMal nutrit
ioninInfantsandChi ldren
6–59Mont hs.Geneva:WHO.
WHO.1998, updat edin2017–2018.ManagementofSev er eMal nutr
ition:AManualf orPhysi ciansandOt herSeniorHealthWor ker
s.
Genev a: WHO.
WHO.2002, updat edin2009.Tr aini
ngCour seont heManagementofSever eAcut eMal nutri
tion.Geneva:WHO.
WHO.2000.Managementoft heChi ldwithSer i
ousI nfectionorSever eAcut eMal nutrit
ion.

i
i
Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

i
i
i
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

WhatI
sNewi
nthe2018Rev
isi
on?
The2018r evisi
onoft histrai
ningguiderefl
ectsguidanceandr ecommendat ionsf r
om thefol
lowing
publi
cations:Updat esont heManagementofSever eAcut eMal nutri
ti
oninInf antsandChil
dren( WHO
2013) Updat
, esonHI VandI nfantFeedi
ng(WHO2016) ,theTechni calNoteonSuppl ementar
yFoodsf or
theManagementofModer ateAcuteMalnutri
ti
oninInfantsandChi l
dren6–59Mont hsofAge(WHO
2012) ,
andt heJoi ntStatementonWHOChi l
dGr owthStandardsandt heIdent i
fi
cati
onofSAM i nInf
ants
andChi ldr
en( WHO/ UNICEF2009) .Therevi
sionalsoprov i
desaddi ti
onalguidancebasedont hemost
recentev i
dence,lessonsl earned,andbestpract
ices.Belowarehi ghli
ghtsoft hechangesmadet othe
trai
ningguide:

1. Identi
fi
cat i
on,Admi ssi on,and Di scharge ofChil
dr en with Acut e Mal nutri
ti
on:Mid-upperar m
cir
cumf erence(MUAC)andbi lateralpi
tti
ngoedemaar eusedast hepr i
mar ycri
ter
iai
nthecommuni t
y
fortheiniti
alscreeningofacut emal nutr
iti
onandreferralfortreatment .Trai
ningmothersandf amil
y
member sonMUACmeasur ementandassessmentofbi l
ateralpitt
ingoedemaoft hei
rchildrenhas
beenaddedasast rat egytofaci l
i
tateearlycasedet
ect i
onandr eferralfortr
eatment.I
naddi t
ion,t
he
foll
owingchangeshav ebeenmade:
 Admi ssi
onofchi l
dr en6–59mont hsfortreat
mentofSAM i sbasedonaMUACof<115mm and
anydegr eeofbil
at eralpi
tti
ngoedema; f
orMAM treatment ,
admi ssioni sbasedonaMUACof115
to<125mm.
 Thewei
ght
-f
or-
hei
ght
/wei
ght
-f
or-
lengt
h(WFH/
WFL)<-
3z-
scor
eoft
heWHOr
efer
encest
andar
dsi
s
al
sousedt
oadmitf
ort
reat
mentofSAM,
andWFH/
WFL-
3to<-
2z-
scor
eisusedt
oadmi
tfor
tr
eat
mentofMAM.
 Thesameant
hropomet
ri
cindi
cat
orusedt
oident
if
yandconf
ir
m SAM orMAM onadmi
ssi
oni
s
usedt
odet
ermi
ner
ecover
yanddi
schar
gef
rom t
reat
ment
.

2. VitaminASuppl ementati
onintheTreatmentofSAM:Ahi ghdoseofv i
taminAisnotgiventoinf
ants
andchi l
dreni
ftheyarerecei
vingther
apeuti
cfoodsthatcomplywit
hWHOspeci f
icat
ions.Ahighdose
ofv i
taminAisgivenonadmi ssi
ononlyift
hetherapeut
icfoodspr
ovidedarenotfort
ifi
edas
recommendedi ntheWHOspeci f
icat
ionsandvit
aminAi snotpar
tofotherdai
lysupplements.
Ahighdoseofvit
aminAi sgivenonday1tochildr
enwithSAM whoalsohav
eeyesignsofvi
tami
nA
def
ici
encyandtochil
drenwithSAM whorecentl
yhadmeasles,wit
hasecondandathir
ddoseonday
2andday15,respect
ivel
y,r
egardl
essoft
het ypeofther
apeut
icfoodt
hechil
disr
eceivi
ng.

3. ManagementofHI V-I
nfect
edChi l
drenwithSAM:I nadditiontot herecommendat ionsprovidedinthe
2013WHOupdat esont hemanagementofSAM i ninfantsandchi ldren,tr
eatmentofHI V-infect
ed
chil
drenwit
hacut emal nut
ri
tionshouldfollow t
henat i
onalHI Vpr ot
ocol s.I
nhighpr eval
encear eas,
univer
salt
esti
ngofchi l
drenwi t
hacutemal nutr
it
ionisencour agedifHI Vstatusi
sunknown.I fachil
d
i
sf ai
li
ng t
or espond t ot r
eatmentofacut e mal nutri
ti
on,and HI V status is unknown,i tis
recommendedt hatthechil
dbet est
edforHI Vaspartoft heroutinetreatment.
4. ManagementofAt -RiskMot her sandI nfantsunder6Mont hsofAge( MAMI):Followingt he2013
WHOupdat esont hemanagementofSAM i ni nfant sandchi ldren, i
nfantsunder6mont hsshoul dbe
managed accor di
ng t ot he same basi c pr i
nciples as chi l
dr en age 6–59 mont hs,i ncluding
disti
nguishi
ngt hoseinfantswi thmedi calcompl i
cationsf r
om t hosewi thoutmedi calcompl i
cati
ons
andmanagi ngtheuncompl i
cat edcasesi nout patientcare.Cur r ent
ly,thereisal ackofev i
denceon
thecasemanagementofat -
riskmot hersandi nf antsunder6mont hsofage; thi
si ncl
udesanongoi ng
debat eonant hropomet ri
candnon- anthropomet ricindi
cat orsandwhatcr it
eriatouset odef ine
nutrit
ionalr
isk.Whiler esearchonMAMIi songoi ng,exper topi nionandpr ogrammi ngexper i
ences
from member soft heMAMISpeci alInterestGr ouphav ebeenusedt oprovidegui dancei nt hi s
trai
ningguide.Thet echnicalcont entisdrawnf rom andr eferencest ot heC- MAMIToolVer si
on2. 0.
Pr i
ort ocountrylevelimplement ation,itisr ecommendedt hatuser sr efertolatestev idenceand
recommendat ionsasdet ai
lsofcasemanagementst rat
egiesandappr oachesar eevol v
ingr apidly.

i
v
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Addi
ti
onal
ref
erencesar
eav
ail
abl
eher
e:ht
tps:
//www.
ennonl
ine.
net
/our
wor
k/r
esear
ch/
mami
.
Keygui
dingpr
inci
plest
otheMAMIcont
enti
nthi
str
aini
nggui
dear
easf
oll
ows:
 I
nst
eadof“
acut
emal
nut
ri
ti
on”
,thet
erm“
nut
ri
ti
onv
ulner
abi
l
ity
”ispr
efer
redbecausei
tcapt
ures
broaderchar act
eri
sticsoftheneedsofi nfantsunder6mont hsofageandr ecognizest hatnotall
theseinfantsareequal l
yvulner
abl e;
forexampl e,somehadal owbi r
thwei ghtbutar esubsequent l
y
growingwel l,whi
leotherinfant
sar epresent l
ynotwastedbutar eatr iskandt her
eforei nneedof
i
ntervention.Iti
simpor t
antthatinfants“atrisk”ar
edisti
nguishedandt hatthecasemanagement
i
dent i
fi
esandaddr essesunderl
yingpr oblemssuchasabi li
tytof eed,underlyi
ngmedi calcondit
ions,
mat er
nal il
l
nessandpoorment al healt
h, andadversesoci
alcircumst ances.
 Nut
ri
ti
onal
l
yvul
ner
abl
einf
ant
sunder6mont
hsofagewi
thoutcompl
i
cat
ionsar
emanagedi
n
out
pati
entcare,
wher
easnut
ri
ti
onal
l
yvul
ner
abl
einf
ant
swi
thcompl
i
cat
ionsar
eref
err
edf
or24-
hour
i
npati
entcar
e.
 Nut
ri
ti
onsuppor
t,par
ti
cul
arl
yest
abl
i
shmentofef
fect
iveexcl
usi
vebr
east
feedi
ng,
ist
hemai
n
i
nter
vent
ioni
nthecasemanagementofi
nfant
sunder6mont
hs.
 Thewel
l-
bei
ngofani
nfanti
sst
rongl
yinf
luencedbyamot
her
’sheal
th,
ment
alheal
th,
nut
ri
ti
on,
andsocialci
rcumst
ances;ther
efor
e,t
hemotherandinf
antar
ebestconsi
der
edasa“
mot
her
-
i
nfantpair
”andareenrol
ledandmanagedt
ogether.

5. Combined ProtocolforSAM and MAM Tr eat

ment:In except
ionalemergency si
tuat
ions,t
he
combi
nedpr ot
ocolforSAM andMAM tr
eat
menthasbeenpr ovi
dedasanopt i
onintheabsenceofa
SFPand/oroutpati
entcar
efort
hemanagementofSAM wi
thoutmedicalcompl
icat
ions.
6. Str
engthening t
he Health Syst
em and Pl anni
ng and Managi ng I
ncreased Demand forAcute
Malnutri
ti
on:The t
raini
ng guide emphasizes i
ntegr
ati
on ofser vi
ces formanagementofacut e
malnutr
iti
onint
onati
onalhealthcaresy
stemswher et
heyexistandprovi
desadditi
onalgui
danceand
ref
erencesonhowheal t
hsystemscanbettercopewi t
hperi
odicpeaksindemandf orCMAM servi
ces.

Emer
gingEv
idenceont
heManagementofAcut
eMal
nut
ri
ti
on
Ongoi
ngresearchandemergi
ngevidenceonthemanagementofacut
emal nut
ri
ti
oni
sant
ici
pat
edt
o
becomeavail
ablei
n2018–2020.Someoft hepr
ior
it
yresear
chtopi
careasare:
 Ef
fect
iveappr
oachest
odet
ect
,di
agnose,
andt
reatacut
emal
nut
ri
ti
on
 Appr
opr
iat
eent
ryanddi
schar
gecr
it
eri
afort
reat
mentofacut
emal
nut
ri
ti
ononacont
inuum t
oensur
e
opt
imal
out
comes
 Opt
imal
dosageofr
eady
-to-
usef
ood(
RUF)f
ort
reat
mentofacut
emal
nut
ri
ti
on
 Ef
fect
ivet
reat
mentofdi
arr
hoeai
nchi
l
drenwi
thSAM
 Rat
esandcausal
fact
orsofpost
-t
reat
mentr
elapseacr
osscont
ext
s
 I
dent
if
icat
ionandmanagementofat
-r
iskmot
her
sandofi
nfant
sunder6mont
hsofage
 Al
ter
nat
ivef
ormul
ati
onsf
orRUFf
oracut
emal
nut
ri
ti
on

Wher
enecessar
y,onli
neli
nkstot
heresear
chandgl
obal
discussi
onsont
het
opi
car
eashav
ebeen
pr
ovi
dedi
nthetrai
ningguidemodul
es.

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TABLEOFCONTENTS
Acknowl
edgement
s i
Pr
eface i
i
Abbr
evi
ati
onsandAcr
ony
ms v
ii
i
Tr
ainer
’sGui
de 1
Annex1.Pr
inci
plesofAdul
tLear
ning 6
Annex2.Tr
aini
ngMet
hodsandHowt
oUseThem 8
Annex3.Suggest
edRev
iewEner
giser
s(Gr
oupandTeam Bui
l
ding) 10
Handout–Ev
aluat
ionFor
mforModul
e 11
ModuleOne:Overvi
ewofCommuni t
y-BasedManagementofAcut eMal nutr
it
ion(CMAM) 12
Int
roducePart
ici
pants,Trai
ningCour se,Modules,andCourseObj ecti
ves 16
Learni
ngObjecti
ve1:DiscussAcut eMal nutr
it
ionandtheNeedf oraResponse 17
Learni
ngObjecti
ve2:Identi
fythePrinciplesofCMAM 18
Learni
ngObjecti
ve3:DescribeInnovationsandEv i
denceMaki ngCMAM Possi ble 20
Learni
ngObjecti
ve4:Identi
fytheComponent sofCMAM andHowTheyWor kToget
her 22
Learni
ngObjecti
ve5:ExploreHowCMAM CanBeI mpl
ement edinDiffer
entContext
s 23
Learni
ngObjecti
ve6:Identi
fyKeyNat i
onalandGlobalDevelopment sandCommi tment
sRel
ati
ng
toCMAM 24
Wrap-UpandModul eEv al
uati
on 25
Fi
eldVi
sitt
oOut
pat
ientCar
eSi
te 26
Modul
eTwo:Def i
ningandMeasur i
ngAcut eMal nutr
it
ion 27
Learni
ngObjecti
ve1:Di
scussCausesandConsequencesofUnder nut
rit
ionandUnder
nutr
iti
on
Terminol
ogy 31
Learni
ngObjecti
ve2:I
dentif
yt heCli
nicalSignsofAcut eMalnut
ri
ti
on 34
Learni
ngObjecti
ve3:Measure, Cal
cul
at e,andClassi
fyAcuteMalnutri
ti
on 35
Learni
ngObjecti
ve4:AssessandCl assifyNutri
ti
onal Vul
ner
abil
it
yinAt-RiskMot
hersandInfant
s
Under6Mont hsofAge 40
Wrap-UpandModul eEval
uation 41
Modul
eThree:Communi tyOut r
each 42
Lear
ningObject
ive1:Explai
nt heImportanceofCommuni tyOutreachtoCMAM Out comes 45
Lear
ningObject
ive2:I
dent i
fyKeyEl ementsofaCommuni tyAssessment 49
Lear
ningObject
ive3:I
dent i
fyKeySt epsinDevelopi
ngaCMAM Out reachSt
rat
egy 51
Lear
ningObject
ive4:DiscussConsi der
ationsforDevel
opingandUsi ngCMAM Messages 55
Lear
ningObject
ive5:DiscussPr eparat
ionsforCommuni t
yMobi l
isati
onandTrai
ning 56
Wrap-UpandModul eEvaluati
on 58
Fi
eldVi
sitf
orCommuni
tyOut
reach 59
Modul
eFour :Outpati
entCarefortheManagementofSAM Wi t
houtMedi
calCompli
cati
ons 63
LearningObj ect
ive1:Descr
ibeOutpati
entCarefort
heManagementofSAM Wi t
houtMedi
cal
Compl icat
ions 68
LearningObj ect
ive2:Descr
ibeAdmissionCrit
eri
ainOutpat
ientCar
e(I
nfant
sUnder6Months
andChi ldr
en6–59mont hs) 69
LearningObj ect
ive3:Descr
ibetheProcessforAdmissi
onsandOutpati
entCar
eFoll
ow-On
Sessionsf orChil
dren6–59Mont hs 71

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LearningObj ective4: Expl ainMedi calTreatmentf ortheManagementofChi l

drenWi thSAM
WithoutMedi cal Compl icationsi nOut patientCare 73
LearningObj ective5: Expl ainNut r
iti
onRehabi l
it
ati
onf ortheManagementofSAM Wi thoutMedical
Compl icat
ionsi nOut patientCar e(Chil
dren6–59Mont hs) 75
LearningObj ective6: Descr i
bet heKeyMessagesf orMot hers/Car egiversofChi ldren6–59Mont hs
Usedi nOut pat i
entCar e 76
LearningObj ective7: Expl aint heManagementofAt -
Ri skMot hersandI nfantsUnder6Mont hs
ofAgeWi thoutMedi cal Compl icati
onsi nOut pati
entCar e 78
LearningObj ective8: Recogni singWhenFur therActi
onI sNeeded: Ref erraltoInpatientCare and
Foll
ow- UpHomeVi sits 80
LearningObj ective9: Expl ainDi schargeCr i
teri
aandPr ocedur esforAt -RiskMot hersandI nf
ants
Under6Mont hsandChi ldren6–59Mont hs 83
LearningObj ective10: Descr ibeLinkagesBet weenOut patientCar eandOt herSer v
ices,
Programmes, andI nit
iatives 85
Wrap- UpandModul eEv aluation 86
Outpat i
entCar eFi eldPr actice 88
Fi
eldPr acticeLear ningObj ect i
ve1: AssessandAdmi taChi l
dt oOut patientCar e 90
Fi
eldPr acticeLear ningObj ect i
ve2: AssessandTr eataChi ldDur inganOut pati
entCar e
Foll
ow- OnSessi on 91
Fi
eldPr acticeLear ningObj ect i
ve3: AssessandManageanAt -
RiskMot herandI nf
antUnder 6
Mont hsofAgewi t
houtMedi cal Compl i
cationsinOut patientCar e 92
Modul eFi ve:I
npatientCar efort heManagementofSAM wi thMedicalCompl i
cati
ons int
he
Cont extofCMAM 93
Lear ni
ngObj ect
ive1: Outli
net heManagementofChi l
drenWithSAM Wi thMedicalCompli
cat
ions
i
nI npat i
entCare 96
Lear ni
ngObj ect
ive2: Descr i
beAdmi ssi
onandDi schargefort
heManagementofSAM Wi t
h
Medi calCompl i
cationsinI npatientCare 97
Lear ni
ngObj ect
ive3: ReviewMedi calandDietaryTreatmenti
nInpat i
entCare 99
Lear ni
ngObj ect
ive4: Practicet heRefer
ral
Pr ocessBetweenInpatientCareandOutpati
entCare 101
Wr ap-UpandModul eEv aluation 103
Inpat i
entCareFieldVisit 104
Modul
eSi x:ManagementofModer ateAcut eMalnutri
ti
on( MAM)int heContextofCMAM 106
Lear
ningObj ecti
ve1:DescribeSomeTy pesofProgrammest oManageMAM andHowThi s
ComponentFi tsWithi
nCMAM 110
Lear
ningObj ecti
ve2:DescribeAdmi ssi
ont oandDischargefrom t
heManagementofModer at
e
AcuteMal nut r
it
ion(MAM) 113
Lear
ningObj ecti
ve3:DiscussMedi calTreatmentandNut r
it
ionRehabil
i
tat
ionfortheManagement
ofMAM 114
Lear
ningObj ecti
ve4:Practi
ceMaki ngRef er
ral
sfrom Supplementar
yFeedingtoOutpat
ientorInpat
ient
Care 115
Wrap-UpandModul eEvaluati
on 117
Supplement aryFeedingFieldVisi
t 118
ModuleSev
en:Pl
anni
ngCMAM Ser vi
cesatt heDist
ri
ctLev
el 120
Learni
ngObj
ecti
ve1:Descr
ibeKeyElementsofCMAM andPrepar
eforthePl
anni
ngProcess 123
Learni
ngObj
ecti
ve2:I
denti
fyKeyComponent sofaSit
uati
onAnal
ysi
sandConductaBasi
c
Sit
uati
onAnal
ysi
s 125
Learni
ngObj
ecti
ve3:Devel
opaLogicalFr
amewor kforCMAM 128
Learni
ngObj
ecti
ve4:Devel
opanActionPlanforCMAM 129

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,2018Ver
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Lear
ningObject
ive5:Pl
anningforSpeci
alCases:
Transi
ti
oni
ngandCont
ingenci
es 132
Wrap-UpandModul eEv
aluati
on 134
ModuleEight:Monit
oringandRepor ti
ngonCMAM 135
LearningObject
ive1: DescribethePrinci
pl esofaMoni t
ori
ngandRepor t
ingSystem forCMAM 139
LearningObject
ive2: DescribeHowt heI ndivi
dualI
nf antorChil
dIsTr ackedandMoni t oredin
CMAM 140
LearningObject
ive3: Compl eteSi
teTal l
ySheet sandSi teandDistr
ictReports;
Interpretthe
Findings 143
LearningObject
ive4: Calculat
eandDi scussSer vi
ce/ Progr
ammePer formanceandCov erage 150
LearningObject
ive5: Moni t
orandRespondt oBarr
ierstoAccess 152
LearningObject
ive6: Explai
nt hePurposeofSuppor tandSupervisi
onVi sit
sandt heRol eofa
Super vi
sor
/Mentor 155
LearningObject
ive7: PrepareanOut l
inef orCMAM Repor t
ing 158
Wr ap-UpandModul eEv aluati
on 159
Moni
tor
ingandRepor
ti
ngonCMAM:
Out
pat
ientCar
eFi
eldPr
act
icef
orHeal
thCar
ePr
ovi
der
s 160

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,2018Ver
sion

ABBREVI
ATI
ONSANDACRONYMS
ACF Act i
onCont reLaFai m
ACT artemi si nin-basedcombi nat iont her
apy
AED Academyf orEducat ional Dev elopment
ARI acut er espi rat oryinf ect i
on
ART antiretr oviral therapy
ARV Ant i
ret rov i
ral
AWG aver agedai l
ywei ghtgai n
BCC behav iourchangecommuni cation
BMS breastmi lksubst i
tut e
CBO communi ty-basedor ganisat ion
CCC Communi t yCar eCoal i
t i
on
CDC U.S.Cent ersf orDi seaseCont rolandPr event
ion
CHC childheal thcar d
CHP communi tyheal thpr omot er
CHPS Communi t y-BasedHeal thPl anni ngandSer vi
cesI ni
ti
ati
ve
CHPS-TA Communi t y-BasedHeal thPl anni ngandSer vi
cesI ni
ti
ati
ve–Techni
calAssi
stance
CHW communi tyheal thwor ker
CMAM communi ty-basedmanagementofacut emalnut r
iti
on
C-MAMI Communi t y-BasedManagementofAt -
RiskMot hersandInf
ant
sunder6Mont hs
CMV combi nedmi neral andv itami nmi x
CRS Cat holicRel iefSer vices
CSAS cent ricsy st emat icar easampl i
ng
CSB corn- soybl end
CTC communi ty-basedt her apeut iccar e
DHMT districtheal thmanagementt eam
DHS Demogr aphi cHeal thSur vey
DSM dryski m mi lk
EBF exclusi v ebr east feedi ng
EDL Essent ialDr ugLi st
ENA Essent ialNut rit
ionAct ions
ENN Emer gencyNut riti
onNet wor k
EPI expandedpr ogr ammeofi mmuni sation
FANTA FoodandNut rit
ionTechni cal AssistanceProject
FAO FoodandAgr icultur eOr gani sat i
onoft heUnitedNat i
ons
FBF fortifi
edbl endedf ood
GAM global acut emal nut ri
ti
on
GHS GhanaHeal thSer vices
GI Gast roi ntest inal
GMP growt hmoni toringandpr omot ion
GSHP GhanaSust ainabl eHeal thPr oject
HBC home- basedcar e
HEW heal thext ensi onwor ker
HFA height -for-age
HIRD HighI mpactandRapi dDel i
ver y

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sion

HIV humani mmunodef iciencyv irus

HMI S heal thmanagementi nf or mat ionsy stem
IEC i
nf or mat ion, educat ion, andcommuni cat i
on
IFE InfantFeedi ngi nEmer genci es
IMAM i
ntegr atedmanagementofacut emal nut ri
ti
on
IMCI i
ntegr atedmanagementofchi ldhoodi l
lness
INAAM Integr atedNut ri
tionAct ionAgai nstMal nut r
iti
on
ITN i
nsect icide- treat ednet
IU i
nter nat ional uni ts
IYCF i
nf antandy oungchi ldrenf eedi ng
KCAL Kil
ocal or i
es
LFA l
engt h-for -age
LNS l
ipid- basednut rientsuppl ement
LOS aver agel engt hofst ay
LRTI l
owerr espi r
at oryt racti nf ect ion
M&E moni toringandev al uation
MAM moder ateacut emal nut rition
MAMI ManagementofAcut eMal nut ritioninInf antsProjectoft
heInst
it
uteofChi
l
dHeal
th
MAMI managementofat -ri
skmot her sandi nfant sunder6mont hsofage
MCH mat ernal andchi l
dheal th
MCHN mat ernal andchi l
dheal thandnut r
iti
on
MDG Millenni um Dev elopmentGoal
MICS Mul tipleI ndi cat orCl ust erSur v ey
MOH Mini stryofHeal th
MSF Médeci nsSansFr ont ièrs
MUAC mid- upperar m ci rcumf er ence
NCHS Nat ional Cent ref orHeal thSt atist i
cs
NFDM nonf atdr ymi l
k
NGO nongov ernment al or gani sat ion
NRC nut ri
t i
onr ehabi l
itationcent re
NRU nut ri
t i
onr ehabi l
itationuni t
OI oppor tuni stici nfect ion
OICI Oppor tuni tiesI ndust rializat ionCent ersI nternati
onal
OPD out pat i
entdepar tment
OTP out pat i
entt her apeut icpr ogr amme
OVC orphansandv ulner ablechi ldr en
PD Posi t i
veDev iance
PHC primar yheal thcar e
PLHIV peopl eliv i
ngwi thHI V
PMTCT prev ent ionofmot her -to-chi l
dt ransmi ssionofHI V
PRA Par ticipat oryRur alAppr aisal
QHP Qual i
tyHeal thPar tner s
ReSoMal Rehy drat ionSol ut i
onf orMal nut ri
ti
on
RRA Rapi dRur al Appr aisal
RUF ready -
to- usef ood
RUSF ready -
to- usesuppl ement ar yf ood
RUTF ready -
to- uset her apeut icf ood

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,2018Ver
sion

SAM sev ereacut emal nut r

ition
SC stabili
sat ioncent re
SC-
USA Sav et heChi ldr enUSA
SD standar ddev iation
SFP suppl ement aryf eedi ngpr ogr amme
SMART Standar disedMoni toringandAssessmentf orReli
efandTr
ansi
ti
on
SNNPR Sout her nNat i
ons, Nat i
onal i
ties,andPeople’
sRegion
SQUEAC semi -quant itativeev al uati
onofaccessandcov er
age
SST suppl ement arysuckl ingt echni que
SWOT strengt hs, weaknesses, oppor tuni
ti
es,
andt hreat
s
TB Tuber cul osis
TF taskf orce
TFC therapeut i
cf eedi ngcent re
UN UnitedNat i
ons
UNICEF UnitedNat i
onsChi l
dr en’sFund
UN/SCN UnitedNat i
onsSy stem St andi ngCommi tt
eeonNut ri
ti
on
USAID UnitedSt atesAgencyf orInternati
onalDevelopment
VCT volunt arycounsel l
ingandt esting
WFA wei ght-for-age
WFH wei ght-for-height
WFL wei ght-for-l
engt h
WFP Wor l
dFoodPr ogr amme
WHO Wor l
dHeal thOr ganisat ion
WSB wheat -
soybl end

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TRAI
NER’
SGUI
DE

1.Tr
aini
ngPar
ti
cipant
sandTr
ainer
s
Parti
cipants
Thet r
ainingguideisdesi gnedf orhealthcaremanagersandheal thcareprovi
derswho manage,
supervise,andimpl ementser vi
cesforthemanagementofSAM.Thi si
ncludeshealt
hcarepr ovi
derswho
areinvolvedinhealthout reachact i
vit
ies(e.
g.,
healt
hout reachcoor di
nators,
communi tymobi l
i
sati
on
coordinators,di
str
ictsuper visorsforcommuni t
yhealthwor kers[CHWs] )
.Itwil
lal
sobeusef ulforMini
str
y
ofHeal th(MOH)of ficial
satt henat i
onal,r
egi
onal,
anddi stri
ctlev
els;healt
handnut r
iti
onprogramme
manager sandtechni calstaffofnongov er
nmentalorganisati
ons( NGOs);andUnitedNations(U.N.
)
techni
cal staffi
nvolvedint hemanagementofacut emal nutri
ti
oni nchil
dren.Theguideisdesignedtobe
adaptedf orthetargetaudi encewhennecessar y.

Trainers/Faci
lit
ators
Atleasttwot rai
ners/f
acili
tat
orsper15–25par ti
ci
pantsshouldleadthet
rai
ning.Thetrai
nersshouldbe
famili
arwi t
hCMAM andexper i
encedinthepracti
calappl
icati
onofcommunity-basedoutpati
entcaref
or
SAM.Thi sov ervi
ewmodul econt ai
nsguidancefortr
ainer
s/ f
acil
i
tat
orsonpl
anni ngthecourseand
describesthecommuni cati
onandt r
aini
ngmet hodsusedi nthegui
de.

Traini
ngi ntheCl assroom andt heFiel
d
Thet rai
ningmet hodsandact iv i
tiesusedthr
oughoutt hemoduleswillbepr acti
calandparti
cipat
ory,
buil
dingonpar t
icipants’knowl edge,skil
l
s,andexperi
ence.Inadditi
ont othewr i
tt
enmat er
ial
sand
practi
calexer ci
sesi ntheclassr oom, someofthetrainingmodulesincludef i
eldworkincommuni t
ies,
healthfacil
i
ties,andout patientandi npati
entcaresi
tes.Thisfi
eldworkcompl ementsthetheoryl
earnedi
n
theclassroom andgi v
espar t
icipantsanopportuni
tytodevelopthepract i
calskill
srequi
redtoimplement
CMAM.

2.Met
hodsandMat
eri
als
Thefullcour
setakesabout11daysandpl
acessi
gnif
icantemphasi
sondev el
opi
ngpr
act
ical
ski
l
ls.I
t
requi
resabout4½day sofcl
assr
oom workandabout6½day si
nthefi
eld.

Modules
Thereareei
ghtmodulesorder
edsequential
ly.Tr
ainers/f
acil
it
atorsmayadaptt helengthofthemodules,
l
eaveoutamodul eorchangetheorderofthemodul esaccordingtothecontextandthet ar
getaudi
ence’
s
needs.Themodulesaregener
ic.Ever
ycontextisdif
ferent,
andt r
ainers/f
aci
li
tator
swi l
lneedtomodify
themodulesaccordi
ngtothecontext
,gui
deli
nes,andnat i
onalprotocolsinagivencountry.

Fortrainers:Thecompletetr
ainercour
semat erial
sincl
udethi
st r
ainerguidanceandi nf
ormati
on,t
he
ei
ghtmodul es,andpar
tici
panthandouts.Theeightmodulesaredesi gnedt obeusedby
tr
ainers/faci
lit
ator
sasguidanceandar enotintendedtobegiventopar ti
cipants.Aneval
uat
ionfor
m,
i
ncludedasahandoutatt heendoft hi
sov er
view,canbeusedf oreachmodul e.

Eachmodul
eincl
udes:
 Anovervi
ew
 At
abl
edet
ail
i
ngl
ear
ningobj
ect
ivesandr
elat
edhandout
sforcl
assr
oom wor
k
 Al
i
stofmat
eri
alsr
equi
red,
incl
udi
ngr
efer
encemat
eri
als(
ifappl
i
cabl
e)
 Advancepr
epar
ati
ont
hatt
het
rai
nerwi
l
lneedt
odo
 Suggest
edact
ivi
ti
esandt
rai
ningmet
hodsbasedoneachl
ear
ningobj
ect
ive,
wit
hinst
ruct
ionsf
ort
he
t
rai
ner
/faci
l
itat
or

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 Awr
ap-
upandev
aluat
ionsessi
onf
ort
hemodul
e
 Atabledetai
li
nglearni
ngobj
ecti
vesandrel
atedhandoutsf
ort
hefiel
dv i
sit(
whenappl
icabl
e)
 Suggestedacti
vi
tiesandmethodstobeconduct
edduringt
hefi
eldvi
sit(whenappl
i
cable)

Forpar
ti
cipant
s:Par
ti
cipant
sar
egi
venapackaget
hatcont
ainshandout
sforeachmodul
e.

Addi
ti
onalr
efer
encemat
eri
als:
 Gui
del
i
ne:Updat
esont
heManagementofSever
eAcut
eMal
nut
ri
ti
on(
SAM)i
nInf
ant
sandChi
l
dren
(WHO2013)
,av
ail
ableat
:
htt
p:/
/www.
who.i
nt/
nutr
it
ion/
publ
i
cat
ions/
gui
del
i
nes/
updat
es_
management
_SAM_
inf
ant
andchi
l
dren/
en/
 Gui
del
i
nesf
ort
heI
npat
ientTr
eat
mentofSever
elyMal
nour
ishedChi
l
dren(
WHO)
,expect
ed
publ
i
cat
ioni
n2018/
2019atwww.
who.
int
/nut
/publ
i
cat
ions
 WHO,WFP,Uni
tedNat
ionsSy
stem St
andi
ngCommi
tt
eeonNut
ri
ti
on,
andUNI
CEF2007j
oint
st
atementoncommunity-
basedmanagementofsevereacut
emal
nut
ri
ti
on,
avai
l
abl
eat
ht
tps:
//www.uni
cef
.or
g/publ
icat
ions/
index_
39468.
html
 Nat
ional
gui
del
i
nesandpr
otocol
sforSAM,
out
pat
ientcar
e,i
npat
ientcar
e,andmanagementof
moder
ateacut
emal
nut
ri
ti
on(
MAM)
 Localout
pat
ientcar
etr
eat
mentcar
ds,
inpat
ientcar
etr
eat
mentcar
ds,
suppl
ement
aryf
eedi
ng
tr
eatmentcar
ds,
ready
-to-
uset
her
apeut
icf
ood(
RUTF)r
ati
oncar
dsandsuppl
ement
aryf
eedi
ngr
ati
on
cards

Thetr
ainers/f
acil
i
tator
swill
needtopr
ovideal
lot
hercour
semat
eri
als,
incl
udi
ngv
ideos,
blankcar
ds,
cal
cul
ators,pens,andnot
ebooks,
asneeded.

Methodsf orInstr
uction
Thiscour seisdesignedt obui l
dupont hepar ti
cipants’knowl edgeandexper i
enceandt ober el
ev antto
thei
rneedsandt heneedsoft heircommuni t
ies.Itusesav arietyoft rainingmet hodsi ncl
udingwr it
ten
exercises,practi
calexercisesinsmal l
gr oups,discussions, role-plays,videodemonst r
ati
ons,practice,
casest udiesandguestspeaker s.Thesemet hodsgi veparticipant sat hor oughov ervi
ewofconcept sand
protocols.Thecour sestructureisdesignedt ochal l
engepar ti
cipant stocomeupwi ththei
rownsol uti
ons
toproblems.Thepr acti
cal fi
eldcomponentwi l
lreinforcetheor yl earnedi nt heclassroom andgiv e
part
icipantsanoppor tunitytodev el
opt hepracticalskill
srequi redt oimpl ementser v
ices.Descripti
onsof
methodsandgui dancef orconduct i
ngt rai
ningswi thadultlear ner sappearatt heendoft hismodul e.
Parti
cipantsal
soserveasresourcesforoneanother.Respectf
ori
ndi
vi
dual
trai
neesi
scent
ral
tot
he
tr
aini
ng, andshar
ingofexperi
encesisencouragedthroughout.

3.Cour
sePl
anni
ng
Cour seTimeFr ame
Theappr oxi mateti
mei ttakestocovereachf ullmoduleisnot edinthetabl
ebel owasagui def or
planningpur poses.Courseplanswillvaryaccordingtothetargetaudienceandt hecontext, and
trai
ners/facili
tat
orsshouldadaptthet r
ainingmodul estosuitparti
cipant
s’needs.Trainersmaychooset o
shortenorski psomemodul esandspendext rati
meonot hersdependingont hepartici
pants’ knowledge,
skil
ls,andobj ecti
ves,
aswel lasthetraini
ngt i
meav ail
able.Not et
hatifModuleOnei sskippedf orany
reason, t
rainersshoul
dgi vepart
ici
pantst hefoll
owingModul eOnehandout st hatarereferr
edt oinother
modul es:Handout1. 1Abbr evi
ati
onsandAcr onyms, Handout1. 2Ter mi
nologyf orCMAM andHandout
1.3Ref erencesandFur therReading.
Appr
oximate Appr
oximate
Modul
e
Cl
assroom Ti
me Si
teVisi
t/Fi
eldPr
act
iceTi
me

2
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ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

I
ntr
oduct
ion 1hour

Over
viewofCommunity
-Based
1 ManagementofAcut
eMal nut
ri
ti
on 1½hour 1daysi
tev
isi
t
(
CMAM)
Def
ini
ngandMeasur
ingAcut
e
2 3hour
s SeeModul
eFour
Mal
nutri
ti
on

3 Communi
tyOut
reach 3½hour
s 1dayf
iel
dpr
act
ice

3daysfieldpr
acti
ce,duri
ngwhich
Out
pati
entCar
efortheManagementof
4 8hour
s par
ti
cipantswil
lalsopract
iceski
l
ls
SAM Wi
thoutMedi
calCompli
cat
ions
cov
eredi nModuleTwo
I
npatientCar
efortheManagementof
5 SAM wi t
hMedical
Complicat
ionsint
he 2hour
s ½daysi
tev
isi
t
ContextofCMAM
ManagementofModer at
eAcut e
6 Malnutri
ti
on(MAM)intheContextof 2hour
s ½daysi
tev
isi
t
CMAM
Planni
ngCMAM Ser
vicesatt
heDi
str
ict
7 8hour
s
Level

½dayf
iel
dpr
act
ice
8 Moni
tor
ingandRepor
ti
ngonCMAM 5hour
s

34hours
Tot
al 6½day
s
(about4½day
s)

Pl
anni
ngt
heAgendaf
oraCMAM Tr
aini
ng
Trainers/
faci
li
tat
orsshoul
ddevel
opacourseplanthatbestsui
tstheneedsofthei
rpar
ti
cipant
sandt
hei
r
resources.Herearesomeconsi
derat
ionswhenplanni
ngthetrai
ningagenda:
 Heal
thcar
epr
ovi
der
s(pr
act
it
ioner
s)wi
l
lusual
l
ycompl
eteal
lcl
assr
oom modul
es,
onet
otwoday
sof
si
tev
isi
tsand4½day
sofpr
act
icei
nthef
iel
d.
 Heal
thcar
emanager
swi
l
lusual
l
ycompl
eteal
lcl
assr
oom modul
esandonet
otwoday
sofsi
tev
isi
ts.
 Conductasi
tev
isi
tassoonaspossi
blesopar
ti
ci
pant
scanseet
her
elev
anceoft
hecl
assr
oom
sessi
ons.
 Tof
aci
l
itat
ethehands-
onnat
ureoft
hef
iel
dvi
si
ts,
iti
sideal
tohav
enomor
ethanf
ivet
osev
en
part
ici
pant
satt
hesamesit
eatthesameti
me.Itmightbenecessar
ytoschedul
evi
sit
satmul
ti
ple
si
tesorti
mestoaccommodat
eallt
hepar
ti
cipant
s.
 Pr
ovi
desuf
fi
cientt
imef
ort
ranspor
tat
iont
oandf
rom f
iel
dsi
tes.
 Schedul
eti
mef
ordebr
ief
inganddi
scussi
onoff
iel
dvi
sit
s.
 Beawar
eoft
heschedul
esoft
hesi
tesy
ouar
evi
si
ti
ng.Forexampl
e,i
fout
pat
ientcar
eisav
ail
abl
e
onl
yint
hemor
ning,
thosef
iel
dvi
si
tsshoul
dbeconduct
edi
nthemor
ning.
 Schedul
eti
meont
hef
ir
standl
astday
sforf
ormalopeni
ngandcl
osi
ngoft
heover
allt
rai
ning,
as
necessar
yandappr
opr
iat
e.

3
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Tr
aini
ngTasksandResponsi
bil
it
ies:KeyPoi
ntsf
orPr
epar
ati
onandPl
anni
ngBef
ore
Tr
aini
ng
Itisnecessaryt
opl anforopti
mal outcomeswel lbefor
ethet
rai
ning.Thefol
l
owingcheckli
stout
li
nes
someessent ial
tasksandr esponsibi
l
iti
es.Thelistshoul
dbeadaptedfort
hespecifi
cneedsofagiven
trai
ning.Trai
ner
s/facil
it
atorsandkeyst akehol
dersinthepar
ti
cipant
s’or
ganisat
ionsshoul
ddeci
dewhois
responsibl
eforeacht ask.

1. Set
ti
ngt
heObj
ect
ivesandExpect
ati
onsoft
heTr
aini
ng
 I
dent
if
yandcol
l
abor
atewi
thappr
opr
iat
eor
gani
sat
ionsandpar
tner
s.
 Tr
ainer
s/f
aci
l
itat
orsandor
gani
sat
ionst
oget
heri
dent
if
ythedesi
redgoal
sandobj
ect
ives.
 Commi
tresour
ces.
 Devel
opat
rai
ningst
rat
egyt
oachi
evet
her
esul
ts,
incl
udi
ngr
efr
eshert
rai
ningsandf
oll
ow-
up.
 Est
abl
ishandcommi
ttoasy
stem ofsuper
visi
on/
ment
ori
ng.

2. Par
ti
cipantSel
ect
ion
 Est
abl
i
shpar
ti
cipantsel
ect
ioncr
it
eri
a.
 Knowt
heaudi
ence(
numberandt
ypeofpar
ti
ci
pant
s,e.
g.,
MOH,
NGO,
doct
ors,
nur
ses,
auxi
l
iar
ies,
CHWs,
heal
thcar
emanager
s,heal
thcar
epr
ovi
der
s).
 I
nfor
m par
ti
cipant
soft
hepur
poseoft
het
rai
ningandcl
ari
fyt
hei
rrol
esandr
esponsi
bil
i
tiesaf
ter
t
rai
ning(
i.
e.,
clearj
obexpect
ati
ons)
.
 Askpar
ti
cipant
stobr
ingr
elev
antmat
eri
alst
oshar
e:
o Nut
ri
ti
onsur
vey
saccor
dingt
odi
str
ict
/regi
on
o Inf
ormat
iononheal
th,nutr
it
ionandunder
nut
ri
ti
onpr
event
iveandcur
ati
veser
vicesi
nthei
r
communiti
esandcountr
ies
o I
nfor
mationonthecont
extoft
heirheal
thsyst
em:Howitwor
ks,
whet
heri
tiscent
ral
i
sedor
de-
cent
rali
sed,
whooperat
esinkeyareas(e.
g.,
NGO,MOH)

3. Under
standi
ngt
hePar
ti
cipant
s’Cont
ext
:Mi
ni-
Sit
uat
ionAnal
ysi
s
 I
dent
if
ythepr
obl
em i
npar
ti
ci
pant
s’set
ti
ngs:
o Emer
gency
/dev
elopment
o Ur
ban/
rur
al
o Seasonal
chal
l
enges
 I
dent
if
ynat
ional
gui
del
i
nesf
ort
hemanagementofSAM andMAM.
 Resear
chnut
ri
ti
onsur
vey
saccor
dingt
odi
str
ict
/regi
on.
 I
nvest
igat
eheal
th,
nut
ri
ti
onandunder
nut
ri
ti
onpr
event
iveandcur
ati
veser
vicesi
npar
ti
cipant
s’
communi
ti
esandcount
ri
es.
 Descr
ibet
hecont
extofpar
ti
cipant
s’heal
thsy
stems:howt
heywor
k,whet
hert
heyar
ecent
ral
ised
orde-
cent
ral
ised,
whooper
atesi
nkeyar
eas(
e.g.
,NGOorMOH)
.

4. Tr
aini
ngCont
ent
 Adaptcour
secont
entt
othecont
ext
;li
mitt
hecont
entt
owhatpar
ti
cipant
sneedt
oper
for
mthei
r

4
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

pr
ofessi
onal
responsi
bil
i
tieswel
l
.
 Ensur
ethatcour
semat
eri
alsar
econsi
stentwi
thnat
ional
gui
del
i
nesoni
ndi
cat
orcut
off
sfor
admissi
onanddi
schar
ge,
mid-upperar
m ci
rcumf
erence(
MUAC)oruseofwei
ght
-f
or-
hei
ght
/wei
ght
-
for
-l
engt
h(WFH/WFL)asdet
erminedbytheWHOchi l
dgr
owt
hstandar
ds.
 Pr
epar
ethet
rai
ningagendaandi
dent
if
yper
sonsr
esponsi
blef
oreachel
ement
.
 Est
abl
isheval
uat
ioncr
it
eri
a.

5. Logi
sti
cs
 I
dent
if
ytr
aini
ngday
sandt
imes.
 Det
ermi
net
het
rai
ningl
ocat
ion(
est
abl
i
shcr
it
eri
aforadequat
ewor
kspace,
suppl
i
es,
equi
pment
,job
ai
ds)
.
 I
dent
if
yguestspeaker
s,i
fappl
i
cabl
e,ensur
ethei
rav
ail
abi
l
ityanddet
ermi
nepossi
blel
ogi
sti
cal
needs
(
e.g.
,speci
fi
cti
ming,
transpor
tat
ion)
 I
dent
if
ylocat
ionsf
ort
hef
iel
dvi
si
ts.
 Pl
ant
hef
iel
dvi
sit
swi
tht
hesi
tes’
super
visor
sandst
aff
:
o Rev
iewt
heschedul
eofv
isi
ts.
o Ensur
ethatst
aff
ingandsuppl
i
esar
esuf
fi
ci
ent
.
o Ensur
ethatsi
te-
basedr
esour
ceper
sonscanpar
ti
cipat
e.
o Consi
derdoi
ngaf
iel
dvi
si
tasear
lyaspossi
blei
nthet
rai
ning..
 Or
gani
set
ranspor
tat
ionf
ort
hef
iel
dvi
sit
s.
 Pl
anf
oranyl
anguagebar
ri
ers(
bet
weent
rai
nerandpar
ti
cipant
sorbet
weenpar
ti
cipant
sandl
ocal
s).
Whenavail
abl
e,pai
rparti
ci
pant
swi t
htransl
ator
sorcommuni t
ymemberswhospeakthei
rlanguage
andthel
ocall
anguage.Arr
angeforthetr
ansl
ators(
e.g.
,tr
anspor
tat
ioni
fneeded,
compensati
onif
appl
i
cabl
e).
 I
nvi
tepar
ti
cipant
s.

5
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aini
ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

ANNEX1.PRI
NCI
PLESOFADULTLEARNI
NG

1. Dial
ogue:Adultl
earni
ngisbestachievedt
hroughdialogue.Themaj or
it
yofadult
shaveadequatel
if
e
exper
iencetodial
oguewithanyteacheraboutanysubjectandwi l
ll
earnnewatti
tudesorski
ll
sbesti
n
rel
ati
ontothatli
feexperi
ence.Di
aloguemustbeencour agedandusedi nformalt
rai
ning,
inf
ormal
tal
ks,one-
on-onecounsel
li
ngsessionsoranysituat
ionwher eadult
slearn.

2. Safetyinenvi
ronmentandprocess:Makepeopl
efeel
comf ort
abl
eaboutthepossi
bil
i
tyofmaking
mistakes.Adult
sar
emor er
eceptivet
olear
ningwhentheyarebot
hphysical
lyandpsychol
ogi
call
y
comf ort
able.
 Physicalsur
roundings(
e.g.
,temper
atur
e,v
enti
lat
ion,
over
crowdi
ng,
li
ght
)canaf
fectl
ear
ning.
 Learningisbestdonewhentherearenodi
str
acti
ons.

3. Respect:Appreci
atelearner
s’cont
ri
buti
onsandlif
eex peri
ence.Adult
slear
nbestwhenthei
r
exper
ienceisacknowl edgedandwhennewi nf
ormationbuildsonthei
rpastknowl
edgeand
exper
ience(see“Relevancetoprevi
ousexperi
ence”below).

4. Aff
ir
mat i
on:Learner
sneedtorecei
vepr
aisef
orev
ensmallat
tempt
s.Theyneedt
obesur
etheyar
e
cor
rect
lyrecal
li
ngorusi
nginformat
iont
heyhavel
ear
ned.

5. Sequenceandrei
nfor
cement :Startwi
ththeeasiesti
deasorskil
lsandbuil
dont hem.Int
roducet
he
mostimport
antonesfi
rst
.Reinforcekeyideasandskill
srepeat
edly.Peopl
elear
nf ast
erwhen
i
nformati
onorski
ll
sarepresentedi nast
ructur
edway .

6. Pr
act
ice:
All
owl
ear
ner
stopr
act
icef
ir
sti
nasaf
epl
aceandt
heni
nar
eal
set
ti
ng.

7. Ideas,feel
ings,
andacti
ons:Learni
ngt
akespl
acet
hrought
hinki
ng,
feel
i
ng,
anddoi
ngandi
smost
effect
ivewhenitinv
olv
esall
t hr
ee.

8. 20/40/80rul
e:Wer emember20per centofwhatwehear
,40per
centofwhatwehearandsee,
and
80percentofwhatwehear,see,anddo.Learner
sremembermorewhenvisual
sareusedt
osuppor
t
thever
balpresent
ation,
andtheyrememberbestwhentheypr
acti
cethenewskil
l.

9. Rel
evancetoprevi
ousexperi
ence:Peopl
elear
nfast
erwhennewi
nfor
mat
ionorski
l
lsar
erel
atedt
o
whattheyal
readyknoworcando.
Immediater
elev
ance:
Peoplelear
nbestwhent
heycanappl
ytot
henewt
opi
cthi
ngst
hatt
hey
hav
elearnedinl
if
eoronthejob.
 Fut
urerel
evance:Peopl
egener
all
ylear
nfast
erwhent
heyr
ecogni
set
hatwhatt
heyar
elear
ning
wil
lbeusef
ulinthefut
ure.

10.Teamwork:Encour
agepeopl
etolear
nfr
om oneanot
herandsol
vepr
obl
emst
oget
her
.Thi
smakes
l
earni
ngeasiert
oappl
ytoreall
i
fe.

11.Engagement:Invol
velear
ners’
emot i
onsandint
ell
ect.Adul
tspr
efertobeacti
vepart
ici
pantsi
n
l
earni
ngratherthanpassiv
erecipi
ent
sofknowledge.Peopl
elear
nf ast
erwhentheyact
ivel
ypr
ocess
i
nformat
ion,solveprobl
ems,orpract
iceski
l
ls.

12.Account
abi
li
ty:
Ensur
ethatl
ear
ner
sunder
standandknowhowt
oputwhatt
heyhav
elear
nedi
nto
pr
acti
ce.

13.Mot
ivat
ion:
Peopl
elear
nfast
erandmor
ethor
oughl
ywhent
heywantt
olear
n.Thet
rai
ner
’schal
l
enge

6
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ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

i
stocr
eat
econdi
ti
onsi
nwhi
chpeopl
ewantt
olear
n.
 Lear
ningi
snat
ural
,asbasi
caf
unct
ionofhumanbei
ngsaseat
ingorsl
eepi
ng.
 Somepeopl
ear
emor
eeagert
olear
nthanot
her
s,andev
enwi
thi
nani
ndi
vi
dual
,ther
ear
edi
ff
erent
l
evel
sofmot
ivat
ion.
 Thepr
inci
plesout
li
nedher
ewi
l
lhel
pthel
ear
nerbecomemot
ivat
ed.

14.Cl
ari
ty
 Messagesshoul
dbecl
ear
.
 Wor
dsandsent
encest
ruct
uresshoul
dbef
ami
l
iar
.
 Tr
ainer
sshoul
dexpl
aint
echni
cal
wor
dsandmakesur
ethel
ear
ner
sunder
standt
het
erms.
 Messagesshoul
dbeVI
SUAL.

15.Feedback:
Feedbacki
nfor
mst
hel
ear
nerabouther
/hi
sst
rengt
hsorweaknesses.

Adapt
edf
r a.1994.Lear
om J.Vel
l ningt
oLi
sten,
Lear
ningt
oTeach.

7
 Tr
aini
ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

ANNEX2.TRAI
NINGMETHODSANDHOW TOUSETHEM

Tr
aini
ngMet
hod Howt
oUse

Groupdiscussion:Agr oupofnomoret han Outl

i
net hediscussi
on’
spurposeandwri
tequest
ions
sevenpartici
pantsdiscussandsummar isea andtasksclearl
ytoprov
idefocusandst
ruct
ure.
givensubjectortheme.Thegroupselectsa
Al
lowenoughtimef
oral
lgr
oupst
ofi
nisht
het
askand
chair
person, ar
ecorderand/orsomeonet o
gi
vefeedback.
reportt
opl enar
y.
Announcer
emai
ningt
imeatr
egul
ari
nter
val
s.
Ensur
ethatpar
ti
cipant
sshar
eorr
otat
erol
es.

Buzzgroup:Twotothreepart
icipant
sdiscuss Cl
ear
lyst
atet
hetopi
corquest
iont
obedi
scussed
thei
rimmediater
eact
ionstoinformati
on al
ongwit
htheobj
ect
ives.
present
edandshareexamplesand
experi
ences.
Brainstorm: Aspontaneousprocesst hrough Stat
eclear
lythebrainstor
mi ngrul
ethatther
eisno
whichgr oupmember s’i
deasandopi nionsona wrongorbadi dea.
subjectarev oi
cedandwr it
tenforselection,
Askforavolunteert
or ecordtheideas.
discussion,andagreement.Allopi
nionsand
i
deasar evali
d.
Plenar
y:Theent
ir
egr
oupcomest
oget
hert
o Appoi
ntat
imekeeper
.
sharei
deas.
Poseaf
ewquest
ionsf
orgr
oupdi
scussi
on.

Role-play
:Parti
cipant
sactoutaspeci
fi
c Struct
uret
her
ole-
playwel
l
,keepi
ngi
tbr
iefandcl
eari
n
sit
uationbasedont hedetai
l
saboutthe focus.
“person”theyareaskedtoplay
.
Gi
vecl
earandconci
sei
nst
ruct
ionst
opar
ti
ci
pant
s.

Casestudy:Pai
rsorsmall
groupsaretol
dor Makethesit
uat
ion,
eventori
nci
dentr
eal
andf
ocused
readaboutaspeci
fi
csit
uati
on,eventori
nci
dent onthetopi
c.
andaskedtoanaly
seandsolveit
.
Demonstrati
on:Aresour
cepersonper
for
msa Demonst
ratet
heappr
opriat
eandinappropr
iat
eway
sto
specif
ict
ask,showi
ngothershowtodoit.The per
for
m ataskanddi
scussthedi
ffer
ences.
part
ici
pantsthenpr
acti
cethesametask.
Havepart
ici
pant
sper
for
mthet
askandgi
vet
hem
f
eedback.

Fi
eldvisi
t:Par
ti
cipant
sandt r
ainers/
facil
i
tat
ors Beforet
hev i
sit
,coordinat
ewiththesit
e, gi
ve
vi
sitahealt
hfaci
lit
yorcommuni tysett
ingto part
ici
pantscl
eardirecti
onsbeforearr
ival,
anddi v
ide
observ
eat askorprocedur
eandt henpracti
ce. them i
ntosmallgroupsaccompani edbyaf aci
l
itator
.
Meetwiththesit
esuper
visor
,st
aff
,orot
her
r
epresentat
iveonar
ri
val
.
Provi
deoppor
tuni
tyt
oshar
eexper
iencesandgi
veand
recei
vef
eedback.

8
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ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Acti
onpl anpreparati
on: Part
ici
pants Shar
eact
ionpl
ans.
synthesi
seknowl edge,skil
ls,
atti
tudes,
and
beli
efsintoadoableplan.Thi sbri
dges
cl
assroom activ
iti
eswithpr acti
calappl
icat
ion
atwor ksit
e.
Tal
k/pr
esentat
ion:
Aspeakershar
es St
artwithast
oryorv
isualt
hatcapt
urest
heaudi
ence’
s
i
nfor
mation,
sometimesusi
ngaudioorv
isual at
tent
ion.
ai
ds.
Presentanini
ti
alcasepr
oblem aroundwhi
cht
he
tal
k/present
ati
onwill
bestr
uctured.
Askparti
cipant
stestquesti
onseveni
ftheyhaveli
tt
le
pri
orknowledgetomot i
vat
ethem tol
i
stentothe
tal
k/pr
esentati
onfortheanswer
.
Setat
imel
imi
t.
Al
lowt
imef
orf
eedback,
comment
s,andquest
ions.
Poseaquestionforpar
ti
cipant
stosol
vebasedont
he
tal
k/pr
esent
ation.

9
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

ANNEX3.SUGGESTEDREVI
EW ENERGI
SERS(
GROUPAND
TEAM BUI
LDI
NG)

1. Thepartici
pant
sandtrainer
sform acircl
e.Onetrai
nerthrowsabal lt
oapar ti
cipantandaskst he
part
ici
pantaquesti
on.Whent heparti
cipantanswerscorrect
lytothegroup’ssatisfacti
on,she/he
thr
owst heball
toanotherpart
ici
pantandasksanot herquesti
on.Thepr ocessisr epeatedunti
lal
l
part
ici
pantsansweraquestionsati
sfactor
il
y.

2. Thepar t
ici
pantsformtwor owsf aci
ngeachother,eachrowr epresent
ingat eam.Aparticipantfrom
oneteam/ rowasksaquest ionoftheparti
ci
pantoppositehim/ herint
hef acingt
eam/ r
ow.The
parti
cipantanswer i
ngthequest i
oncanaskf orhim/herteam’shelpwi t
hthequest i
on.Whent he
questi
oni sansweredcorrectl
y,t
herespondingteam ear
nsapoi ntandthenasksaquest ionoft he
otherteam.I fthequesti
onisnotanswer edcorr
ectly,
theteam thataskedt hequesti
onrespondsand
earnst hepoint.Theteam withthemostpointswins.

3. Theparti
cipantsformtwoteams.Eachper sonr ecei
vesawr it
tenanswertoaquest
ionthatt
he
faci
l
itat
orwillask.Whenaquestionisasked, t
hepartici
pantwhobel i
evesshe/
hehasthecorrect
answerreadst heanswer
.Ifcor
rect,
theper sonscoresapoi ntforhi
s/hert
eam.Theteam wi
tht he
mostpointswi ns.

4. Apart
ici
pantpicksaquesti
onfrom abasketandanswer
sit
;ot
herpar
ti
cipant
sgi
vef
eedback.The
pr
ocessisrepeatedf
ortheotherpar
ti
cipant
s.

10
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

HANDOUT–EVALUATI
ONFORM FORMODULE

1. Di
dthei
nfor
mat
ionpr
esent
edmeett
hemodul
e’
sobj
ect
ives?

2. Whati
nfor
mat
ionwoul
dyoul
i
ket
oseemor
ein-
dept
h?

3. Whati
nfor
mat
ionwasnotpar
ti
cul
arl
yusef
ul/
hel
pful
?

4. Wer
ethemat
eri
alspr
esent
edi
nthemodul
eusef
ulov
eral
l
?

5. Whatmat
eri
alswer
epar
ti
cul
arl
yusef
ul?Pl
easedescr
ibe.

6. Whatmat
eri
alswer
enotusef
ul?Pl
easedescr
ibe.

7. Doy
ouf
eel
youmast
eredt
heski
l
l(s)neededf
oragi
venexer
cise/
fiel
dpr
act
ice?

8. Howcoul
dtheexer
cises/
fiel
dpr
act
icebei
mpr
oved?

9. Whi
chexer
cisesorf
iel
dpr
act
icesessi
onsdoy
out
hinkwor
kedbest
?

10.Howcoul
dthi
smodul
ebei
mpr
ovedt
omeett
heobj
ect
ives?

11.Doyouhaveanysuggest
ionsonthetr
aini
ngmechani
cs(
e.g.
,tr
aini
ngspace,
sit
evi
sit
s,v
isual
pr
esent
ati
ons,l
engt
hofthecourse)
?

Pl
easef
eel
freet
ouset
heot
hersi
det
ocont
inuer
esponses.Thanky
ou!

11
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def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
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ti
on(
CMAM)
,2018Ver
sion

MODULEONE:OVERVI
EW OFCOMMUNITY-
BASED
MANAGEMENTOFACUTEMALNUTRITI
ON( CMAM)

Modul
eOv
erv
iew
Thismodul eisagener alor i
ent ati
onandov er
v i
ewofcommuni t
y-basedmanagementofacut e
malnutr
iti
on( CMAM) .I
tdescr i
best heextentoft heproblem ofacutemal nutr
it
ion,andout l
inesthekey
concepts,pri
nci pl
es,andcomponent sofCMAM.Themodul eal
sodi scussesready-to-
usetherapeut i
c
food(RUTF)andt heuseofmi d-upperar m ci
rcumf er
ence(MUAC)asar apidscreeningandadmi ssi
on
toolf
orpot entialbenefi
ciari
es.Themodul ebrief
lylooksattheev idencet odateandnot eshowCMAM
mightbeappl icableindif
f erentcont extsandincorporatedintoroutinehealthservices,nati
onalpol i
cies,
andguideli
nes.I nadditi
on, globalcommi tmentst oCMAM ar ement i
oned.

CMAM ev olvedf r
om Communi t
y-BasedTher apeuti
cCare(CTC),
acommuni t
y-basedapproachforthe
managementofacut emal nut
rit
iondev el
opedi n2001.TheCMAM approachconsistsoffourmain
component s:communi tyoutr
each, out
patientcarefort
hemanagementofSAM wi thoutmedical
compl i
cat
ions,inpati
entcareforthemanagementofSAM wi thmedicalcompl
icati
ons,andprogrammes
forthemanagementofmoder ateacutemal nutri
ti
on(MAM) ,
suchasasupplement ar
yfeeding
programme( SFP) .I
nsomecount ri
es,CMAM i srefer
redtoastheint
egr
atedmanagementofacut e
malnutri
ti
on( I
MAM) .

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises
Int
roducePar
ti
cipants, 10 Handout1.
1Abbr
evi
ati
onsandAcr
ony
ms
Trai
ningCour
se,Modules, minut
es Handout1.
2Ter
minol
ogyf
orCMAM
andCourseObjecti
ves
PowerPoi
nt:
Ov er
viewofCommuni
ty-
BasedManagementof
Acut
eMalnutri
ti
on( CMAM)

1.Di
scussAcute 10 Handout1.
3KeyI
nfor
mat
iononUnder
nut
ri
ti
on
Malnut
ri
ti
onandthe minut
es
NeedforaResponse PowerPoi
nt:
Ov er
viewofCommuni
ty-
BasedManagementof
Acut
eMalnutri
ti
on( CMAM)

2.I
dent
if
ythePr
inci
ples 10 Handout1.
4CMAM Pr
inci
ples
ofCMAM minut
es
PowerPoi
nt:
Ov er
viewofCommuni
ty-
BasedManagementof
Acut
eMalnutri
ti
on( CMAM)

3.Descr
ibeInnovati
ons 15 Handout1.
5Cl
assi
fi
cat
ionofAcut
eMal
nut
ri
ti
onf
orCMAM
andEvidenceMaking minut
es
CMAM Possi bl
e Handout1.
6Scr
eeni
ng,
Admi
ssi
on,
andDi
schar
geUsi
ng
MUAC
PowerPoi
nt:
Ov er
viewofCommuni
ty-
BasedManagementof
Acut
eMalnutri
ti
on( CMAM)
RUTFpacket
s
Col
ouredMUACt
apes(
desi
gnedf
orusei
ncommuni
ty-
based
pr
ogrammes)

4.Ident
if
ythe 15 Handout1.
7CMAM Component
sandHowTheyWor
k
ComponentsofCMAM minut
es Toget
her
andHowTheyWor k PowerPoi
nt:
Ov er
viewofCommuni
ty-
BasedManagementof
Together Acut
eMalnutri
ti
on( CMAM)

12
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ngGui
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

5.ExploreHowCMAM 15 Handout1.
8CaseSt
udi
es
CanBeI mplementedi
n minut
es
Dif
ferentCont
exts Handout1.
9Impl
ement
ingCMAM i
nDi
ff
erentCont
ext
s
Handout1.10Fact
orst
oConsi
derinSeeki
ngt
oPr
ovi
de
Ser
vicesfort
heManagementofSAM
Handout1.
11I nt
egrat
ingCMAM i
ntoRout
ineHeal
thSer
vices
att
heDistr
ictLevel
PowerPoi
nt:
Ov er
viewofCommuni
ty-
BasedManagementof
Acut
eMalnutri
ti
on( CMAM)

6.Identi
fyKeyNati
onal 10 2007joi
ntstat
ementoncommuni
ty-
basedmanagementof
andGl obal minut
es sever
eacutemalnut
ri
ti
onbyWHO,WFP, t
heUN/SCN,and
Dev el
opmentsand UNICEF
Commi t
mentsRel
ati
ng
toCMAM PowerPoi
nt:
Ov er
viewofCommunity
-BasedManagementof
Acut
eMalnutri
ti
on( CMAM)-al
soseeHandout1.
14
Power
Poi
ntPr
esent
ati
onSl
i
deI
mages.
Wrap-
UpandModul
e 5mi
nut
es Handout1.
12Essent
ial
sofCMAM
Eval
uat
ion
Fi
eldVi
sitt
oOut
pat
ient 1day Handout1.
13Fi
eldVi
sitCheckl
i
st
Car
eSit
e

Modul
eDur
ati
on:1½hour
sincl
assr
oom f
oll
owedbyaone-
daysi
tev
isi
t
Not
e:Dependi
ngont heneedsoft hei
raudi
ence(s),
trai
ner
smaychooset
oski
porspendmor
eorl
ess
t
imeoncertai
nlear
ningobject
ivesandacti
vit
ies.Themoduledur
ati
oni
sanest
imat
eofthet
imei
ttakes
t
ocompleteal
llear
ningobject
ivesandacti
vit
ies.

Mat
eri
als
 Comput
erandpr
oject
orf
orPower
Poi
nt:
Over
viewofCommuni
ty-
BasedManagementofAcut
e
Mal
nut
ri
ti
on(
CMAM)
 St
ickynot
esorcol
our
edcar
ds
 Fl
i
pchar
tandmar
ker
s
 Maski
ngt
ape
 RUTFpacket
s
 Col
our
edMUACt
apes
 Wor
ldHeal
thOr
gani
sat
ion(
WHO)
,Wor
ldFoodPr
ogr
amme(
WFP)
,theUni
tedNat
ionsSy
stem
StandingCommi tt
eeonNut r
it
ion(UN/SCN),andt
heUnitedNationsChil
dren’
sFund( UNICEF)
.
2007.Communi ty-BasedManagementofSever eAcut
eMal nut
ri
tion:AJointStatement
.
https:
//www.unicef.
org/publ
icat
ions/
fil
es/
Communi t
y_Based_Management _of_
Sever_
Acute_
_M
al
nut i
rti
on.
pdf.

Adv
ancePr
epar
ati
on

13
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orCommuni
ty-
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eMal
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ti
on(
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,2018Ver
sion

 Room set
up,
mat
eri
alsnot
edabov
e
 Revi
ewand,
ifnecessar
y,adapt“
Over
viewofCMAM”Power
Poi
ntpr
esent
ati
on(
thi
smayi
ncl
ude
r
emov
ing,
addi
ng,
orr
eor
gani
si
ngsl
i
des)
.Rev
iewal
lpar
ti
cipanthandout
s.
 Opt
ional
:Ar
rangef
oraguestspeaker
(s)t
odi
scusst
hedesi
gnandpl
anni
ngofaCMAM i
nter
vent
ion.
Thespeakershouldprefer
abl
ybesomeonef rom theMi
nist
ryofHeal t
h(MOH)( regi
onalordi
str
ict
l
evel
)whohasexper ienceinpl
anni
ngandset ti
ngupCMAM services.Thespeakercanalsobe
someonefrom anongov er
nmental
organisat
ion(NGO)whohaswor kedclosel
ywiththeMOH.(Give
gui
danceont hecasestudytobepresent
edifaguestspeakeri
sinvited.
)
 Revi
ewr
elev
antr
efer
encer
esour
cesandf
urt
herr
eadi
ngr
esour
cesl
i
stedbel
ow.

Ref
erenceResour
ces
1. WorldHealthOrgani
sati
on(WHO) .2013.Guidel
i
ne:UpdatesontheManagementofSever
eAcute
Malnutr
it
ioninI
nfantsandChil
dren.Geneva:WHO.Availabl
eat:
ht
tp:/
/www. who.i
nt/
nutri
ti
on/
publicat
ions/
guideli
nes/
updates_
management_
SAM_ i
nfant
andchi
l
dren/
e
n.
2. WHOandUNI CEF.2009.WHOChi l
dGrowthStandardsandIdent
if
icat
ionofInf
antsandChi
l
drenwi
th
Sever
eAcut
eMal nutr
it
ion:AJointStat
ement.Avai
labl
eat:
htt
p:/
/www.
who.int/
nutri
ti
on/publi
cati
ons/
severemalnut
ri
ti
on/9789241598163/en/
.
3. WHO, Wor l
dFoodPr ogramme( WFP),t
heUnit
edNati
onsSystem St
andi
ngCommi t
teeonNutri
ti
on
(UN/ SCN), andUNICEF.2007.Community-
BasedManagementofSever
eAcuteMalnut
ri
ti
on:AJoint
Statement .Avail
abl
eat:
https://www. uni
cef
.or
g/ publ
i
cat
ions/
fil
es/
Community_
Based_Management
_of_
Sever_
Acute_
_Malnut
i
rti
on. pdf.
4. Vali
dInter
nati
onal.2006.Communit
y-basedTherapeuti
cCare:AFieldManual.Oxf
ord:
Valid
I
nternat
ional
.Chapters9and10.Avai
lableat:
ht
tps://
www. f
antaproj
ect.
org/
sit
es/
default
/fi
les/
resources/
CTC-Fiel
d-Manual-
Oct
2006-508.
pdf
.

Fur
therReadi
ngResour
ces
1. Bhut
ta,
Z.A.etal.2017.“
Sev ereChil
dhoodMalnutr
it
i ”Nat
on. ur
eRevi
ewsDi
seasePr
imer
s.3,
17067.
Avai
l
ableat:
https:/
/www. nature.
com/art
icl
es/
nrdp201767.
2. CouncilofResearch&Techni cal
Adv iceonAcut eMalnutri
ti
on( CORTASAM).2018.AResearch
Agendaf orAcuteMal nut
ri
tion.Avail
abl eat:
ht
tps://
stati
c1.squarespace.com/ st
at i
c/58da81cdd1758e39ca705526/t/
5a5cbfcdf
9619a9a191c6f
3
4/1516027854696/ NoWast edLives_Research_Agenda_2018.pdf.
3. UNICEF/WHO/WorldBank.2017.Lev
elsandTrendsi
nChil
dMalnutri
ti
on.UNICEF,WHOandWor
ld
BankGroup.Av
ail
ableat
:htt
p:/
/www.who.i
nt/
nutgr
owt
hdb/
esti
mates2016/en/
.
4. UNICEF.2013.Eval
uat
ionofCommunit
yManagementofAcut
eMalnut
ri
ti
on:Gl
obalSynt
hesi
sRepor
t.
Avai
labl
eat:htt
ps:/
/www.uni
cef
.or
g/ev
aldat
abase/
index_
CMAM.
html.
5. Bhut
ta,Z.
A.etal.2013.“
Evidence-BasedI
nter
venti
onsforImpr
ov ementofMat er
nal
andChild
Nutr
iti
on:WhatCanBeDoneandatWhatCost ?”TheLancetmaternalandchi
ldheal
thser
ies.
Avai
labl
eat:ht
tps:/
/www.thelancet.
com/seri
es/mater
nal
-and-
child-
nutr
it
ion.
6. Caulf
iel
d,L.
;deOnis,M.;Blössner
,M.;andBlack,
R.2004.“
Undernut
ri
ti
onasanUnderl
yingCauseof
Chil
dDeathsAssociatedWi t
hDiarr
hea,Pneumonia,
Malari
a,andMeasl ”Amer
es. icanJournalof
Cl
ini
calNutr
iti
on.80:193–8.
7. Coll
i
ns,S.2004.“Communi t
y-BasedTherapeut
icCar
e:ANewParadi
gm forSelect
iveFeedingi
n
Nutr
iti
onalCr
isi
s.”Humanitar
ianPracti
ceNetworkPaper48,
Over
seasDevelopmentInsti
tute(
ODI
).
Avai
labl
eat:www. val
i
dint
ernati
onal.
org.

14
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aini
ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

8. Coll
i
ns,S.etal
.2006.“ManagementofSever
eAcuteMalnut
ri
ti
oni
nChi
l
dr ”Lancet
en. .
368:
1992–2000.Avail
abl
eat:www.val
idi
nter
nat
ional
.or
g.
9. Coll
i
ns,S.andYat
es,
R.2003.“
TheNeedt
oUpdat
etheCl
assi
fi
cat
ionofAcut
eMal
nut
ri
ti ”Lancet
on. .
362:
249.
10.Diop,
E.etal.2003.“Compari
sonoftheEf
ficacyofaSoli
dReadyt
oUseFoodandLiqui
dMilkBased
Dietf
ortheRehabili
tati
onofSever
elyMal
nourishedChi
l
dren:
ARandomi
zedTri
al.Ameri
canJournal
ofCli
nicalNut
ri
tion.78:
302–7.
11.Gatchell
,V.
;For
sythe,V.
;andReesThomas, P.TheSustai
nabil
ityofCommuni t
y-BasedTher
apeut
ic
Care(CTC)inNon-AcuteEmergencyContexts.WHOTechnicalBackgroundPaper.Avai
l
ableat
:
ht
tp://www.who.
int/nut
ri
ti
on/
topics/
backgroundpaper
s_The_sustai
nabil
i
ty.
pdf.
12.Gross,R.andWebb,
P.2006.“WastedTi
mef orWastedChil
dren:Sev
ereChi
ldUndernutri
ti
onMustBe
Resolv
edi nNon-
EmergencySet
ti ”Lancet
ngs. .367:
1209–1211.Avai
labl
eat
:www.thelancet.
com.

15
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e1I nt
roducePar
ti
cipant
s,Tr
aini
ngCour
se,
Modul
es,
andCour
se
Obj
ect
ives

TRAI
NER:Becomef
ami
l
iarwi
thHandout1.
1Abbr
evi
ati
onsandAcr
ony
msandHandout1.
2
Ter
minol
ogyf
orCMAM.

I
CEBREAKER:PRESENTATI
ONOFNEI
GHBOUR.Askpar
ti
cipant
stoi
ntr
oducet
hemsel
vesandsay
ali
tt
leaboutwhytheyareat
tendi
ngthetrai
ning,
whatt
hei
rint
eresti
sinat
tendi
ngt
hecour
se,
andhow
t
heyplantousetheskil
l
stheywil
lacqui
re.

ALTERNATI
VEI
CEBREAKER:Askpar
ti
ci
pant
stopai
rupandi
nter
vieweachot
heraboutt
hei
r
exper
iencewi thprogrammesmanagingacutemalnutr
it
ion.Havet
hem askeachot herwhethertheyare
i
nvolvedinserv i
cesorprogr
ammest oaddresssever
eacutemalnutr
it
ion(SAM)ormoder at
eacute
malnutr
it
ion( MAM) ,andwhethert
heserv
ice/pr
ogr
ammei scommunity-
basedorfacil
it
y-based,et
c.Then,
haveparti
cipantsintr
oducethei
rpart
ner
sandsharethisinf
ormati
on.Discusssi
milari
ti
esandv ari
eti
esof
exper
iences.

POWERPOI
NT:PRESENTATI
ONOFCOURSEPURPOSEANDOBJECTI
VES(
Showsl
i
de1)
.Ask
part
icipantst
owritethr
eet hi
ngstheyexpecttogai
nfrom t
het
rai
ningoncardsorstickynot
es,one
expectati
onpercard.Coll
ecttheexpectat
ionsandgroupsi
mil
aronestoget
her.Posttheexpect
ati
onsi
n
thetraini
ngroom anddiscussthem.

PRESENTTHECOURSEPURPOSEANDOBJECTI
VES(
SLI
DES1–2)
.Compar
ethel
ear
ning
obj
ecti
vest
opar t
ici
pant
s’expect
ati
ons,andexplai
nwhichexpect
ati
onsarel
i
kelyandunl
i
kel
ytobemet
dur
ingthet
rai
ning.Leav
etheexpectat
ionsposteddur
ingtr
aini
ngandrevi
ewthem att
heendofeachday
.

Tel
lpart
ici
pantsthatafli
pchartwil
lbekeptf
reet
opostideas,quest
ions,andsuggesti
onsthatari
se
thr
oughoutthecourse(oft
enrefer
redtoasa“par
kingpl
ace”)
.Checkt heparki
ngplaceper
iodical
l
y
thr
oughoutthecourseandrespond.

Ref
erpart
ici
pant
stoHandout1.1Abbrevi
ati
onsandAcr onymsandHandout1.
2Terminol
ogyforCMAM.
Askthem t
ousethem asr
efer
encetoolsandinv
itequest
ionsnoworatanypoi
nti
nthetr
aini
ng.

16
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e1LearningObj
ect
ive1:Di
scussAcut
eMal
nut
ri
ti
onandt
heNeed
f
oraResponse

TRAI
NER:Becomef
ami
l
iarwi
thHandout1.
3KeyI
nfor
mat
iononUnder
nut
ri
ti
on.

BRAI
NSTORM:UNDERNUTRI
TIONASAPUBLI
CHEALTHCONCERN.Askpar
ti
cipant
sto
cont
empl
atethestat
ement“Under
nut
ri
ti
oni
sapubl
i
cheal
thconcer
n”andt
obr
ainst
ormr
easonswhet
her
andwhyt
hisstat
ementi
strue.

PARTI
CIPATORYLECTURE:I
NTRODUCTI
ONTOACUTEMALNUTRI
TION.Askpar
ti
cipant
s
“Whatisacutemal
nutr
it
ion?”and“
Whyisafocusonacutemal
nutri
ti
onimpor
tant
?”Discussi
onshoul
d
touchonthedif
fer
encebetweenMAM andSAM, andt
extfr
om Handout1.
3KeyInfor
mat i
onon
Undernut
rit
ion.

Bi
lateralPi
tt
ing WFHz-score
MUAC
Oedema (
WHOst andards)
SAM Present <115mm <-3z-
score
MAM Notpr
esent ≥115mm and<125mm ≥-
3and<-
2

POWERPOINT:UNDERNUTRI TI
ONANDACUTEMALNUTRI
TION.(
Showsl
i
des3–6.
)
 Sl
ide3:
Expl
ainunder
nut
ri
ti
onandi
tst
ypes.
 Sl
i
de4:
Askpar
ti
cipant
swhatt
heyseeandt
odescr
ibet
henut
ri
ti
onal
stat
usofal
lthr
eechi
l
dren.Tel
l
par
ti
cipant
sallt
hreechi
ldrenar
ethesameage.Di scusshowthischangesthei
rimpr
essi
onsofthe
chi
l
dren’snut
ri
ti
onalst
atus.Note:
Thechil
dont helefti
sstunt
ed,themiddl
echil
disnormal
,andthe
chi
l
dont heri
ghtiswastedandprobabl
ystunt
edaswel l.
 Sli
de5and6:Remindparti
cipant
sthatwast
ingcont
ri
but
est
o875,000deat
hsofchil
drenunder5
eachy .TheLancetser
ear iesandtheUNICEF/WHO/Worl
dBankj
ointchi
l
dmalnut
rit
ionesti
mates
hi
ghl
i
ghtt
heext
entoft
hepr
obl
em ofacut
emal
nut
ri
ti
on.Not
etopar
ti
cipant
sthat
:
- Acut
emalnutr
it
iondoesnotjustoccuri
nemer genciesandi
snotlimi
tedtoAfri
ca.
- Wasti
ngoccur
si nbot
hemergenciesandnon- emergenci
es.
- Acut
emalnutr
it
ionisnotonl
ycausedbyi nadequat
ef oodi
ntakebutacombinat
ionoff
act
ors
i
ncl
udi
ngunder
lyi
ngi
nfect
ionsandenv
ironment
alf
act
ors.
- I
ndiaandPakist
an(non-
emergencysett
ings)havethehi
ghestnumberofchil
drenwi
thwast
ing.
- Ranki
ngisbasedonabsolut
enumber sandwi l
lchangewhenbasedonoveral
lwasti
ng.

17
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e1 Lear
ningObj
ect
ive2:I
dent
if
ythePr
inci
plesofCMAM

TRAI
NER:
Becomef
ami
l
iarwi
thHandout1.
4CMAM Pr
inci
ples.

BUZZGROUPS:WHATI
SCMAM?Havepar
ti
ci
pant
sfor
m gr
oupsoft
woort
hreet
oqui
ckl
yname,
if
t
heycan,
afewkeyf
act
saboutCMAM.Wr
it
eresponsesonaf
li
pchar
t.

POWERPOI
NT:I
NTRODUCTI
ONTOCMAM (
Showsl
i
des7–14.
)Hi
ghl
i
ghtt
hef
ourmai
ncomponent
s:
1. Communi
tyout
reach
2. Out
pat
ientcar
eforSAM wi
thoutmedi
cal
compl
i
cat
ions
3. I
npat
ientcar
eforSAM wi
thmedi
cal
compl
i
cat
ions
4. Ser
vicesorpr
ogr
ammesf
ormanagementofMAM canbepr
ovi
deddependi
ngont
hecont
ext

DI
SCUSSI
ON:CMAM.Askpar
ti
ci
pant
stoqui
ckl
yhi
ghl
i
ghtsomeadv
ant
agesanddi
sadv
ant
agesof
CMAM ser
vices.Di
scussandwr
it
eresponsesonaf
li
pchar
tandbepr
epar
edt
oret
urnt
othi
stopi
c.

POWERPOI
NT:PRI
NCI
PLESOFCMAM (
Showsl
i
des15–17.
)Ref
erpar
ti
cipant
stoHandout1.
4
CMAM Pr
inci
plesandrev
iewbri
efl
ytoget
her.Expl
ainthatinbri
ngi
ngtoget
herthef
ourmai
ncomponent
s
ofCMAM,ser
vicescanbecar
ri
edoutaccordingtothefol
lowingkeypr
inci
ples:
1.Maxi
mum accessandcov
erage
2.Ti
mel
i
ness
3.Appr
opr
iat
emedi
cal
andnut
ri
ti
oncar
e
4.Car
eforasl
ongasi
tisneeded

POWERPOI
NT:KEYPRI
NCI
PLE1.MAXI
MUM ACCESSANDCOVERAGE(
Showsl
i
des18–20.
)
Sli
de19:Expl
aint
hatest
abl
i
shi
ngdecent
ral
i
sedout
pat
ientcar
esi
tesi
ncr
easesaccessandgeogr
aphi
c
cover
ageofservi
ces.

POWERPOI
NT:KEYPRI
NCI
PLE2.TI
MELI
NESS(
Showsl
i
des21–24.
)Sl
i
de23:
Not
etopar
ti
cipant
s
thatthisisachildwi thSAM whoi ssti
llal
ert
,li
kelyhasagoodappet i
te,andcanbet reat
edasan
outpatient.Timelyidentifi
cati
onalsohelpsusi dentif
ychildrenwithMAM bef oreitdet er
ior
at estoSAM.
Thecol ouredstri
pmeasur esMUACi ninfantsandchi ldr
en.Out r
eachwor kers(e.g.,
communi t
yheal
th
workers[ CHWs] ,volunteers)
,mothersandot herf amil
ymember s(e.g.
,aunts,grandmot hers,andfather
s)
caneasi lyident
if
ychi ldrenwithacutemalnutri
tionusingMUACt apeandcanbet rainedtor ecogni
se
bil
ateralpitti
ngoedema.Thi smakesi teasytoi denti
fychildrenwit
hacut emalnut r
it
ioninthecommuni t
y.

POWERPOI
NT:KEYPRI
NCI
PLE3.APPROPRI
ATEMEDI
CALANDNUTRI
TIONCARE(
Show
sl
ides25–26.)Sl
i
de26:Anassessmentofthemedicalcondit
ionfol
lowingtheintegr
atedmanagementof
chil
dhoodil
l
ness(IMCI
)approachaswell
asanappet i
tetestwil
ldeterminewhethertheinf
antorchi
ld
canbet r
eat
edasanoutpati
entwit
hregul
arvisi
tst
otheheal t
hfacil
i
t yormustber ef
erredtoi
npati
ent
care.

POWERPOI
NT:KEYPRI
NCI
PLE4.CAREFORASLONGASI
TISNEEDED(
Showsl
i
des27–28.
)

DI
SCUSSI
ON:
Askpar
ti
cipant
sift
heyhav
efur
thert
hought
sont
headv
ant
agesordi
sadv
ant
agesof

18
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

CMAM.Thenaskhoweachcomponentcont
ri
but
est
oachi
evi
ngt
hepr
inci
ples.

19
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e1Lear
ningObject
ive3:Descr
ibeI
nnov
ati
onsandEv
idence
Maki
ngCMAM Possi
ble

TRAI
NER:Becomef
ami
l
iarwi
thHandout1.
5Cl
assi
fi
cat
ionofAcut
eMal
nut
ri
ti
onf
orCMAM and
Handout1.
6Scr
eeni
ng,
Admi
ssi
on,
andDi
schar
geUsi
ngMUAC.

ELI
CITATI
ON:Askpar
ti
cipant
sifanycannamei
nnovat
ionst
hathavemadeCMAM possi
ble.Di
rect
conver
sat
iont
othef
oll
owi
ngt
hreei
nnovat
ions:
1. Av
ailabil
it
yofRUTF
2. Cl
assifi
cationofacut
emalnutr
it
ionforCMAM
3.Screening,admissi
on,anddi
schargeusi
ngMUAC

POWERPOI
NT:AVAI
LABI
LITYOFRUTF(
Showsl
i
des29–33.
)

Sli
de30:Expl
ainthatRUTFi sanoi l
-basedpastewithverylowwatercont
ent .I
tdoesnotgr owbacteri
a
evenwhenaccidental
lycontaminated.Itissafet
ousei nmostenvir
onment s.Iti
senergy-densebutthe
quanti
tyofpr
otei
ns, f
at,
v i
tamins,andmi neral
sper100kilocal
ori
es(kcal
)isequival
enttot hatofF100,
recommendedbyWHOf ortheinpatienttr
eatmentofSAM.RUTFcanbeeat enstrai
ghtfrom thepacketor
potandcanbeconsumedeasi lybychi l
drenfr
om theageof6mont hs.Nowat erisadded.

Sli
de31:RUTFhassev er
aladvantages.I
tcanbekeptinsimpl
epackagingf
orsever
almonthswithout
ref
ri
ger
ation.RUTFcanbekeptf orsever
aldaysevenwhenopened.Al
so,RUTFcontai
nsi
ron,v
itaminA,
andsever
al ot
hermicr
onutr
ientsneededfortheSAM chi
ldtor
ecover.

Sli
de32: RUTFcanbepr oducedl ocall
yusingsimpleequipment.However,t
horoughinspectionsand
quali
tycontrol
areneededf orl
ocal producti
ontoensurethatt
hereisnor i
skofcontami nat
ionofthe
i
ngredientsandthattheproducthast herightcomposi
ti
onandqual i
ty.Thecostforlocalproduct
ioncan
varybasedonav ai
labil
i
tyofingredientsandthecapacit
yoflocalmanufacturer
s.

DEMONSTRATI
ON:FAMI
LIARI
ZATI
ONWI
THRUTFANDI
TSPACKAGI
NG.Af
tert
hePower
Poi
nt
sl
i
des,
dist
ri
but
eRUTFpacket
ssot
hatpar
ti
ci
pant
scanf
ami
l
iar
izet
hemsel
veswi
tht
hepr
oduct
.

POWERPOI
NT:ACUTEMALNUTRI
TIONCLASSI
FICATI
ONFORCMAM (
Showsl
i
des34–35.
)

Sli
de34:Not
etopar
ti
cipantst
hati
nthepast
,acut
emal
nut
ri
ti
onwasdi
vi
dedi
ntot
wocat
egor
iest
hat
deter
minedt
hemodeoft r
eatment
.

Sl
i
de35:Anupdat
edclassi
fi
cati
onhasbeenproposedf
oruseinCMAM: di
vi
dingt
hecat
egor
yforchi
l
dren
wi
thSAM i
ntoSAM wi
thmedicalcompl
icat
ionsandSAM wi
thoutcompl
i
cati
ons.

ELI
CITATI
ON:COMPARI
NGTHETWOCLASSI
FICATI
ONS.Askpar
ti
cipant
swhathaschanged
betweenthetwocl assi
fi
cat
ionsandwhatimpli
cati
onsthishasfortr
eati
ngchi l
drenwit
hSAM.Fil
linthe
gaps:
 Thenewcl assifi
cati
onrecommendsthatchil
drenwit
hSAM andmedi calcompli
cati
onsbet
reatedin
i
npati
entcar
eunt il
thei
rcondit
ioni
sstabi
l
ised.Thi
sensuresthatchi
ldrenwithincr
easedmort
alit
y
r
iskaretr
eatedappropri
atel
y.
 I
tal
sor
ecommendst
hatt
hosewi
thSAM wi
thappet
it
eandwi
thoutmedi
calcompl
icat
ionsbe
t
reat
edi
nout
pat
ientcar
e.

20
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Askpar
ti
cipant
saboutcri
ti
calf
act
orsi
nidenti
fyi
ngchi
ldr
enwit
hmedi cal
compl i
cati
ons.Not
ethatthe
mostcr
it
icali
ndicat
orofwhet
herachi
l
dwi t
hSAM requir
esi
npati
entoroutpat
ientcarei
sAPPETITE.

POWERPOI
NT:SCREENI
NG,
ADMI
SSI
ON,
ANDDI
SCHARGEUSI
NGMUAC(
Showsl
i
des36–38.
)

Sl
i
de36:
Not
ethat
:
 MUACmakesi
teasyt
ounder
standhowchi
l
drenar
ecl
assi
fi
edandwhet
hert
heywi
l
lqual
i
fyf
or
t
reat
ment
.Thi
sincr
easest
ranspar
encyandcommuni
tysuppor
tforser
vicedel
i
ver
y.
 MUACi
ssi
mpl
etouse.AMUACt
apecanbeusedbyoneper
sonandi
seasi
l
ytr
anspor
tabl
e.I
tcanf
it
i
ntoapocket
.Ital
sodoesnotrequir
elit
eracy,
numeracy,oraddi
ti
onalequi
pment.Thi
smakesiteasy
t
ouseatthecommuni tyl
evel
,i
ncreasi
ngt hel
ikel
i
hoodofearlyi
denti
fi
cati
onandpresent
ati
on.
However
,si
mpletrai
ningi
sneededt oensurecorr
ectuseoftheMUACt ape.

Sl
i
de37:
Not
ethat
:
 MUACi
susedf
ori
dent
if
icat
ionofacut
emal
nut
ri
ti
ondur
ingscr
eeni
ngatt
hecommuni
tyl
evel
admissi
onanddi schargef
rom t
reatmentattheheal
thf
aci
li
ty.Usi
ngMUACal oneforadmissi
on
meanst hatall
chil
drenwhoarerefer
redbyCHWsandwhocomet oout
pati
entcarewouldbe
admitt
edandt heref
orewouldnotbereject
edift
heydonotmeettheweight
-for
-hei
ght(WFH)cri
ter
ia
foradmission.
 Usi
ngMUACal
oneasani
ndependentcr
it
eri
onf
ori
dent
if
icat
ion,
admi
ssi
on,
anddi
schar
gef
or
t
reat
mentofSAM i
srecommendedbyWHO.
 Ther
eisr
ecentemer
gingev
idenceont
heuseofMUACt
oident
if
ynut
ri
ti
onal
l
yvul
ner
abl
eini
nfant
s
under6months.However,acl
assi
fi
cati
oncutof
fforthi
sagegr
ouphasnotyetbeenest
abli
shed.
Countr
iesandprogr
ammesar eencour
agedtocoll
ectMUACdataf
orinf
antsunder6monthstohelp
bui
ldtheevi
dencebaseforcut
off
sandcasemanagement .

DEMONSTRATI
ON:FAMI
LIARI
SATI
ONWI
THMUACTAPES.Di
str
ibut
ecol
our
edMUACt
apesand
bri
efl
yshowhowtheyareused.All
owpar
ti
ci
pantstof
ami
li
ari
set
hemsel
veswi
ththem.Referpart
ici
pant
s
toHandout1.
6Screeni
ng,Admissi
on,
andDischar
geUsi
ngMUACandrevi
ewthecategor
isat
ionby
col
ourandwhatt
heymean.Answeranyquesti
ons.

21
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e1Lear
ningObject
ive4:I
dent
if
ytheComponent
sofCMAM and
HowTheyWor
kTogether

TRAI
NER:
Becomef
ami
l
iarwi
thHandout1.
7CMAM Component
sandHowTheyWor
kToget
her
.

POWERPOI
NT:CMAM COMPONENTS(
Showsl
i
des39–51)
.Rev
iewt
hef
ourcomponent
sofCMAM
(
below)andref
erpar
ti
cipant
stoHandout1.
7CMAM Component
sandHowTheyWor
kToget
herf
or
f
uturer
efer
ence.
1. Communi tyoutreach
2. Outpati
entcaref orSAM wit
houtmedi cal
compl i
cat
ions
3. I
npatientcar
ef orSAM withmedicalcompl i
cat
ions
4. Programmesf orMAM ( e.
g.,SFPs,dependingonthecontext
)

POWERPOI
NT:HOW THECOMPONENTSOFCMAM WORKTOGETHER(
Showsl
i
des52–53.
)
Sli
de52:Pointouteachoft
hecomponent
sandaskpar
ti
cipant
swhyt
heci
rcl
esar
eofdi
ff
erentsi
zes.
Explai
nthat
:
 I
fcommuni
tyout
reachi
sef
fect
iveandi
nter
vent
ioni
sti
mel
y,chi
l
drenwi
thacut
emal
nut
ri
ti
onwi
l
lbe
i
dent
if
iedear
lyandmostwi
llhav
eMAM wi
thoutmedi
cal
compl
i
cat
ions.Theycant
henber
efer
redt
o
pr
ogr
ammest otreatMAM.
 Mor
ethan80per
centoft
hosewi
thSAM wi
l
lhav
enomedi
cal
compl
i
cat
ionsandwi
l
lqual
i
fyf
or
out
pat
ientcar
e.
 Thef
ewchi
l
drenwi
thSAM whohav
emedi
cal
compl
i
cat
ionsornoappet
it
ewi
l
lrequi
rer
efer
ral
to
i
npat
ientcar
e.

GROUPDI
SCUSSI
ON:HOW THECOMPONENTSWORKTOGETHER.Havepar
ti
cipant
sbr
eaki
nto
gr
oupsoff
ourt
ofi
vepeopl
e,showsl
i
de52(
Component
sofCMAM)
,andaskt
hegr
oupst
odi
scuss:
 Thecomponentwher
echi
l
drenmostatr
iskar
etr
eat
ed
 Thecomponentwher
echi
l
drenatmedi
um r
iskar
etr
eat
ed
 Thecomponentwher
echi
l
drenatl
owerr
iskar
etr
eat
ed

Askgroupstodiagr
am themov ementofthefol
lowingchi
l
damongCMAM component
sbasedonthe
i
nformati
onbelow.Askthequesti
onsbelowoneatat i
meandmakesur
ethegr
oupshaveanswer
edthe
cur
rentquesti
onbefor
ey ouaskthenextquesti
on
 I dent
if
iedbycommuni t
y-l
evelscr
eenerwit
hr edMUAC
- Wher
edoest
hechi
l
dgonext
?(out
pat
ientcar
e)
 I
noutpat
ientcar
e,t
hechil
disfoundtohav eredMUACandmedi
cal
compl
i
cat
ions
- Wher
edoest hechi
ldgonext
?(inpat
ientcare)
 Thechi
ld’
smedical
compli
cati
onsr esol
ve,buts/
hest
il
lhasr
edMUAC
- Wheredoeschi
l
dgonext?(outpat
ientcare)
 Thechi
l
dhasbeeni
ntr
eat
mentf
ort
hemi
nimum amountoft
imeandMUACshowss/
hei
snow
moder
atel
ymal
nour
ished
- Wher
edoest
hechi
l
dgonext
?(pr
ogr
ammesf
ormanagementofMAM,
e.g.
,suppl
ement
aryf
eedi
ng,
if
av
ail
abl
e)
Askpar
ti
cipant
stodi
scusst
hei
rownexper
ienceswi
thi
mpl
ement
ingt
hedi
ff
erentcomponent
s.

22
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module1Learni
ngObj
ect
ive5:Expl
oreHowCMAM CanBeI
mpl
ement
ed
i
nDiff
erentCont
ext
s

TRAI
NER:Becomef
ami
l
iarwi
thHandout1.
8:CaseSt
udi
es,
Handout1.
9:I
mpl
ement
ingCMAM i
n
Dif
fer
entCont
ext
s,Handout1.
10:
Fact
orstoConsi
deri
nProvi
dingSer
vicesfort
heManagementofSAM,
andHandout1.
11:I
ntegr
ati
ngCMAM i
ntoRout
ineHeal
thSer
vicesatt
heDi st
ri
ctLev
el.

WORKI
NGGROUPS:Askpar
ti
ci
pant
stof
orm gr
oupsoff
iveorsi
x.Gi
veeachgr
oupHandout1.
8:Case
St
udies.Askthegr oups:“
Whichcasestudybestrepr
esent
sy ourworkingcontext
,andwhy ”?Askthe
gr
oupst opresentbackandthendiscuss.I
fnotrai
sedindi
scussion,askwhetherthecontextwasan
emer
gencyset ti
ngornot ,
whetherCMAM servi
ceswer ei
ntegrat
edintorouti
nehealthser
vices,and
whet
hert her
ewasahi ghHIVpreval
encerat
e.

POWERPOI
NT:CMAM I
NDI
FFERENTCONTEXTS(
Showsl
i
des54–55.
)Hi
ghl
i
ghtt
opar
ti
cipant
s
t
hef
oll
owingcharact
eri
sti
csofCMAM i ndiff
erentcont
exts:
 Emergencyandpost-emergencysetti
ngs:CMAM wor kswellinanemer gencycont
extbecausel
arge
numbersofchil
drenwit
hacutemal nutr
it
ioncanber eached,
duet otheavail
abi
li
tyofext
ernal
fi
nanci
alandtechni
calresour
cestointr
oduceorstrengthenservi
ces.
 Non-
emer
gencycont
ext
:CMAM cant
akepl
acei
nthecont
extofongoi
ngheal
thpr
ogr
ammi
ng.
Inpat
ientcaretakesplaceatexi
sti
ngheal
thfaci
li
ti
eswi
th24-
hourcare(e.
g.,
hospit
als,
healt
hcent
res
withhospit
alisat
ion)
,whil
eoutpati
entcar
eoperat
esatt
hefir
st-
lev
elhealt
hfaci
l
ity(
e.g.
,heal
th
centr
es,cli
nics,heal
thposts)
.
 I
nhi
ghHI
Vpr
eval
encear
eas:Al
argepr
opor
ti
onofchi
l
drenwi
thSAM i
ninpat
ientandout
pat
ientcar
e
wil
lbeHIV-posi
ti
ve.MostHIV-posit
ivechi
ldr
enwit
hSAM wil
lbenef
itf
rom community-
based
tr
eatmentwithRUTF.Str
onglinkagesbetweenCMAM,HIVtest
ingandcounsel
li
ng,andtreat
ment
serv
ices(
i.
e.,of
fer
inganti
ret
rovir
al[ARV]andcot
ri
moxazol
eprophyl
axi
s)areessent
ial
.

WORKI
NGGROUPS:I
NTEGRATI
NGCMAM I
NTOEXI
STI
NGHEALTHSERVI
CES.Wi
th
parti
cipant
si nthesamewor kinggroups,referthem toHandout1.11Int
egratingCMAM i nt
oRout i
ne
HealthServicesattheDistr
ictLevel.Askpar t
icipantstor
eaditqui
etl
yandt hendiscusswhat
programmesi nthei
rdi
str
ictcouldbei nt
egratedwi thCMAM andhow.Askt hem totakeintoaccountt
he
fact
or sout
li
nedi nHandout1.10Fact orstoConsi deri
nProv
idingSer
v i
cesfortheManagementofSAM.

23
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module1Learni
ngObj
ect
ive6:I
dent
if
yKeyNat
ionalandGl
obal
Dev
elopment
sandCommitmentsRel
atingt
oCMAM

TRAI
NER:
Becomef
ami
l
iarwi
tht
heWHO,
WFP,
UN/
SCN,
andUNI
CEF2007Joi
ntSt
atementon
Communi
ty-
BasedManagementofSev
ereAcut
eMal
nut
ri
ti
on.

POWERPOI
NT:GLOBALCOMMI
TMENTFORCMAM (
Showsl
i
des56–57.
)

DI
SCUSSI
ON:Di
str
ibut
etheWHO,
WFP,
UN/
SCN,
andUNI
CEF2007Joi
ntSt
atementonCommuni
ty-
BasedManagementofSevereAcuteMalnutr
it
ionandbr
ief
lyr
evi
ewt
hecont
ent
stoget
her
.Make
par
ticul
arnot
eoft
hejoi
ntstatement
’ssuppor
tfor:

 Adopti
ngnat i
onalpoli
ciesandpr ogr
ammesto:
- Ensurethatnati
onalprotocol
sformanagementofSAM hav
east rongcommunit
ycomponent
- Achievehighcover
aget hroughreachi
ngchi
l
drenwhoneedtreat
mentthroughef
fect
ivecommuni
ty
out
reachandact
ivecase-
fi
ndi
ng
- Pr
ovi
det
rai
ningandsuppor
tforCHWst
oident
if
ychi
l
drenwi
thSAM andt
orecogni
set
hosewi
th
medi
cal
compl
i
cat
ionst
hatneedur
gentr
efer
ral
s
- Pr
ovi
det
rai
ningf
ori
mpr
ovedmanagementofSAM atal
ll
evel
ssot
her
eisanef
fect
ivei
ntegr
ated
appr
oach(
i.
e.,
combi
nedi
npat
ientandout
pat
ientcar
e)

 Pr
ovi
dether
esour
cesneededf
oref
fecti
vemanagementofSAM i
ncl
udi
ng:
- Maki
ngRUTFavai
l
ablei
ncommunit
y-basedser
vicesandpr
ogr
ammesaswell
asot
heressent
ial
i
tems(
e.g.
,F75,
ReSoMal
,scal
es,
MUACt
apes)
- Encouragi
ngnati
onal
product
ionofRUTF
- Ensuri
ngfundi
ngtoprovi
defr
eetreat
mentf
orSAM

 Li
nkCMAM wi
thot
herheal
thandnut
ri
ti
onact
ivi
ti
es,
incl
udi
ngI
MCIandpr
event
ionser
vices

Fur
ther
,highl
i
ghttothepar
ti
cipant
saddi
ti
onal
global
commi
tment
sont
hemanagementofacut
e
malnut
ri
ti
oninthepast10years:
 WHOandUNI
CEFj
ointst
atementonchi
l
dgr
owt
hst
andar
dsandi
dent
if
icat
ionofSAM i
ninf
ant
sand
chi
ldr
en(2009)–cal
l
sf ori
dent
if
icat
ionandadmissi
onofi
nfantsandchi
ldrenwi
thSAM usi
ngMUAC
andtheuseofwei
ghtforhei
ght(WFH)z-scor
eoftheWHOgr owthst
andards.
 WHOupdat
eont
hemanagementofSAM i
ninf
ant
sandchi
l
dren(
2013)
,whi
chpr
ovi
desupdat
ed
ev
idenceandbestpr
act
icest
oinf
ormt
hemanagementofSAM i
nout
pat
ientandi
npat
ientcar
e
 AnewUN(
WHO/
UNI
CEF/
WFP)j
ointst
atement
,expect
edt
ober
eleasedi
n2018/
19,
thatwi
l
lref
lect
ont
heemer
gingev
idenceandgl
obal
commi
tment
sont
hemanagementofacut
emal
nut
ri
ti
on

DI
SCUSSI
ON:Askaf
ewpar
ti
ci
pant
stogi
veexampl
esofnat
ional
commi
tment
sandpol
i
ciesr
egar
ding
CMAM.

GUESTSPEAKER:Li
stent
oaguestspeakershar
ehi
s/herexper
iencesi
npl
anni
ng,i
mpl
ement
ing,and
i
ntegr
ati
ngaCMAM pr
ogr
amme.

24
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e1Wr
ap-
UpandModul
eEv
aluat
ion

SUGGESTEDMETHOD:REVI
EW OFLEARNI
NGOBJECTI
VESANDCOMPLETI
ONOF
EVALUATI
ONFORM
 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.I
nthi
smodul
eyouhav
e:
1. Di
scussedacut
emal
nut
ri
ti
onandt
heneedf
orar
esponse
2. I
dent
if
iedt
hepr
inci
plesofCMAM
3. Descr
ibedi
nnov
ati
onsandev
idencemaki
ngCMAM possi
ble
4. I
dent
if
iedt
hecomponent
sofCMAM andhowt
heywor
ktoget
her
5. Dev
elopedanappr
eci
ati
onf
ort
hei
ssuesr
elat
edt
oimpl
ement
ingCMAM
6. Expl
oredhowCMAM canbei mpl
ement
edindi
fferentcont
ext
s
7. I
denti
fiedkeynat
ional
andgl
obal
commitment
sr el
ati
ngtoCMAM

 Askf
oranyquest
ionsandf
eedbackont
hemodul
e.
 Di
rectpar
ti
cipant
stoHandout1.
12Essent
ial
sofCMAM f
orf
utur
eref
erence.
 Tel
lpar
ti
cipant
sthatt
heywi
l
lhav
eanoppor
tuni
tyt
oobser
vepr
ocedur
esandt
alkwi
thst
affdur
ing
t
hef
iel
dvi
sit
.
 Askpar
ti
cipant
stocompl
etet
hemodul
eev
aluat
ionf
orm.
*

*Theevaluat
ionf
orm canbedi
str
ibut
edatt
heendofeachdayorper
iodi
cal
l
y,dependi
ngont
rai
ner
s’
pref
erences.

25
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

FI
ELDVI
SITTOOUTPATI
ENTCARESI
TE

Ov
erv
iew
 Tr
ainer
:Becomef
ami
l
iarwi
thHandout1.
13Fi
eldVi
si
tCheckl
i
st.
 Amaxi
mum off
ivepar
ti
ci
pant
sshoul
dbeateachout
pat
ientcar
esi
teonagi
venday
.Coor
dinat
ewi
th
asmanysi
tesasnecessar
ytokeept
henumberofpar
ti
cipant
satf
iveorf
ewer
.
 Pai
rpar
ti
cipant
swi
thsomeonewhospeaksbot
hthel
ocal
languageandt
hepar
ti
cipant
s’l
anguage.
 I
ntr
oducepar
ti
cipant
stot
heper
soni
nchar
ge.

Lear
ningObj
ect
ives
1. Obser
vet
hef
oll
owi
ngact
ivi
ti
es:
- Hownutr
it
ionall
yvul
nerabl
eat
-r
iskmot
her
sandi
nfant
sunder6mont
hsofagear
eadmi
tt
edand
di
schar
ged,ifpossi
ble
- Howchi
l
drenwi
thSAM ar
eadmi
tt
edanddi
schar
ged,
ifpossi
ble
- Howchil
drenwit
hSAM aret
reat
edandeval
uatedi
noutpat
ientcar
efol
l
ow-
onsessi
ons(
e.g.
,
ant
hropometr
icmeasur
ement,medi
cal
assessment,
suppl
yofRUTF)
- Hownutri
ti
onal
lyvul
nerableat
-ri
skmothersandinfant
sunder6monthsar
emanagedand
monit
oredinoutpat
ientcaref
oll
ow-onsessi
ons( f
eedi
ngassessment,
medical
assessment
,
ant
hropometri
cmeasur ement
s,counsel
li
ng,andfeedi
ngsupport
)
2. Di
scusswi
thst
afft
hef
oll
owi
ng:
- Whatdot
heyl
i
keanddi
sl
ikeaboutt
heCMAM ser
vice?
- Howdoest
hisser
viceaf
fectt
hei
rov
eral
lwor
kload?
- Whatshor
tcomi
ngsorpr
obl
emsdot
heyseewi
tht
heser
vice?
- Howdot
heywor
kwi
thout
reachwor
ker
s(e.
g.,
CHWs,
vol
unt
eer
s)?
- Howdotheyli
nkwit
hotherheal
thser
vices(
e.g.
,expandedpr
ogr
ammeofi
mmuni
sat
ion[
EPI
],
HI
Vtest
ingandcounsel
l
ing)
?
- Whattypeofsuppor
tispr
ovi
dedtothechi
l
d’sfamil
yaf
terthechil
disdischar
ged(e.
g.,
social
prot
ecti
onincl
udi
ngcashtr
ansf
ers,
agri
cul
tur
alsuppor
t,i
nfantandyoungchil
dfeedi
ng[IYCF]
counsel
li
ng)
3. Tal
kwi
thmot
her
s/car
egi
ver
s:
- Howdi
dtheyf
indoutaboutt
heser
vice?
- Whatdot
heyl
i
keanddi
sl
ikeaboutt
heser
vice?

Act
ivi
ty:FeedbackonFi
eldVi
sitSessi
on
Af
tert
hef
iel
dvi
sit
,conductaf
eedbacksessi
oni
nwhi
chpar
ti
cipant
swi
l
l:
 Pr
ovi
def
eedbackonst
rengt
hsobser
vedateachout
pat
ientcar
esi
tev
isi
ted
 Rai
sei
ssuesf
orcl
ari
fi
cat
ionbyf
aci
l
itat
ors
 I
dent
if
ykeygapst
hatneedmor
eobser
vat
iont
ime

26
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

MODULETWO:DEFI
NINGANDMEASURI
NGACUTE
MALNUTRI
TION

Modul
eOv
erv
iew
Thismodul ereviewscommonnutri
ti
onandanthropomet
ri
cter
msandt hecausesofundernut
ri
ti
onand
providespract
icalski
ll
sonhowtomeasureacutemalnut
ri
ti
on,andnut
ri
ti
onvulner
abil
i
tyinat-
ri
sk
mot hersandinfantsunder6mont
hsofage.
Themodul ewi l
lgi
vefiel
dimplementersanov erv
iewofmet hodsusedt odeterminet
henut r
it
ional st
atus
ofaninfantorchil
d:testi
ngforbi
lat
eral pi
tt
ingoedema;usingmi d-upperarm cir
cumference(MUAC) ,
weight,
height,andageasmeasur es;andassessingfeedingininfantsunder6mont hs.Profi
ciencyin
theseskil
l
si scri
ti
calfori
denti
fyi
nginfantsandchil
drenwhomi ghtbeel i
gibl
eformanagement .Hands-on
pract
iceusingthesemet hodswil
lbepr ovi
dedinthefiel
dv i
sit
stoout pati
entcaresit
esinModul eFour.

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises
1.Di
scussCausesand 30mi
nut
es Handout2.
1Causal
Framewor
kofUnder
nut
ri
ti
on
Consequencesof
Handout2.
2Under
nut
ri
ti
onDef
ini
ti
ons,
Indi
ces,
Undernutr
it
ionand
I
ndicat
ors,
andI
ndi
cat
orCut
off
s
Undernutr
it
ionTerminol
ogy
2.I
denti
fytheCli
nical
Signsof 15mi
nut
es Handout2.
3Cl
i
nical
Mani
fest
ati
onsofAcut
e
AcuteMalnutri
ti
on Malnut
ri
ti
on
3.Measure,
Calcul
ate,and 1hour,15 Handout2.
4Assessi
ngAge,Bi
l
ater
alPi
tt
ingOedema,
Classi
fyAcuteMalnutr
it
ion minut
es MUAC, Wei
ght
,andHeight
(
1¼hour
s)
Handout2.
5Wei
ght
-f
or-
Hei
ght
/Lengt
hTabl
esf
orFi
eld
Use
Exer
cise2.
1Gr
adesofBi
l
ater
alPi
tt
ingOedema
Exer
cise2.2Cal
cul
ati
ngWFH/
WFLandCl
assi
fyi
ng
Acut
eMal nut
ri
ti
on
4.AssessandClassi
fy 45mi
nut
es Handout2.
6C-
MAMITool
Ver
sion2.
0
Nutri
ti
onalVulner
abi
li
tyi
nAt
-
RiskMothersandInf
ants
Under6Mont hsofAge

Wr
ap-
UpandModul
eEv
aluat
ion 15mi
nut
es

Modul
eDur
ati
on:3hour
s
Note:
Dependi ngontheneedsoft hei
raudiences,
trai
nersmaychooset
oskiporspendmoreorlesst
ime
oncertai
nlearni
ngobject
ivesandactivi
ti
es.Themodul edur
ati
onisanest
imat
eoft het
imeitt
akesto
completeall
thelear
ningobject
ivesandact i
vi
ti
es.

Mat
eri
als

27
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ngGui
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orCommuni
ty-
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eMal
nut
ri
ti
on(
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,2018Ver
sion

 Bl
ankcar
ds
 Fl
i
pchart
,marker
s
 Maski
ngtape
 Car
dswithheadi
ngs:
Basic,
Under
lyi
ng,
Immedi
ate,
andConsequences
 Set
sofcardswit
hunder
nutri
ti
ont
ermsandset
sofcar
dswithmatchingdef
ini
ti
ons
 Cal
culat s(
or onl
yneededift
rai
ningcover
sWFH/
WFL)
 Sal
terscal
es(cal
ibr
atedt
ozero[“0”
])
 El
ect
ronicscal
e(e.
g.,
UNISCALE)(
cal
ibrat
edtozero[“
0”]
)
 Hei
ght/
lengt ds(
hboar onl
yneededi
ftrai
ningcover
sWFH/ WFL)
 Number
edandsimpl
ethr
ee-col
ourMUACtapes
 Phot
osofchi
l
drenwi
thmarasmus,kwashi
orkor
,andmar
asmi
ckwashi
orkor

Adv
ancePr
epar
ati
on
 Room set
up,
mat
eri
alsnot
edabov
e
 Revi
ewal
lpar
ti
cipanthandout
s
 Ar
rangement
sshoul
dbemadef
orpar
ti
ci
pant
stoconductant
hropomet
ri
cmeasur
ement
sofchi
l
dren
i
nthecont
extofongoi
ngscr
eeni
ngorCMAM ser
vices
 Revi
ewr
elev
antr
efer
enceandf
urt
herr
eadi
ngr
esour
cesl
i
stedbel
ow.

Ref
erenceResour
ces
1. EmergencyNutr
it
ionNetwor
k(ENN)
.2018.C-
MAMITool
Ver
sion2.
0.Av
ail
abl
eat
ht
tps:
//www.ennonli
ne.
net
/c-
mami.

2. FoodandNutrit
ionTechnicalAssist
anceIIIPr
oject(FANTA).2018.Ant
hropomet
ryPocket
Refer
encesf
orChi l
drenandAdol escent
s.Avail
ableat:
htt
ps:/
/www.fantapr
oject
.org/t
ools/ant
hropomet r
y-pocket
-r
efer
ence.

3. Cashin,K.andOot ,L.2018.GuidetoAnthropomet ry:APracti

calToolf
orProgram Planner
s,
Manager s,
andI mplementers—Modul e6:Pr otocolsandEquipment .Washi
ngton,DC: FANTA/
FHI360.
(Forref
erencemat erial
onwei ghtandheightequi pmentandonwher etopurchaseequipmentand
avail
abl
eki t
s.)Avai
lableat:ht
tps:/
/www. fantaproject.
org/si
tes/def
aul
t/f
il
es/resour
ces/MODULE-6-
FANTA- Anthr
opomet ry-
Guide-
May 2018.pdf.

4. FoodandAgri
cul
tur
eOrganisat
ion(FAO)
.2008.Gui
deli
nesforEsti
matingtheMonthandYearofBi
rt
h
ofYoungChi
l
dren.Avai
l
ableat:ht
tp:/
/www.f
ao.or
g/docrep/
pdf/011/
aj984e/aj
984e00.
pdf

5. Worl
dHealt
hOr gani
sat
ion(
WHO).2006.WHOChi
l
dGr
owt
hSt
andar
ds.Av
ail
abl
eat
:
ht
tp:
//www.who.i
nt/
chi
ldgr
owt
h/st
andards/
.

Fur
therReadi
ngResour
ces
1. CouncilofResearch&Techni cal
Adv iceonAcut eMalnutr
it
ion(CORTASAM) .2018.AResearch
Agendaf orAcuteMal nut
rit
ion.Avail
abl eat:
ht
tps://
stati
c1.squarespace.com/ st
at i
c/58da81cdd1758e39ca705526/
t/5a5cbfcdf
9619a9a191c6f
3
4/1516027854696/ NoWast edLives_Research_Agenda_2018.
pdf.

28
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

2. Bri
end,A.;
Mwangome, M.K.
;andBerkl
ey,J.
A.2017.“Usi
ngMi d-
UpperAr m Ci
rcumferencetoDetect
High-
RiskMalnour
ishedPati
entsinNeedofTr eat
ment.
”Preedy,V.R.andPatel
,V.B.(
eds.).Handbook
ofFamine,St
arvat
ion,andNutri
entDepr
ivat
ion.DOI10.
1007/978-3-319-
40007-5_
11-1.

3. Lelij
vel
d, .2017.ARev
N.etal i
ewofMet hodstoDet
ectCasesofSever
elyMalnour
ishedInf
ant
sLess
than6Mont hsforTheirAdmissi
onintoTher
apeut
icCar
e.EmergencyNutr
it
ionNetwork.Avai
l
abl
eat:
https:
//www.ennonl
ine.net
/mamicasedet
ecti
onr
evi
ew.

4. Tang,A.M.2016.DeterminingaGl obalMid-UpperArm Ci
rcumferenceCutofft
oAssessMalnut
ri
ti
on
i
nPr egnantWomen.Washi ngton,DC: FHI360/FANTA.Av ai
labl
eat:
htt
ps://www.f
ant
aproject
.org/si
tes/defaul
t/fi
les/
resour
ces/FANTA- MUAC-cut
off
s-pr
egnant
-women-
June2016.pdf
.

5. Bl
ackwell
,N.etal
.2015.“Mot hersUnderst
andandCanDoI t(MUAC) :ACompar i
sonofMot her
sand
CommunityHealt
hWor kersDet er
mini
ngMi d-
UpperArm Cir
cumferencein103Chi l
drenAgedfr
om
6 
Monthsto5 Year ”Ar
s. chivesofPubli
cHealth.Avai
l
ableat:
ht
tps:
//ar
chpubli
cheal
th.
biomedcent r
al.
com/arti
cl
es/10.
1186/s13690-015-
0074-z.
6. WHOandUNI CEF.2009.WHOChi l
dGrowthStandar
dsandtheIdent
if
icat
ionofSAM inI
nfant
sand
Chi
ldren:AJointSt
atement.Avai
lableat:
ht
tp:/
/ www.who.i
nt/
nutri
ti
on/publi
cati
ons/sev
eremal
nut
ri
ti
on/9789241598163/en/
.

CEF.Nut
7. UNI ri
ti
oni
nEmer
genci
es.Avai
l
abl
eat
:ht
tps:
//www.
uni
cef
.or
g/nut
ri
ti
on/
trai
ning/
li
st.
html
.

8. WHODepart
mentofHealt
handDevel .2002.Tr
opment aini
ngCour
seont
heManagementofSever
e
Mal
nut
ri
ti
on.Geneva:WHO.Modul
e2.

9. WHO.1983.Measur
ingChangei
nNut
ri
ti
onalSt
atus.Geneva:WHO.
10.WHO.2000.ManagementofNut
ri
ti
oni
nMaj
orEmer
genci
es.Geneva:WHO.

11.Young,H.andJaspar
s,S.2006.TheMeaningandMeasurementofAcut
eMal nutr
it
ioni
n
Emergenci
es:APrimerforDeci
sion-
Maker
s.OverseasDevel
opmentI
nst
itut
e( ODI
),Humani
tar
ian
Pract
iceNetwor
kPaperNo.56, Nov .
ember

29
 Tr
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def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module2Lear
ningObj
ecti
ve1:Di
scussCausesandConsequencesof
Under
nut
ri
ti
onandUndernut
ri
ti
onTerminol
ogy

TRAI
NER:Becomef
ami
l
iarwi
thHandout2.
1Causal
Framewor
kofUnder
nut
ri
ti
onandHandout2.
2
Under
nut
ri
ti
onDef
ini
ti
ons,
Indi
ces,
Indi
cat
ors,
andI
ndi
cat
orCut
off
s.

BRAI
NSTORM:CAUSESOFMALNUTRI
TION.Gi
veeachpar
ti
cipantt
wobl
ankcar
dsandaskt
hem t
o
thi
nkaboutwhatt
hecausesofchi
ldunder
nut
ri
tionareandt
owr
it
eonecauseoneachcar
d.Ask
part
ici
pant
stopostt
hei
rcardsandsharet
hei
rideas.

Usingcar
dsmarked“Immediat
e,”“Underl
yi
ng”and“Basi
c,
”havepar
ti
cipant
swor
ktoget
hert
ogr
oupt
he
causesbycat
egoryandtopl
aceundert hecorr
espondi
ngl
ylabel
l
edcard.
 I mmediat
e:e.
g.,f
oodint
ake,il
l
ness
 Under
lyi
ng:
e.g.
,foodi
nsecur
it
y,i
nadequat
efeedi
ngandcar
epr
act
ices,
poorsani
tat
ion/
wat
erand
i
nadequat
eheal
thser
vices
 Basi
c:e.
g.,
pol
i
tical
,cul
tur
al,
rel
i
gious,
economi
candsoci
alsy
stemsi
ncl
udi
ngwomen’
sst
atus

Dir
ectpar
ti
cipant
stoHandout2.1.CausalFramewor
kofUnder
nut
ri
ti
onandaskpar
ti
cipant
sift
heycan
namesomespeci f
iccausesofunder
nutr
it
ion.

Notetopar
ti
cipant
sthatt
hesecausescontr
ibutet
oallf
ormsofunder
nut
ri
ti
on,andt
hei
rpr
esenceand
i
nter
acti
onwil
l det
ermi
nehowtheymanifestthemsel
vesinachi
l
dorapopulat
ionov
ert
ime.

ELI
CITATI
ON:UNDERNUTRI
TION.I
fcov
eredi
nModul
eOne,
askpar
ti
cipant
stodef
ineunder
nut
ri
ti
on
andt
hef
ormsi
tcant
ake.I
fnot
,pr
esentt
hef
oll
owi
ngpoi
nts:

Under
nut
ri
ti
onisaconsequenceofadefi
ciencyi
nnut
ri
entsi
nthebodyandcant
aket
hef
orm of
:
 Acutemalnut
ri
ti
on(bil
ater
alpi
tt
ingoedemaorwasti
ng)
 St
unt
ing
 Under
wei
ght
 Mi
cronut
ri
entdef
ici
enci
es

Notetopar t
ici
pantsthatmal
nut
ri
ti
oncompri
sesover
nut
ri
tion(
e.g.
,over
wei
ghtandobesi
ty)and
undernutr
it
ion,buttheter
m mal
nut
ri
ti
onismostof
tenut
il
izedf
orformsofunder
nut
ri
ti
on(e.g.,
acut
e
malnutri
ti
on).

Askpart
ici
pantst
onameconsequencesofunder
nutr
it
ion(e.g.
,incr
easedri
skofil
lness,i
ncr
easedriskof
morbi
dit
yandmor tal
i
tyduet
oweakenedabil
it
ytofi
ghtil
lness,aswellaspoorgr
owt handcognit
ive
devel
opment).

PARTI
CIPATORYLECTURE:ACUTEMALNUTRI
TION.Askpar
ti
cipant
sift
heycani
dent
if
ythef
ive
met hodscommonlyusedt oassesst henut r
it
ionalstatusofchi ldren(ifpart
ici
pantshavenonut r
iti
on
background,si
mplydeli
vertheinformationinlectur
e):1)bilateralpitt
ingoedema; 2)MUAC; 3)WFH/ WFL;
4)height-
for
-age(
HFA) /
length-
for-age(LFA);5)weight-for-
age( WFA) .Remi ndparti
cipantst
hatthese
tr
ainingmodulesf
ocusonacut emal nutr
iti
on,andnut r
iti
onv ulnerabil
ityinat-r
iskmothersandinfants
under6mont hsofage.Askpar ti
cipantswhichassessmentmet hods( above)assessacutemalnutri
ti
on.
 Def i
neacutemalnutr
it
ionandt hecut off
sforSAM andMAM.

 Acut
emal
nut
ri
ti
oni
scausedbyi
nadequat
efoodconsumpt
ionand/
ori
l
lnessr
esul
ti
ngi
nbi
l
ater
al
pi
tt
ingoedemaorsuddenwei
ghtl
oss.I
tisdef
inedbyt
hepr
esenceofbi
lat
eralpi
tt
ingoedemaor

30
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ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

wast
ing(
lowMUACorWFH/
WFL)
.
 Acut
emal
nut
ri
ti
oncompr
isesbot
hSAM andMAM andcanhav
ethef
oll
owi
ngi
ndi
cat
ors(
wit
h
cut
off
sforchi
l
drenage6–59mont
hs)
:

Bi
lat
eralpi
tt
ingoedema MUAC WFH/
WFLz-
scor
e

SAM: Pr
esent <115mm <-
3

MAM: Notpr
esent ≥115mm and<125mm ≥-
3and<-
2

 Fur
therexpl
aint
hatMUACi
sabet
terpr
edi
ctorofmor
tal
i
tyi
nchi
l
drenunder5t
hanWFHz-
scor
e.I
tis
al
sorel
ati
vel
yeasyt
omeasur
eandcanbedonebymot
her
sandot
herf
ami
l
ymember
sint
he
communit
y.

BRAI
NSTORM:NUTRI
TIONVULNERABI LI
TYI NAT-RISKMOTHERSANDI NFANTSUNDER6
MONTHSOFAGE.Askpar
ti
ci
pant
stoi
denti
fyi
ndi
cat
orsusedt
oident
if
ynut
ri
ti
onvul
ner
abi
l
ityi
n
i
nfant
sunder6mont hsandt heli
mi t
ati
onsofthei
ndicat
ors.Completetheresponsesbyexpl ai
ningt
he
f
oll
owing:
 Ther ei
sgrowingev i
denceont heuseofMUACt oidenti
fynut
rit
ionvulnerabi
l
ityininfant
sunder6
months.However,cl
assif
icat
ioncutof
fshavenotyetbeenestabli
shed.Itisr
ecommendedt hat
MUACdat afori
nfantsunder6mont hsbecoll
ectedtohelpbuil
dtheev i
dencet oinform case
management.
 Recentevi
dencehasshownt
hatWFAcanhel
pident
if
yunder
wei
ghti
nfant
swhoar
eal
soathi
gher
r
iskofmort
ali
ty.WFAwi
llt
heref
orebeusedasacr
it
eri
aforadmi
ssi
onofnut
ri
ti
onal
l
yvul
ner
abl
e
i
nfant
sunder6monthsofage.
 I
ninf
ant
sunder6mont
hsofage,
assessmentofnut
ri
ti
onv
ulner
abi
l
ityi
snotl
i
mit
edt
o
anthropometr
icindicat
ors.Abi
l
ityt
ofeed,
medi
calcondi
ti
on,
andmat
ernal
ment
al,
phy
sical
,and
socialci
rcumstancesarealsoofpri
maryi
mpor
tance.
 Thei
nfant
’swel
l
-bei
ngi
sdet
ermi
nedbyt
hemot
her
’swel
l
-bei
ng;
ther
efor
e,t
hemot
herandi
nfantar
e
consi
der
edasa“
mot
her
-i
nfantpai
r.
”
 Mor
einf
ormat
ionwi
thbecov
eredl
ateri
nthi
smodul
eunderObj
ect
ive4:AssessandCl
assi
fy
Nut
ri
ti
onVul
ner
abi
li
tyofAt
-Ri
skMot
her
sandI
nfant
sUnder6Mont
hsofAge.

31
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

PRACTI
CE:ACUTEMALNUTRI
TIONANDNUTRI
TIONVULNERABI
LITYDEFI
NITI
ONS.Have
par
ti
cipantsf
orm pai
rs.Gi
veeachpai
rasetofmatchi
ngcards:6wi
thundernut
ri
ti
ont er
msand6wi t
h
matchingdef
ini
ti
ons(seebel
ow).Askeachpai
rtomatcht
het er
mswiththedefi
nit
ions.Di
scussi
n
pl
enary.

Referpart
ici
pant
st oHandout2.
2Under
nut
ri
ti
onDef
ini
ti
ons,
Indi
ces,
Indi
cat
orsandI
ndi
cat
orCut
off
sfor
l
aterreadi
ngandr efer
ence.

Mat
cht
erm wi
thcor
rectdef
ini
ti
on(
answerkey
)

Ter
ms Def
ini
ti
ons
Nutr
iti
onvulnerabi
l
ityi
n  Bi
l
ater
alpi
tt
ingoedema+/
++/
+++
at
-ri
skmot hersand  WFLz-
scor
e<-
2(l
owWFL)
i
nfantsunder6mont hs
 WFAz-
scor
e<-
2(l
owWFA)
 MUAC(
cut
offTBD)
I
nadequat
ewei
ghtgai
norgr
owt
hfal
ter
ing
 Abi
l
ityt
ofeedef
fect
ivel
y
 Medi
cal
condi
ti
onoft
hei
nfant(
seedet
ail
sinC-
MAMITool
Ver
sion2.
0)
 Mot
her
’sorcar
egi
ver
’sment
al,
nut
ri
ti
on,
heal
thandsoci
alci
rcumst
ances
Acutemalnut
ri
ti
oni
n  Bi
l
ater
alpi
tt
ingoedema
chi
ldren6–59mont
hs  MUAC<125mm
 OrWFH/
WFLz-
scor
e<-
2(l
owWFHorWFL)
Moderat
eacute  MUAC<125mm and≥115mm
malnut
ri
ti
on(MAM)in  OrWFH/
WFLz-
scor
e<-
2and≥-
3
chi
l
dren6–59months

Sev
ereacut
emal
nut
ri
ti
on(
SAM)
I
nchi l
dren6–59months  Bi
lateralpi
tt
ingoedema+/ ++/
+++
 MUAC<115mm
 OrWFH/ WFLz-score<-3
Cli
nicalmani
fest
ati
ons  Ma r
asmus( severewasti
ng)
ofSAM  Kwa shior
kor(bi
lat
eral
pit
ti
ngoedemaorswel
l
ingofnut
ri
ti
onal
ori
gin)
 Mar
asmi
ckwashi
orkor(
bot
hbi
l
ater
alpi
tt
ingoedemaandsev
erewast
ing)
Bi
l
ater
alpi
tt
ingoedema  Asi
gnofSAM
 Al
socal
l
edkwashi
orkor
,nut
ri
ti
onal
oedema,
oroedemat
ousmal
nut
ri
ti
on
 Anabnor
mal
inf
il
tr
ati
onandexcessaccumul
ati
onofser
ousf
lui
din
connect
iveti
ssueorinaser ouscavit
y
 Veri
fi
edwhent humbpr essureappl
iedontopofbot
hfeetfort
hreeseconds
l
eavesapi t(
indent
ati
on)inbothfeetaft
erthet
humbisli
ft
ed
Sev
erewast
ing  Asi
gnofSAM
 MUAC<115mm i
nchi
l
dren6–59mont
hs
 OrWFH/
WFLz-
scor
e<-
3
Achi
l
dwi
thsev
erewast
inghasahi
ghr
iskofdeat
h

32
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e2Learni
ngObj
ect
ive2:I
dent
if
ytheCl
ini
calSi
gnsofAcut
e
Mal
nutr
it
ion

TRAI
NER:Becomef
ami
l
iarwi
thHandout2.
3Cl
ini
cal
Mani
fest
ati
onsofAcut
eMal
nut
ri
ti
on.

BRAI
NSTORM ANDWORKI NGGROUPS:CLI NICALMANI FESTATIONSOFACUTE
MALNUTRI
TION.I
npl
enar
y,askpar
ti
ci
pant
sift
heycannamethet
hreecl
i
nical
mani
fest
ati
onsofacut
e
mal
nut
ri
ti
on:
 Marasmus(
sev
erewast
ing)
 Kwashi
orkor(
bil
ater
alpi
tt
ingoedema)
 Mar
asmi
ckwashi
orkor(
sever
ewast
ingandbi
lat
eralpi
tt
ingoedema)

Di
videpart
ici
pantsi
ntoworkinggroupsandaskthem tonamet hecharact
erist
icsofcl
i
nical
manif
estat
ionsofacutemalnutr
it
ion:marasmus,kwashi
orkorandmar asmickwashior
kor.Hav
eone
gr
ouppresentthei
ranswer
sandt heot hergr
oupsaddadditi
onalpoi
nts.Fil
li
nanygaps.

Ref
erpart
ici
pantstoHandout2.3Cli
nical
Manifest
ati
onsofAcut
eMal
nut
ri
ti
onandr
evi
ewt
he
cl
assi
fi
cati
onstogether
.Inv
iteandansweranyquest
ions.

PRACTI
CE:CLI
NICALMANI
FESTATI
ONS.Showpi
ctur
esofchi
l
drenwi
thmar
asmus,
kwashi
orkor
andmar asmi
ckwashi
orkorandaskpar
ti
ci
pant
stocl
assi
fyt
hem bycl
i
nical
mani
fest
ati
on.Answerany
quest
ions.

33
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orCommuni
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eMal
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on(
CMAM)
,2018Ver
sion

Modul
e2Learni
ngObj
ect
ive3:Measur
e,Cal
cul
ate,
andCl
assi
fyAcut
e
Mal
nutr
it
ion

TRAI
NER:Becomef
ami
l
iarwi
thHandout2.
4Assessi
ngAge,
Bil
ater
alPi
tt
ingOedema,
MUAC,
Wei
ght
andHei
ghtandHandout2.
5Wei
ght
-f
or-
Hei
ght
/Lengt
hTabl
esf
orFi
eldUse.

PARTI
CIPATORYLECTURE:ASSESSI
NGAGE.Askpar
ti
cipant
sift
heyknowwhenest
imat
ionofa
chi
ld’
sagei
simport
ant.Notet
hatageisrel
evantbecausethecasesofinf
antsunder6mont hsand
chi
ldr
en6–59monthsaremanageddiff
erentl
y.I
ncaseswher etheageofthechi
ldcannotbev er
if
ied
thr
oughachil
dheal
thcard(
CHC)orimmuni sati
oncard,methodsofest
imati
ngageinclude:
 Est i
mat
ingthemonthandyearofbi
rthwiththehel
pofal ocalev
ent
scalendar
.
 Recal
loft
hemot
her
/car
egi
verwhi
chi
seasi
ert
oest
imat
eini
nfant
sandy
oungerchi
l
dren.
 Forol
derchi
ldr
en,
agemaybeest
imat
edbasedonhei
ght
.Thest
andar
dint
ernat
ionalpr
oxyf
or
chi
ldr
en59mont
hsi
s110cm.

PARTI
CIPATORYLECTURE:BI
LATERALPI
TTI
NGOEDEMA.Descr
ibehowbi
l
ater
alpi
tt
ingi
s
assessed( seeHandout2.4), not
ingthati
tisi
mpor tantt
hatbothfeetaretest
ed.Ifitisneitherbil
ater
al
norpitt
ing,theoedemai snotofnut ri
ti
onori
gin.Descri
bethethreegradesofbil
ateral pi
tt
ingoedema.
Discusshowt oassessbil
ateralpit
ti
ngoedemagr ades++and+++.Not ethatpar
ticipantswi l
lhavethe
opportunit
yt oassessbi
lateralpi
tti
ngoedemai nfi
eldsitevi
sit
s.Underl
inetheimpor tanceofasecond
opini
oni ncaseswher ebil
ateralpit
ti
ngoedemai spresent.

PRACTI
CE:RECOGNI
SINGBI
LATERALPI
TTI
NGOEDEMA.Ref
erpar
ti
cipant
stoExer
cise2.
1
GradesofBil
ater
alPit
tingOedema.Havethepar
ti
ci
pant
sworkinpairst
olookatt
hephot
osandi
dent
if
y
t
hesev er
it
yofthebil
ateral
pit
ti
ngoedema.Revi
ewanswerst
ogether
.

Exer
cise2.
1Gr
adesofBi
lat
eral
Pit
ti
ngOedema(
wit
hanswer
s)
PHOTO1

Bi
lat
eralpi
tt
ingoedema+

Thischil
dhasbi
lat
eralpi
tti
ngoedemainbothfeet
.
Thisisgrade+(
mild)
.Butthechi
ldmighthave
grade++or+++,sothelegsandfaceal
soshould
bechecked.

34
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

PHOTO2

Bi
lat
eralpi
tt
ingoedema++

Thischi
l
d’sfeet
,lowerlegs,
handsandlowerar
ms
areswoll
en.Thi
si sgr
ade++( moder
ate).

PHOTO3

Bi
lat
eralpi
tt
ingoedema+++

Thischi
ldhasgeneral
i
sedbil
ater
alpi
tti
ngoedema,
i
ncludi
ngfeet,
legs,
arms,handsandface.Thi
sis
grade+++(sever
e).

DEMONSTRATI
ON:USI
NGMUACTAPE.Ref
erpar
ti
cipant
stoHandout2.
4Assessi
ngAge,
Bil
ater
al
Pitt
ingOedema, MUAC, WeightandHei ght/
Length.Askhowmanypar ti
cipantshav
eusedaMUACt ape.
PassoutMUACt apestoparti
ci
pantsandr eviewbri
efl
ythecutof
fsforSAM andMAM andhowt ofi
ndthe
measur esont hetape.Demonstrat
ehowt ouseMUACt apes,
out
li
ningtheprocessdescr
ibedi
nHandout
2.4,Section3.Explai
nthemeani ngofthecoloursontheMUAC–r ed(SAM) ,y
ell
ow( MAM)andgreen
(normal nutr
it
ionalst
atus)
.Askpar t
ici
pantstopracti
ceoneachother.

PARTI
CIPATORYLECTURE:MEASURI
NGWEI
GHTANDHEI
GHT/
LENGTH.Showpar
ti
cipant
s
theSalterscal
eandtheUnitedNati
onsChil
dren’
sFund(UNICEF)UNISCALE,not
ingthatt
heywil
l
encounterthesescal
esinthefi
eldandhavetheopport
uni
tytopracti
ce.Fort
heSalt
erscal
e,out
li
nethe
considerat
ionsinHandout2.4,
Secti
on4.FortheUNISCALE,br
iefl
youtli
nehowthechil
dcanbeweighed
i
nt hemot her/
caregi
ver
’sarms.

PARTI
CIPATORYLECTURE:MEASURI
NGHEI
GHT/
LENGTH.(
Not
e:I
ncaseswher
ebi
l
ater
al
pi
tt
ingoedemaandMUACar eusedforadmi ssi
oncr
it
eria,adaptthet
raini
ngtoref
lectt
henat i
onal
gui
deli
nes.
)Showpart
ici
pant
stheheightboardandnotethatlengthi
smeasuredforchil
drenundertwo
orwit
haheightbel
ow87cm, whi
leheighti
smeasuredf orchil
drenovertwoorwit
hahei ghtabove87cm.

35
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Descr
ibet
heprocedureoutl
i
nedinHandout2.4,Sect
ion5.Notethati
nthecaseofchi
l
drenov
ertwowho
ar
eunabletost
and,themeasurewil
lbetakenly
ingdown.Inthi
scaseanadjust
mentdownwardof0.
7
cm i
smadet ot
hemeasur ement.

PARTI
CIPATORYLECTURE:CALCULATI
NGWFH/
WFLZ-
SCORE.Ref
erpar
ti
cipant
stoHandout
2.
5Weight
-for-
Height
/Lengt
hTabl
esforFiel
dUseandaskpar
ti
cipant
sift
heyar
efami
l
iarwi
tht
het
abl
es.
I
fnot
,car
efull
yrev
iewtheWFH/WFLtableswitht
hem.

Demonst
rat
est
ep-
by-
steponaf
li
pchar
tthepr
ocessofhowt
odet
ermi
neWFH/
WFLz-
scor
e:

1.Determi
netheageoft hechil
dinordertodeci
dewhethert
ousethel
engt
htabl
eorthehei
ghtt
able.
Remindparti
cipantsthatifachil
dovertheageof2(orover87cm)mustbemeasur
edlyi
ngdownfor
whateverr
eason, subtr
act0.5cm fr
om themeasurement.

2.Findt
hechil
d’sheightintheheightcolumnifusi
ngthehei
ghttabl
eorchil
d’sl
engt
hinl
engt
hcolumnif
usi
ngthelengt
htable.Notethatl
engt handheightmeasur
ementsendingononedeci
malarer
oundedup
ordown:
-0.1,0.2,
0.3,0.
4ar eroundeddownt o0.
0cm
-0.5,0.6,
0.70.8,0.9areroundedupto1.0cm

3.Looki
ngattheri
ghtsi
deofthechartforagir
lort
helef
tsideoft
hechartf
oraboy,
findt
hemedian
weightf
orachil
dofthathei
ghtorl
ength.Deter
minewhethert
heweightoft
hechi
l
disaboveorbel
ow -
1,
-2,
-3or-4st
andarddevi
ati
ons(SDs)
.

4.Cal
cul
atet
heexactz-
scor
ebysubt
ract
ingt
hemedi
anwei
ghtf
rom t
hechi
l
d’swei
ghtanddi
vi
dingby
theSD(i
nkg)
.

(
chil
d’swei
ght
)–(
standar
dchi
l
d’swei
ght
) = z-
scor
e
(
oneSD)

PRACTI
CE:CALCULATI
NGWFH/WFLZ-
SCORE.Ref
erpar
ti
cipant
stoExer
cise2.
2Cal
cul
ati
ng
WFH/WFLandCl assif
yingAcuteMalnutr
it
ion.Workinpl
enar
yt ocalcul
atetheWFH/ WFLz-scorefor
chi
ld1and2i ntheexercise.Answeranyquesti
ons,t
henaskparti
cipant
stowor kinpair
stocalcul
atethe
WFH/WFLz- scoreforchil
d3–10.Askv ol
unteerpai
rstor
eadtheiranswersaloud.Answerf
urther
quest
ions.

Exer
cise2.
2Cal
cul
ati
ngWFH/
WFLandCl
assi
fyi
ngAcut
eMal
nut
ri
ti
on

PARTA.WFH/
WFLZ-
Scor
e
Bi
lat
eral
Age(i
nyear
s MUAC Hei
ght Wei
ght
Chi
ldName Sex Pi
tti
ng WFH/
WFLZ-
Scor
e
unl
essnot
ed) (
mm orcol
our
) (
cm) (
kg)
Oedema
<-
1and
Chi
l
d1 F 3 Gr
een 98.
2 12.
5
>-
2
<-
2and
Chi
l
d2 M 5 123 110.
0 14.
8
>-
3
<-
2and
Chi
l
d3 M 5 ++ Yel
l
ow 102.
2 13.
5
>-
3
Chi
l
d4 F 4 110 91.
1 9.
3 <-
3
<-
2and
Chi
l
d5 M 9mont
hs 125 69.
9(Lengt
h) 6.
7
>-
3
Chi
l
d6 F 4 +++ Yel
l
ow 105.
2 18.
0 >medi
an

36
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ty-
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eMal
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ri
ti
on(
CMAM)
,2018Ver
sion

68.2
Chi
l
d7 F 8mont
hs + 105 5.
0 <-
3
(Lengt
h)
84.3
Chi
l
d8 M 1 Red 8.
9 =-
3
(Lengt
h)
<-
2and
Chi
l
d9 F 2 109 97.
2 11.
0
>-
3
Chi
l
d10 M 1.
5 + Gr
een 89.
7 12.
9 =medi
an

PRACTI
CE:DETERMI
NINGCHI
LD’
SNUTRI
TIONALSTATUS.Ref
erpar
ti
cipant
sbackt
oExer
cise
2.2Calculati
ngWFH/ WFLandCl assify
ingAcut eMal
nutr
it
ion.St
il
lworki
nginpair
s,askthem tousethe
i
nformat i
onont hepresenceofbil
ateralpit
ti
ngoedemaandMUACscor estodetermi
newhet hert
hechil
d
hasSAM orMAM ori snormal.Remi ndparti
cipant
stouseallt
heinf
ormati
onont hesheettomaket hei
r
deter
mi nati
ons.Notetoparti
ci
pantst hat:
 I
fachi
l
dhasbi
l
ater
alpi
tt
ingoedema,
iti
sst
il
lusef
ult
omeasur
eMUACorWFH/
WFLt
ocheckf
or
mar
asmi
ckwashi
orkor
.
 Bi
l
ater
alpi
tt
ingoedemacoul
dincr
easet
hechi
l
d’sWFH/
WFLandmaskwast
ingorot
herwar
ning
si
gns;
howev
erachi
l
dwi
thbi
l
ater
alpi
tt
ingoedemai
saut
omat
ical
l
ycl
assi
fi
edashav
ingSAM.
 I
ncount
ri
est
hatuseonl
ybi
lat
eralpi
tt
ingoedemaandMUACasent
rycr
it
eri
a,i
nfor
mat
ionon
hei
ghtandwei
ghtshoul
dbeadj
ust
edt
oref
lectt
henat
ionalgui
del
ines.

Askforvolunteerpair
storeadthei
ranswersal
oudandt hendi
scussandsummari
zei
nplenar
y.Ask
par
ti
cipantswhatt heywouldrecor
dforChil
d7’sadmissioncr
it
eri
on(t
hischi
l
dhasmarasmic
kwashior
kor).Refertoanswersheetandfi
l
lingaps.

37
 Tr
aini
ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Exer
cise2.
2Cal
cul
ati
ngWFH/
WFLandCl
assi
fyi
ngAcut
eMal
nut
ri
ti
on(
wit
hanswer
s)

Par
tB.Bi
lat
eral
Pit
ti
ngOedemaandMUAC
Bi
lat
eral
Chi
ld Age(i
nyear
s MUAC
Pi
tti
ng Cl
assi
fi
cat
ion
Name unl
essnot
ed) (
mm orcol
our
)
Oedema
Chi
l
d1 3 Green OK
Chi
l
d2 5 123 Moderat
e
Chi
l
d3 5 ++ Yell
ow Sev
ere(bi
lat
eral
pit
ti
ngoedema)
Chi
l
d4 4 115 Moderat
e
Chi
l
d5 9mont
hs 125 Moderat
e
Chi
l
d6 4 +++ Yell
ow Sev
ere(bi
lat
eral
pit
ti
ngoedema)
Chi
l
d7 8mont
hs + 105 Sev
ere(marasmickwashi
orkor
)
Chi
l
d8 1 Red Sev
ere(MUAC)
Chi
l
d9 2 114 Sev
ere(MUAC)
Chi
l
d10 1.
5 + Green Sev
ere(bi
lat
eral
pit
ti
ngoedema)

PARTC.Bi
lat
eral
Pit
ti
ngOedema,
MUAC,
andWFH/
WFLZ-
Scor
e
Age( i
n
Bi
lat
eral MUAC WFHZ-
Chi
ld years Hei
ght Weight
Sex Pi
tti
ng (mm or Scor
e Cl
assi
fi
cat
ion
Name unless (
cm) (kg)
Oedema col
our)
noted)
<-
1and
Chi
l
d1 F 3 Gr
een 98.
2 12.
5 Moder
ate
>-
2
<-
2and
Chi
l
d2 M 5 123 110.
0 14.
8 Moder
ate
>-
3
Sever
e
<-
2and
Chi
l
d3 M 5 ++ Yel
l
ow 102.
2 13.
5 (bi
l
ater
alpi
tt
ing
>-
3
oedema)
Chi
l
d4 F 4 115 91.
1 9.
3 <-
3 Sev
ere(
WFH)
<-
2and
Chi
l
d5 M 9mont
hs 125 69.
9 6.
7 Moder
ate
>-
3
Severe
Chi
l
d6 F 4 +++ Yel
l
ow 105.
2 18 >medi
an (bi
l
ateral
pit
ti
ng
oedema)
Severe
Chi
l
d7 F 8mont
hs + 105 68.
2 5.
0 <-
3 (marasmic
kwashior
kor)

Chi
l
d8 M 1 Red 84.
3 8.
9 =-
3z Sev
ere(
MUAC)

<-
2and
Chi
l
d9 F 2 114 97.
2 11 Sev
ere(
MUAC)
>-
3
Sever
e
Chi
ld 1.
5
M + Gr
een 89.
7 12.
9 =medi
an (bi
l
ater
alpi
tt
ing
10
oedema)

38
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e2Learni
ngObject
ive4:AssessandClassi
fyNut
ri
ti
onal
Vul
ner
abi
li
tyi
nAt-
RiskMothersandInf
antsUnder6MonthsofAge

TRAI
NER:Becomef
ami
l
iarwi
thHandout2.
6C-
MAMIToolVer
sion2.
0.

PARTI
CIPATORYLECTURE:ASSESSANDCLASSI
FYNUTRI
TIONVULNERABI
LITYOFAT-
RI
SKMOTHERSANDI NFANTSUNDER6MONTHSOFAGE( MOTHER-I
NFANTPAIR)
.Usi
ng
thetexti
nHandout2.
6C-MAMIToolVersi
on2.0asaref
erence,r
eviewthest
epsf
orassessi
ngi
nfant
s
under6monthsofageandt
hei
rmothers.Highl
i
ghtt
hefol
lowingareas:
 Tr
iaget
hei
nfantt
ocheckf
orgener
aldangersi
gnsorsi
gnsofsev
eredi
sease.Expl
aint
hatt
ri
agi
ng
shouldfol
lowtheassessmentprot
ocol
sfori
ntegr
atedmanagementofchil
dhoodil
lness(
IMCI)and
acti
onsshouldbetakenaccordi
ngtoIMCIort
henational
gui
del
ines.Formother
s:Checkforsev
ere
depressi
on,anxi
ety
,and/ordi
str
ess.
 Feedi
ngassessmentf
ort
hebr
east
fedi
nfant
—Ident
if
ybr
east
feedi
ngpr
obl
ems(
att
achment
,suckl
i
ng,
f
requencyofbreastf
eeds,andgivi
ngwaterand/orot
herl
iqui
ds/f
oods)andabnormali
ti
es.For
mothers:
Ident
ifyanybreastcondi
ti
onsandpercepti
onofnothavi
ngenoughbreastmil
k.
 Fort
henon-
breast
fedi
nfant
-mot
her
/car
egi
ver
—Det
ermi
net
hei
nfant
’sbi
rt
hhi
stor
y,whet
hert
he
motheri
sthepri
marycar
egiver
,whethert
hei
nfantwasev erbr
east
fed,
theinf
ant
’saccesst
obr
east
-
mi
lksubsti
tut
eandquant
ityconsumed,andt
hepossibi
l
ityofwetnursi
ng.
 Cl
ini
calassessmentoft
hef
oll
owi
ngi
nthei
nfant
—Anyj
aundi
ce,
sev
erepal
l
or/
anaemi
a,di
arr
hoea,
vomit
ing,dehydr
ati
on,
andchesti
n-drawingsi
gns;anypossi
bleunder
lyi
ngconditi
onssuchasHI
Vor
TB;pr
e-term orl
owbir
thwei
ght;t
hrush;andmulti
pledel
iv
ery.Formother
s:Assessforsev
ere
anaemia.
 Ant
hropomet
ri
cassessmentwi
l
linv
olv
eWFLandWFA,
rev
iewoft
hechi
l
dwei
ghtandgr
owt
hchar
t,
andassessmentofbi l
ater
al pit
ti
ngoedemaandanyot hercompl
icat
ions.Remindpar
ti
cipantsthat
thereisgrowingevi
denceont heuseofMUACi ninf
antsunder6mont hsofage.However,cutof
f
pointsareyettobeestabl
ished;therefor
eiti
simport
anttocoll
ectdataonMUACt ogenerate
evidenceinthisar
ea.Formot hers:AssessMUAC.
 Mat
ernalment
alheal
thassessment
—Checkf
orsi
gnsandsy
mpt
omsofdepr
essi
on,
anxi
ety
,and
di
str
ess.Addi
ti
onal
l
y,assesst
hef
oodsecur
it
ysi
tuat
ionandt
hemot
her
’seconomi
csi
tuat
ion.

Askthepar
ti
cipantst
ofor
m pai
rsandrev
iewtheHandout2.
6:C-MAMIToolVersi
on2.0—Assessment
forNut
ri
ti
onalVulner
abi
li
tyi
nAt-r
iskMother
sandInf
antsunder6Months.Answeranyquest
ionst
hat
ari
se.

39
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e2Wr
ap-
UpandModul
eEv
aluat
ion

Suggest
edMet
hod:Rev
iewt
hel
ear
ningobj
ect
ivesandcompl
etet
heev
aluat
ionf
orm.
 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.I
nthi
smodul
eyouhav
e:
1.Discussedcausesandconsequencesofunder nut
rit
ion,
aswel
lasundernut
ri
ti
ontermi
nol
ogy
2.I
dent i
fi
edthecli
nicalsi
gnsofacutemalnut
ri
tion
3.Measur ed,
cal
culatedandclassi
fi
edacutemal nut
ri
ti
on
4.Assessedandclassifi
ednutri
ti
onvul
nerabi
li
tyinat-r
iskmot
her
sandinfantsunder6mont
hsof
age

 Pl
acet
hef
oll
owi
ngquest
ionsi
nabasket
.Askv
olunt
eer
stopi
ckaquest
ionandansweri
t.Di
scuss
answer
s.
1. Whataresomebasi ccausesofunder nutr
it
ion?
2. Whatki
ndsofactionsar ebeingtakeninyourcommuni t
ytoaddr
essunder
nutri
ti
on?
3. Whati
sacutemal nutrit
ion?Howi sSAM defined?
4. Howdoy oumeasur ebilater
alpit
ti
ngoedema?
5. Whatdoestheredcol ourmeanonaMUACt ape?
6. Whati
snutri
ti
onv ulnerabil
it
y?
7. Howdoweassessnut r
iti
onalvul
nerabi
li
tyi
nat -r
iskmot
her
sandinf
antsunder6monthsofage?

 Letpar
ti
cipant
sknowt
hatt
heywi
l
lhav
eanoppor
tuni
tyt
oassessf
orbi
l
ater
alpi
tt
ingoedema,
use
MUACt
apes,
measur
eWFH/
WFL,
andassessf
eedi
ngofi
nfant
sunder6mont
hsdur
ingf
iel
dvi
sit
s.

 Askpar
ti
cipant
stocompl
etet
heev
aluat
ionf
orm.

40
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

MODULETHREE:COMMUNI
TYOUTREACH

Modul
eOv
erv
iew
Thi
smodul eexpl
ains¬whycommuni tyout
reachi
sanindi
spensablecomponentofcommunity-
based
managementofacut emalnutr
it
ion(
CMAM) .Themoduleal
soexplainswhycommunityout
reachshould
beapproachedsystemat
icall
yandwelli
nadvanceofact
ualCMAM st ar
t-
up.

Communi tyoutr
eachi
snotanewconceptwi t
hintheheal
thsect
or.I
tisi
mport
anttoemphasi
set
hatal
l
eff
ortsshouldbemadetoassesstheexi
sti
nghealthoutr
eachsyst
emsandactorsandt
hatcommuni
ty
outr
eachforCMAM shouldbui
lduponandfurtherst
rengt
hentheseexi
sti
ngsy
stems.

Thesuggestedact i
vi
ti
esandmet hodsexplainwhatcommunityoutreachi
s,addresswhatt hebarr
ier
sare
toaccessi
ngCMAM- typeservices,andwhatprepar
ationsar
eneededt oef
fecti
velyreachcommuni ti
es
withmalnouri
shedchildren.Themodul erevi
ewstheelementsinandcomponent sofmobi l
isi
ng
communi t
youtreachwi ththegoalofmaxi misi
ngCMAM services,
empower i
ngcommuni t
ies,mini
mising
thenumberofdef ault
ers,andulti
mat el
yreduci
ngdeathsduetoacut emal
nutri
ti
on.

Themoduleprovi
desparti
cipantswi
thi
nfor
mat i
on,tools,andski
ll
stoplantheirownCMAM community
out
reachacti
vi
ti
esandanoppor t
uni
tyt
opracti
cetheseski l
lsi
nthefi
eld.Duri
ngt hef
iel
dvi
sit
,
par
ti
cipant
swill
gothroughallthest
epsneededtodev elopacommuni tyoutr
eachstrat
egyandanact
ion
pl
an.

Tostrengtheninfantandy oungchildfeeding(I
YCF)pr acti
cesi
nt argetcommuni t
iesandhouseholds,t
his
tr
aini
ngmodul eshouldbecompl ement edwi t
ht hetraini
ngcour seonIntegrat
ionofIYCFsuppor ti
nto
CMAM, avai
lableathttps:
//www. ennonli
ne.net/i
ntegrationi
ycf
intocmam.Thi stwo-daytr
aini
nghelpsto
buil
dtheknowl edgeandski ll
sofheal t
hcar eprovi
der sandcommuni tyhealt
hwor ker
sinvolv
edwi t
h
CMAM ser vicedeli
veryinthefol
lowingar eas:
 I denti
fyi
nggapsbet weenactual andrecommendedI YCFpracticesintheCMAM communi t
ies
 Di
scussi
ngt
her
ecommendedI
YCFpr
act
iceswi
thmot
her
sandcar
egi
ver
s
 Suppor
ti
ngmot
her
sandcar
egi
ver
stoopt
imal
l
yfeedt
hei
rinf
ant
sandy
oungchi
l
drenl
esst
han2
y
ear
sofage

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises
1.Expl
aint
heImport
anceof 30mi
nut
es Handout3.1Pr
inci
plesofCommuni
tyOut
reachi
nthe
CommunityOut
reacht
o ContextofCMAM
CMAM Outcomes
Exer
cise3.
1Bar
ri
erst
oAccessRol
e-Pl
ay
Exer
cise3.2Over
comi
ngObst
acl
est
oCommuni
ty
Part
ici
pat
ioninCMAM
1.I
dent
if
yKeyEl
ementsofa 45mi
nut
es Handout3.
2Communi
tyAssessment
s
Communi
tyAssessment
Handout3.
3Communi
tyAssessmentSt
epsand
Methods
2.I
denti
fyKeyStepsi
n 45mi
nut
es Handout3.4Communi
tyOut
reach:
From Assessment
Devel
opi
ngaCMAM t
oStrategy
Out
reachStr
ategy
Handout3.
5Communi
tyOut
reachSt
rat
egy
Handout3.6Example:
Select
ionofCandi
dat
esf
or
House-
to-HouseCase-
Findi
ng

41
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Exer
cise3.
3Compar
isonofCase-
Findi
ngModel
s
Exer
cise3.
4Worksheet
:Sel
ect
ionofCandi
dat
esf
or
Communi t
yOut
reach
3.DiscussConsider
ati
ons 30mi
nut
es Handout3.
7Devel
opi
ngSi
mpl
eandSt
andar
dised
forDevel
opingandUsing CMAM Messages
CMAM Messages
Handout3.
8Ref
erence:
Handbi
l
lMessages
Handout3.
9Ref
erence:
Visual
Communi
cat
ionTool
s
4.DiscussPr epar
ati
onsf or 45mi
nut
es Handout3.10KeyAct
ionsi
nCommuni
tyMobi
l
isat
ion
Communi tyMobi l
isat
ion andTrai
ning
andTr ai
ning
Handout3.
11Pl
anni
ngandImplement
ingaMass
Tr
aini
ngCampai
gnforMother
sandFamilyMember
s
Wrap-
UpandModul
e 15mi
nut
es Handout3.
12El
ement sandSequenci
ngofCMAM
Ev
aluat
ion CommunityOut
reach
Fi
eldVisi
tforCommuni
ty 1day I
nter
viewgui
dedev
elopedandpr
ovi
dedbyt
rai
ner
Outr
each
Handout3.4Communi
tyOut
reach:
From Assessment
t
oStrategy
Handout3.
8Ref
erence:
Handbi
l
lMessages
Handout3.13Team Checkl
i
stf
orCommuni
tyOut
reach
Fi
eldVisi
t

Modul
eDurat
ion:Thr
eeandhal
fhour
s(3½hour
s)i
ncl
assr
oom f
oll
owedbyone-
day
si
tevi
sit
Not
e:Dependi
ngont heneedsoft hei
raudi
ence(s),t
rai
ner
smaychooset
oski
porspendmor
eorl
ess
t
imeoncertai
nlear
ningobject
ivesandacti
vit
ies.Themoduledur
ati
oni
sanest
imat
eofthet
imei
ttakes
t
ocompleteal
lthelear
ningobject
ivesandactiv
iti
es.

Mat
eri
als
 Fl
i
pchar
t,mar
ker
s
 Car
dsf
orExer
cise3.
1Bar
rier
stoAccessRol
e-Pl
ay

Adv
ancePr
epar
ati
on
 Room set
up,
mat
eri
alsnot
edabov
e,f
li
pchar
ts,
mar
ker
s,maski
ngt
ape
 Theeveni
ngbef
oret
het
rai
ningorear
li
er,
sel
ectsi
xpl
ayer
stot
akepar
tinar
ole-
playanddi
str
ibut
e
r
ole-
playcar
dst
othesel
ect
edpar
ti
ci
pant
s
 Revi
ewr
elevantr
efer
encer
esour
cesandf
urt
herr
eadi
ngr
esour
cesl
ist
edbel
ow.

Ref
erenceResour
ces
1. All
iancef orInt
ernati
onalMedicalAct
ion(
ALIMA).2016.Mother-
MUAC:Teachi
ngMot
her
stoScr
een
forMal nutr
iti
on—Guideli
nesforTrai
ningMother
s.Avail
abl
eat:htt
ps:
//www.al
i
ma-
ngo.org/uploads/b5cb311474e9a36f
414a69bd64d39596.
pdf
2. Dessi
e, .2015.Communi
M.etal t
yEngagementf
orCMAM.Cover
ageMoni
tor
ingNetwor k.Av
ail
abl
e
at
:htt
p:/
/www.coverage-
moni
tor
ing.
org/
wp-
cont
ent/
upl
oads/
2015/
07/
Technical
-br
ief
-Community
-

42
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Engagement
-f
or-
CMAM-
20151.
pdf
.
3. Ki
ttl
e,B.2013.APract
icalGui
detoConductingaBarr
ierAnal
ysi
s.NewYor
k,NY:
Hel
enKel
l
er
I
nter
national
.Avai
l
ableat:ht
tps:
//pdf
.usai
d.gov
/pdf
_docs/PA00JMZW.
pdf.
4. EmergencyNutr
it
ionNetwor
k( ENN).2009.I
ntegr
ati
onofI
YCFSuppor
tint
oCMAM.Avai
l
abl
eat
:
ht
tps:
//www.ennonli
ne.
net
/int
egrat
ioniy
cfi
ntocmam.
5. Vali
dInter
nat i
onal.2006.Communi t
y-basedTherapeut
icCare(CTC)AFiel
dManual.Oxfor
d:Valid
I
nternat
ional.Avail
ableat:ht
tps:
//www. f
antapr
oject
.or
g/si
tes/
defaul
t/f
il
es/r
esour
ces/CTC-Fi
eld-
Manual-
Oct 2006-508.pdf
.
6. Cathol
icReli
efServices(CRS).1999.RapidRur alAppr
aisalandParti
cipat
oryRuralAppraisal
:A
ManualforCRSFi el
dWor ker
sandPar tners.Avail
abl
eat:
htt
ps:/
/www. cr
s.org/si
tes/defaul
t/f
il
es/tools-
resear
ch/rapi
d-r
ural
-apprai
sal
-and-par
ti
cipator
y-r
ural
-
apprai
sal
.pdf.

Fur
therReadi
ngResour
ces
1. Al
varezMor an,J.
L.etal.2018.“Qual
it
yofCar eforTreatmentofUncompl
icatedSever
eAcut
e
Malnutr
iti
onDeliv
eredbyCommuni tyHealthWorkersinaRuralAreaofMali
.”Mater
nal&Chi
ld
Nutri
ti
on.Jan.:
14(1).doi
:10.1111/mcn.12449.Avai
lableat
:
ht
tps://
www. ncbi.
nlm.ni
h.gov/pubmed/28378463.
2. Rogers,E.etal
.2018.“Cost-
Effectiv
enessoftheTreatmentofUncompl i
catedSever
eAcute
Malnutri
ti
onbyCommuni t
yHeal thWorkersCompar edtoTr eat
mentPr ovi
dedatanOut pat
ientFaci
l
ity
i
nRur alMali
.”HumanResour cesf orHeal
th.16:
12.Av ai
labl
eat: ht
tps:
//human-r
esources-
heal
th.bi
omedcentral
.com/arti
cles/10.
1186/s12960-018-0273-0.
3. Fr
anck,G.B.etal
.“MothersScreeni ngf orMalnutr
iti
onbyMi d-UpperArm Ci
rcumferenceIsNon-
I
nfer
iortoCommuni t
yHeal t
hWor ker s:Result
sfrom aLarge-Scal
ePr agmat
icTri
al i
nRuralNiger.
”
Ar
chivesofPubli
cHealth:TheOf ficialJournaloftheBel
gianPubl i
cHealthAssociati
on.2016.74:
38.
Avai
l
ableat:htt
ps:
//doi.
org/10.1186/ s13690-
016-0149-
5.
4. Bl
ackwell
,N.etal .2015.“Mother
sUnderstandandCanDoI t(
Mid-UpperAr m Cir
cumference[MUAC])
:
ACompar isonofMot hersandCommuni tyHealt
hWor ker
sDeter
mi ni
ngMi d-UpperArm
Ci
rcumferencei n103Childr
enAgedf r
om 6Mont hsto5Year ”Ar
s. chivesofPubl i
cHealth.Avai
l
abl
e
at
:htt
ps:/
/ archpubli
cheal
th.
biomedcentr
al.
com/art
icl
es/10.
1186/s13690-015-0074-
z.
5. Puett,C.
;HauensteinSwan, S.
;andGuerr
ero,S.2013.AccessforAll,Vol
ume2:WhatFact ors
I
nfluenceAccesstoCommuni ty-
BasedTreat
mentofSever eAcuteMalnutri
ti
on?(Coverage
Moni t
ori
ngNetwor k,London,November2013).Avai
lableat:
htt
ps://www.act
ionagainsthunger
.or
g/si
tes/
default
/fi
les/publ
icati
ons/Access_
For_All
_Volume_
2_11.
2013.pdf.
6. Forsy
the, V.etal.2010.Communi tyOut r
eachforCommuni t
y-BasedManagementofAcute
Malnutri
tioninSudan:ARevi ewofExper i
encesandtheDevelopmentofaStrat
egy.Washingt
on,
DC:
FHI360: FoodandNut ri
ti
onTechnicalAssist
anceProj
ect(FANTA) .Avai
l
abl
eat:
htt
ps:/
/ www. fantapr
oject.
org/
sit
es/default
/fi
l
es/r
esources/
Sudan_ Communit
y_Out
reach_CMAM_De
c2010.pdf.

43
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module3Lear
ningObj
ect
ive1:Expl
aint
heI
mpor
tanceofCommuni
ty
Out
reacht
oCMAM Outcomes

TRAI
NER:
Becomef
ami
l
iarwi
thHandout3.
1Pr
inci
plesofCommuni
tyOut
reachi
ntheCont
extof
CMAM,Exerci
se3.1Barri
erst
oAccessRol
e-Pl
ay,
andExer
cise3.
2Ov
ercomi
ngObst
acl
est
o
Communit
yParti
cipat
ioninCMAM.

BUZZGROUPSANDPARTICIPATORYLECTURE:WHATI SCOMMUNI TYOUTREACHI NTHE

CONTEXTOFCMAM?Ifpar
ti
cipant
stookpar
tinModul
eOne,
askt
hem t
ofor
m gr
oupsof2-
3and
quickl ydescribewhatt heyknowaboutcommuni tyout
reachi nthecont extofCMAM.Askaf ew
volunt eerstobr i
efl
yr espondandf i
lli
nthegapsi nthediscussionwi t
hHandout3. 1Pr inci
plesof
Communi tyOut r
eachi nt heCont extofCMAM, Secti
ons1- 3.Makepar ticularnoteoft hesekeyact i
vi
ti
es
ofcommuni tyoutreachi nt hecont extofCMAM: 1)communi tymobi li
sation, 2)activecase-fi
ndingf
or
earlydet ecti
onandr efer r
al, 3)homev i
sitsforfoll
ow-upofhi gh-ri
skcases[ i.e.,t
hosenott hrivi
ngor
respondi ng,absent ees, anddef ault
ers],
and4)l inkingwithothercommuni t
yser vices,progr
ammes, and
i
nitiatives.Explai
nt hatt hist rainingmodul elooks
athowt omostef fectivelyest ablishthesef our StepOne: Communi tyAssessment
char acteri
sti
cst hroughaf our -
st epprocess.
StepTwo: Formul ati
onofCommuni ty
Wr i
tet hef ol
lowingf ourst epsonaf li
pchar tso O utr
ea chS t
rat
e gy
thatt heycanber eferredt ot hr oughoutt he StepThr ee:Dev elopmentofMessagesand
modul e. Mat eri
als

GROUPDI
SCUSSION:THEPOWEROF St
epFour:
Communi
tyMobi
l
isat
ionand
Tr
aini
ng
COMMUNITYOUTREACH.Dr
awFi
gur
e3.
1
(bel
ow)onthefl
ipchar
tandrevi
ewt he
componentsofCMAM.Askpar t
ici
pantswhy
communityout
reachsur
roundstheothercomponent
s.
Fi
llingapsinthediscussion, not
ingthatcommuni t yout reachfeedsintoandi snecessar yf ortheother
component stofuncti
onwel l.Experi
encewi t
hCMAM hasdemonst ratedrepeat edlythatprovisi
onof
outpati
entcarewithoutcommuni tyoutr
eachwi l
l r
ar elyresulti
nhighser vi
ceorpr ogrammeser vi
ce
accessandupt ake(orservi
cecov er
age).Therefore, case-fi
ndingandr ef
erral atthecommuni tyl
evelare
necessarytoensurethatcov eragereachesaccept abl elevels(i
.e.
,theSpher est andards:70%i nurban
andcampset t
ingsand>50%i nr
uralset
tings)andt hatacut emal nutr
iti
oni sidentifi
edandpr esented
earl
y,whichleadtogoodcl inicalout
comesanddecr easedst r
ainoninpatientf acil
i
ties.

44
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Fi
gur
e1.Cor
eComponent
sofCMAM

Community
Out
reach
Outpati
entcare
f
ormanagement
ofSAM
WITHOUT
I
npat
ient medical Othernutri
tionandheal th
car
ef or complicati
ons int
erventions,food
mgmtof
SAM WI TH securi
ty,socialprotecti
on
medical andWASH, t
opr event
undernutrit
ion
Management
of
MAM

BRAI
NSTORM ANDGROUPDI
SCUSSI
ON:OBSTACLESTOPARTI
CIPATI
ONI
NCMAM.Ask
parti
cipant
stothi
nkofobstacl
esfacedinacommuni
tyt
hatmi
ghti
mpedepar
ti
cipat
ioni
nCMAM.Wr
it
e
responsesonthefl
ipchar
tandf i
l
lingaps:
 Poorawar
enessofacut
emal
nut
ri
ti
on
 Poorawar
enessofCMAM ser
vicewi
thi
nthecommuni
tybei
ngser
ved
 Communi
tymobi
li
sat
ionhasbeenov
erl
ybr
oad,
resul
ti
ngi
ntoomanyi
nel
i
gibl
ecasesar
ri
vi
ngand
bei
ngr
eject
ed
 Ref
err
alandadmi
ssi
oncr
it
eri
aar
enotal
igned(
e.g.
,mi
d-upperar
m ci
rcumf
erence[
MUAC]i
sused
f
orcommunityscreeni
ngsbutf
inal
admissi
onatsi
teisbasedonwei
ght-
for
-hei
ght[WFH]
),l
eadi
ngt
o
r
eject
ionofr
efer
redindi
vi
dual
satthesi
teandhurt
ingtheprogr
amme’
sreputat
ion
 Peopl
emi
ghtbeawar
ethatt
her
eisanewnut
ri
ti
onser
vice,
butl
ocalmedi
co-
cul
tur
alt
radi
ti
onsdo
notconnectadvancedwasti
ngorswel
li
ngwi
thunder
nut
ri
ti
on,
asawar
enessoft
radi
ti
onal
medici
nesmi ghtbestr
onger
 Ther
emi
ghtbest
igmai
nthecommuni
tyt
hati
sassoci
atedwi
thacut
emal
nut
ri
ti
on
 Thei
nfl
uenceofpeer
sorf
ami
lymember
smi
ghtser
veasadi
sincent
ive
 Communi
tymobi
l
isat
ionmi
ghthav
eov
erl
ookedi
mpor
tantcommuni
tygat
ekeeper
soropi
nion-
maker
s
 Ot
herser
vicesatt
hepr
imar
yheal
thcar
e(PHC)f
aci
li
tyar
epoor
lyr
egar
dedbyt
hecommuni
ty(
e.g.
,
becausemedici
nesar
enotavai
labl
e,becausehoursar
ei r
regul
ar,
becausestaf
fareoverwor
ked,
becausetr
eat
mentrequi
resl
ongwaits),andasaresul
t,whenCMAM isestabli
shedatthePHC
faci
li
ty,
iti
svi
ewednegat
ivel
ybyassociati
on

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eMal
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,2018Ver
sion

 Thel
ocat
ionofout
pat
ientcar
esi
tesmi
ghtr
equi
reanunr
easonabl
eamountoft
rav
elt
imef
ort
arget
communi
ti
esormaket
hesi
tesi
naccessi
bleduet
obar
ri
ersl
i
keseasonal
floodi
ng
 Par
ti
cipat
ioni
sint
err
upt
edbyseasonal
labourpat
ter
nsbey
ondt
hecont
rol
oft
heser
vice,
suchas
temporar
yrel
ocat
ionoff
ami
l
iesf
rom homest
omor
eremot
efar
msdur
ingt
heweedi
ngorhar
vest
ing
seasons

EXERCI
SE3.
1BARRI
ERSTOACCESSROLE-
PLAY.Conf
ir
mthatt
hepl
ayer
shav
ereadt
her
ole-
play
cards( copybel
ow)dist
ri
butedinadv
ance(seeAdvancePreparat
ion)
.Explainthatt
herol
e-pl
ayshould
unfoldasaser i
esofscenesbetweenthemotherandtheotherpl
ayers.Spendf i
veminut
eswithal
lthe
playerstoanswerquesti
onstheymayhaveandsuggestway stomaket heirperf
ormancemorereal
ist
ic.

Theaudience(
thosenotacti
ngouttherol
e-pl
ay)shoul
dnotbepr esentwhenyouexpl
aint
herolestothe
pl
ayers.Theymay,however
,beaskedtoparti
ci
pateinthefi
nalscene,wheret
heymaycoll
ect
ivelyactas
acrowdofcuriousonl
ookersandcare-
seeker
sattheoutpati
entcaresit
e.

Af
tert
her
ole-
play
,hel
pthepar
ti
ci
pant
stol
i
stt
heobst
acl
esandanal
yset
hescenar
io:
 Whi
choft
hesebar
ri
ersar
eli
kel
ytobeani
ssuei
nthei
rowncommuni
ty?
 Whatot
herf
act
orshi
nderpar
ti
ci
pat
ion?
 Whatmeasur
eswoul
dhel
pel
imi
nat
ethesebar
ri
ers?

Communi tyMot her:Youar eamot heroff ivechi l

dren,l
ivi
nginacommuni t
ythatisat wo-hourwal kfrom
thenear estgov ernmentheal thpost .Your2- y ear -
olddaughterhasbeensi cksincehery oungersi st
er’
s
bir
thsi xmont hsago.Youhav et r
iedmanyl ocal remediesbutnothingseemst omakeherbet ter.Sheis
nowv er ythinandhasal mostnoener gy.Youar everyworri
ed.Youhav eheardthatt herearepeopl egoing
houset ohouset omeasur echildren’sarms, buty ouar enotsurewhy .Youar escept icalofthese
volunteersbecausesomeoft hesamepeopl ewer eappointedas“heal t
hmessenger s”lastyearandhav e
areput ati
onf orharassingpeopl eaboutbui ldingl atri
nes.Thereareev enrumour sthatsomef amili
esina
nearbycommuni tywer efi
nedf ornotbui l
dingl atr
ines,andyourhusband( whoi sout )forbadey ouf r
om
all
owingt hemessenger sintothef ami l
ycompound.Whenamessengerar ri
vesandaskst oseey our
chil
dren, youhav emi xedfeelings: Youwantt oobeyy ourhusband,buty oudonotwi sht oangert he
communi tychairmanbyr efusinghi semi ssar ies.Whent hemessengerassur esyout hats/hei snothere
tolookaty ourlatri
ne,your el
uctant l
yagr eet oadmi thim/her.Atfi
rst
, youarenotpl anningt oshow
him/hery oursickchi ld.

Nut ri
tionVol unteer( mal eorf emal e):Youar et rainedt oper form MUACmeasur ement sonchi ldr
enby
goinghouset ohouse.Yourwor kar eacov ersf ourcommuni ties,includingy ourown.Youhav elimit
ed
formal school ing,buty ouar ecl ev erandar er espect edbypeopl einy ourcommuni tywhoknowy ou, even
thoughy ouar ey oung.Whi l
ey ouar ef airl
yconf identofy ourabi l
it
yt omeasur eMUAC, y ouhav enoty et
attendedanout patientcar edaybecauseoft hedi st ancet ot heheal thpost ,
soy ouar euncer tainabout
whathappenst othechi ldreny our eferthere.I nt hisencount er,youar est arti
ngatadi sadv ant age:sev eral
mont hsago, y
ouaskedmot hers/ car egiversf rom y ourcommuni t
iest ogat herthei rchildreni nonespot
forv acci nation,butt hev accinesdi dnotar ri
veont ime, leavingt hemot her s/caregi ver
swai ting.Youhad
tomakeasecondappoi ntment ,andsomemot her s/caregiv ersar est i
l
lr esentful abouthav ingwast ed
theirmor ning.Thi smot herseemsal ittl
eanxi ous, buty ousenseshemi ghtbeper suadedt ol etyou
exami neherchi ldren.Af t
ershef inal l
yal l
owsy oui ntohercompound, youcannotansweral l herquest i
ons.
Yout heref oretrytoemphasi set woi mpor tantpoi nt stoherandherhusband( whohasr eturned) :1)y ou
aret ryingt osav et helivesoft hesi ckestchi ldren, and2)t her ei sanewt reatmentf orthemost
mal nour ishedcasest hatcanbegi venathomesot hatmot her s/caregiver snol ongerhav et ospend
weeksi nthet ownhospi t
al wit
ht hei rchi l
dren.
FirstNei ghbour( i
ncommuni t
y):Youar espendi ngt hemor ningi nthecompoundofy ourf ri
end
(communi t
ymot her)whenshei sv isi
t edbyt heheal thmessenger .Your ecognisehi m/ herast heper son
whowast edy ourt i
meoni mmuni sat iondayandar eopenl yant agoni sti
ct ohi m/ her.Whyshoul dyour
fri
endwast ehert i
mewi thhi s/hernewser v i
ces?Andar en’thi scol l
eaguescausi ngpeopl et obef i
ned

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eMal
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,2018Ver
sion

overl
atri
nes?Wheny ourfr
iendfi
nall
yshowshersi ckchil
dtohim/ her
,yourecognisethi
sasapr obl
em
creat
ednotbyunder nutri
ti
onbutby“ spoil
ed”breastmil
k.Youcounselyourfri
endt ogetrootsfrom a
communi tyhealer
,boilt
hem andbathet hechil
dwi t
hthewater.However,yourf
riendeventuall
ydecides
toacceptrefer
raltooutpati
entcar
e,soy outrytohelpbywatchingherotherchi
ldrenfort
hedayand
cooki
ngf orherhusband.

Husband:Youcomehomet ofindy ourwifetalki

ngwi ththehealthmessengerandar einiti
all
yannoy ed
thatshehasl ethi m/herint othecompound.Howev er,wheni tbecomescl earhe/shei snott r
y i
ngt omake
youbui ldalat
rine,your elax.Youhav etochoosebet weent hetradit
ionalremedysuggest edbyy our
neighbourandt hemessenger ’sadv i
cetoletyourwi fegot ot hehealthpostwher ey ourchildwi l
lrecei
vea
newt reatmentt hatcanbebr oughthome.Youwoul dnotmi ndy ourwi f
e’sgoingtot heheal t
hpost ,buti
n
thepast ,youhav eseent hatchi ldreninthiscondi t
ionhav ebeenmov edfrom theheal t
hpostt ot he
distr
icthospit
al withtheirmot her s/caregi
verswher etheyspentweeksundercar e.Youl ovey our
daught erandwanthert or ecov er,butyouareal soaf raidofhowt hiswoul daffectyourf amily.Howwoul d
yourf amil
yeat?Fur thermor e,itist heweedingseason, andt hetimey ourwifespendsatt heheal th
post—awayf r
om home—wi l
lreducey ourharvest.Youwantassur ancest hatshewi l
l beablet oreturn
from thehealthpostpr ompt l
y.

SecondNei ghbour(returningont her oad) :Youar eony ourwaybackf rom t heout pati
entcar esiteand
arev eryannoyed.Yesterdayy ouwer ecalledt oat t
endascr eeninginy ourcommuni ty
.Youwai tedal l
mor ninginthesunwhi lechi ldrenwer emeasur ed.Yourchi ldwassel ectedt oat t
endout pati
entcar e.But
today ,af
terwalkingoveranhourt ot heheal thpost ,theout pati
entcarest affr e-measuredy ourchi l
dand
refusedt oadmi thi
m.Youandsev eral ot
hermot hers/ caregiverswaitedt ospeakt otheheadcl i
nician
becausey outhoughtthemeasur erswer echeat i
ngy ou.Af terall
,youwer er efer r
edfrom thecommuni ty
withanot e!Howev er,thepr ogr ammeseemedt obet akingal lday,t
hest affwer eoverworkedandshor t
-
temper ed,andt hecrowdingwasst ressful.Ther efore, youleftwi t
houtpr esent ingyourgr i
evance.Why ,
youwonder ,arepeoplefor cedt owast etheirti
mel i
ket hisduringthehar vest ?Asy ouwal khome, you
meetawomanf rom anei ghbour i
ngcommuni ty(communi tymot her)whosay sshewasr eferredtot he
samepr ogramme.Yout ellhery ourst oryandbi t
terl
yadv i
sehernott owast ehert i
me.

OutpatientCar eNurse:Youhav ebeenbusyal lmorningexami ningchi l

dr enaspar toft hesenewser v i
ces.
Youar egladthereisfinall
yanef fectiv
et reat
mentf ormal nour i
shedchi ldren, butt hingscannotgoonas
theyareinthesamedi sorgani
sedf ashion.Peopleareever ywher eint hecl i
nic, askingf orfoodand
assist
ance.Thi sisnotagener alstore!Youar eaclinici
an, butincreasi ngl yy ouar ebei ngaskedt o
managear el
iefoperation.Thest r
esshasbeenmaki ngy oui rri
table,especi all
ywi thmot hers/caregivers
whohav ebeendel i
beratel
yreturningtot hescreeni
ngqueueaf terbei ngr eject edj ustmi nutesear l
ier.Now
herecomesamot her(communi t
ymot her)try
ingtogetint otheout patientcar elinewi t
houtev engoi ngto
thescreeningqueuef ir
st!Thei r
ri
tationist oomuchf oryou.Youangr ilyt ellhert ogoaway .Nowt he
crowdisget t
inginvolved.Asy out urnyourat t
enti
onbackt ot hechi l
di nf rontofy ou, thelastthingy ou
seeisthemot hersurr
oundedbypeopl eloudlyoff
eringcont radictoryadv ice.

WORKI
NGGROUPS:OVERCOMI
NGOBSTACLESTHROUGHCOMMUNI
TYOUTREACH.
Div
idepart
ici
pantsint
owor kinggroupsandr ef
ert hem toExercise3.2Over
comi ngObstacl
est o
Communi t
yPartici
pati
oninCMAM.Poi ntoutthatitcontai
nsasummar yofsomeoft heobstacl
esjust
di
scussed.Askthewor ki
nggr oupstothinkaboutwhoshoul dbeinvolv
edinplanni
ngforcommuni t
y
outr
eachtobestovercomet heseobstaclesandwhatot herstepsmightbeneeded.Di
scuss.

Di
rectpar
ti
cipant
stoHandout3.
1forf
utur
ereadi
ngandr
efer
ence.

47
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aini
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orCommuni
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eMal
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on(
CMAM)
,2018Ver
sion

Module3 Lear
ningObj
ect
ive2:I
dent
if
yKeyEl
ement
sofaCommuni
ty
Assessment

TRAI
NER:
Becomef
ami
l
iarwi
thHandout3.
2
Communi
tyAssessmentsandHandout3.3 >>St
epOne:Communi
tyAssessment
Communi
tyAssessmentStepsandMethods. St
epTwo: Formul
ati
onofCommuni
ty
Out
reachStrat
egy
GROUPDI
SCUSSION:THEROLEOFTHE
St
epThree:
Dev
elopmentofMessagesand
COMMUNITYASSESSMENT.Not
efor
Mater
ial
s
part
ici
pantsthatt
hisisthefir
ststepinpreparati
on
forCMAM communi t
youtreach.I
npl enar
y,ask St
epFour:
Communi
tyMobi
l
isat
ionand
part
ici
pantswhyacommuni tyassessmenti s Tr
aini
ng
i
mpor t
ant,whatkindofinfor
mat i
oncanbegat her
ed,
andhowi tcanbeused.Filli
ngapsi nthediscussi
on
asnecessary,not
ingthat:
 Theassessmenti
sanoppor
tuni
tyt
oconsi
dercommuni
typar
ti
cipat
ionandser
viceaccessand
upt
akei
nCMAM i
nasy
stemat
icwayandi
naspeci
fi
cimpl
ement
ati
oncont
ext
.
 Tobestover
comebar
ri
ersandr
einf
orceexi
sti
ngboost
erst
opar
ti
cipat
ion,
thecommuni
ty
assessmentcanshedli
ghtonhowthecommuni
tyi
sor
gani
sed,howunder
nutri
ti
onisvi
ewed,how
thenewservi
ceisli
kel
ytoberecei
ved,
andhowt
hecommunit
ycanbestsupportt
heoutr
each
component.
 Thecommuni
tyassessmentshoul
dbeusedasanoppor
tuni
tyt
oident
if
yandacknowl
edget
he
l
imi
tsofst
affknowl
edgeoft
hel
ocalcommuni
ty.

PARTI
CIPATORYLECTURE:WHATCOMMUNI
TYASSESSMENTSCONSI
STOF.Revi
ewt
he
cont
entonHandout3.2CommunityAssessments,
Secti
onBmakingnoteofthet
wokeyquesti
onsthat
communit
yassessmentsmustanswer:
1)whatisli
kel
ytoaf
fectdemandforCMAM l
ocal
l
y,and2)how
cancommunit
youtreachbeor
ganised(
supply
)tomeetandi
ncreasethi
sdemandmosteff
ecti
vel
y?

WORKI
NGGROUPS:METHODSOFCOMMUNI
TYASSESSMENT.Di
vi
depar
ti
cipant
sint
owor
king
groupsoff ourorfi
ve.Referthem t
oHandout3.2Sect i
onB.Askthem t
othinkofthei
rowncommuni ti
es
andthemostr el
evantfactor
saffecti
ngdemandthere.Remindi
ngthem t
hattheassessmentisan
opportunit
ytoidenti
fyandacknowl edgethel
i
mitsofstaffknowl
edgeofthelocalcommunit
y,askthem
whoi nthecommuni tytheyshouldapproachtol
earnmor eaboutf
actor
saffecti
ngdemand.Haveone
groupbriefl
yreportbackinplenary.
Askthesamegr oupstothi
nkthr
ought hesupplysi
deandtryt
oanswert
hequest
ionsinHandout3.
2,
Secti
onC.Aswi ththedemandside,askthem whointhecommunit
ymustbei
nvolvedtohel
panswer
thesequest
ions.Haveanot
hergroupbrief
lyr
eportbackinpl
enar
y.
Referpar
ti
cipantstoHandout3.
3Communi t
yAssessmentStepsandMethods.Rev
iewinplenar
yand
di
scussanydi f
ferencesbet
weenthei
rresponsest
otheassessmentst
epsandthoseinv
olv
edont he
handout.

PARTI
CIPATORYLECTURE:METHODSOFCOMMUNI
TYASSESSMENT.Ref
err
ingbackt
o
Handout3. 3,
notef
orpar t
ici
pant
sthat:
 Assessmentmet hodsv ar
ybutarequal
it
ativeandinthespir
itofRapi
dRuralAppr
aisal(
RRA)or
Parti
cipator
yRur
al Apprai
sal(
PRA).TheRRAandPRAaappr oachesshouldai
mt oincorporat
ethe
knowledgeandopinionsofthecommunitymember s,i
ncl
udi
ngmot her
sandcaregiver
s, i
nthe
planni
ngandmanagementofCMAM ser vicesincl
udingcommuni t
youtr
each.

48
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orCommuni
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eMal
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CMAM)
,2018Ver
sion

 Accesst
orel
evantsecondar
yinf
ormat
ionshoul
dbeassessedandi
nfor
mat
ionr
evi
ewed.
 Theobject
ivei
stoqui
ckl
ygener
ateusabl
einf
ormati
on,
nott
oproduceal
engthyr
epor
t.
 ThestepsandmethodsinHandout3.3arearecommendedmini
mum thatcanbebui
ltuponover
t
imeori
faddi
ti
onalr
esour
cesar
eavai
labl
e.

Highl
ightt
heimport
anceofgat
her
ingi
nfor
mati
ononbreastf
eedingpract
icestosuppor
tthemanagement
ofat-
riskmot
hersandinf
ant
sunder6monthswhoar
enut r
it
ional
lyvul
nerabl
e.

49
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module3 Learni
ngObj
ect
ive3:I
dent
if
yKeySt
epsi
nDev
elopi
ngaCMAM
Out
reachStr
ategy

TRAI
NER:
Becomef
ami
l
iarwi
thHandout3.
4
Communi tyOut
reach:From AssessmenttoStr
ategy
, St
epOne:
Communi
tyAssessment
Handout3.5Communi tyOutreachStrat
egy,
>>St
epTwo:Formul
ati
onofCommuni
ty
Handout3.6Example:Selecti
ngCandidatesf
or
Outr
eachSt
rat
egy
House-
to-HouseCase-Findi
ng,Exerci
se3.3
ComparisonofCase-Fi
ndingModel s,
andExerci
se St
epThree:
Dev
elopmentofMessagesand
3.
4Wor ksheet:
Selecti
ngCandi dat
esfor Mater
ial
s
Communi tyOut
reach.
St
epFour:
Communi
tyMobi
l
isat
ionand
Tr
aini
ng
BRAINSTORM:I
NSIGHTSFROM COMMUNI TY
ASSESSMENTS.Not
eforpar
ti
ci
pant
sthat
formul ationofanout reachstrat
egyisthesecond
stepi npr eparat
ionforCMAM communi tyoutr
each.Askpartici
pantstosummar izesomeoftheinsight
s
obt ainedf r
om acommuni t
yassessmentthatcouldhelpt
of ormthebasi sofacommuni t
youtreach
strategy .Answer smayi ncl
ude:
 Theobj ecti
vesandnat ureoftheCMAM service:shor
tterm orl
ongt erm;nongover
nmental
organisati
on( NGO)-assi
stedorMinist
ryofHealt
h( MOH) -r
un;i
ntegr
atedortemporary/
stand-al
one
 Oppor
tuni
ti
esandbar
ri
ersi
nfl
uenci
ngpar
ti
ci
pat
ion(
demand)i
nthecommuni
ty
 Resour
cesandcapaci
ti
esi
nfl
uenci
ngt
heav
ail
abi
l
ityofser
vices(
suppl
y),
par
ti
cul
arl
ywi
thr
egar
dto
communi
tyout
reach.
 Opi
nionl
eader
sandkeyi
nfl
uencer
sincl
udi
ngt
radi
ti
onal
heal
ers,
tradi
ti
onal
bir
that
tendant
s,l
eader
s,
r
eli
giousl
eader
s,t
eacher
s,gr
andmot
her
s,f
ather
s,hai
rdr
esser
s,shopowner
s,andphar
maci
sts
 Oppor
tuni
ti
esf
ori
ntegr
ati
onwi
thot
hersect
ori
nit
iat
ivesi
ncl
udi
ngmat
ernal
andchi
l
dheal
th;
r
epr
oduct
iveheal
th;
gender
-basedv
iol
enceandchi
l
dpr
otect
ion;
andwat
er,
sani
tat
ionandhy
giene
(
WASH)

WORKI
NGGROUPS:FROM COMMUNI
TYASSESSMENTTOSTRATEGY.Di
vi
depar
ti
cipant
sint
o
fourworki
nggroups.Tel
lthem youwil
lexpl
ainf
ourdi
ff
erentkeyf
indi
ngsf
rom acommunit
yassessment
i
nEt hi
opiaandwanteachgr ouptodi
scussonefi
ndi
ngandhowt hecommunit
youtr
eachstr
ategycan
addressit
:
1. Locall
y,avariet
yofcausesaret
houghttounderl
ieswel
li
ngandwasting,
andnotal
laref
ood-
rel
ated.Presumedcausesincl
udebreast
feedi
ngwhilepr
egnant
,exposuret
obri
ghtsunl
i
ght,
malevolentspir
it
s,andthedi
spl
easureofancest
ors.
2. Localchur
chesar
eof
tent
hef
ir
str
esor
tfami
l
ieswi
thsi
ckchi
l
drent
urnt
o;t
heybor
rowf
undsf
or
tr
eatment.
3. Al
lpar
tsofthecommunityareuncer
tai
naboutt
her
elat
ionshi
pbetweenproposedout
pat
ientcar
e
ofSAM andpre-
exi
sti
nganthr
opometri
cscr
eeni
ngf
orthetarget
edgener
al r
ati
on.
4. Acadreofunpai
dcommuni t
yheal
thworker
s(CHWs)areal
readyconduct
inghouse-
to-
house
heal
theducat
ionr
egul
arl
y,butonl
yli
ter
atewor
ker
srecei
veregul
artr
aini
ng.

Askeachwor ki
nggrouptoreportbackont hei
rfi
ndingsanddiscusstogether
.Ref
erpart
icipantst
o
Handout3. 4Communi t
yOutreach:From AssessmenttoStrategyandcompar et
he“impl
icationsf
or
strategy”f
oundi nt
hesecondcolumnwi ththewor ki
nggroups’responses.
Discussandf il
li
nanygapsbyexpl ai
ningthatthecommuni t
yout r
eachstrat
egywil
lbedeterminedby
sev eral
fact
orsincl
udi
ng:

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 Whatt
heneedsar
e—asi
dent
if
iedbyt
hecommuni
tyassessment
 Whatcase-
findi
ngmodel
wil
lbeadopt
ed
 Howparti
cipant
swil
lbet
rai
ned(
whattool
s,whatscope)i
ncase-
fi
ndi
ngandsensi
ti
sat
ion
 Whethercommunityout
reachworkerswi
ll
beremuner
atedormotiv
at edbyot
hermeans
 Whatmat er
ial
sandtool
swi l
lbeusedandhowtheywi
llbesuppl
i
ed( e.g.
,MUACtapes,
ref
err
alsl
i
ps)
 Whatcommunicat
ionchannel
swil
lbesuppor
tedbet
weencommuni
ti
esandhealt
hfacil
it
ies
 Whatli
nkagesmayexistbetweencommunityout
reachf
orCMAM ser
vicesandothernutri
ti
on-
specif
icandnutri
tion-
sensi
tivecommunit
ymobi li
sati
onactivi
ti
es(e.g.
,cooki
ngdemonstrati
ons,
caregroups,mother-t
o-mothersuppor
tgroups,gr
owt hmonitori
ng,PDHearth,demonst
rati
on
gardens,heal
thpromot i
on,
hy gi
enepromotion,
vil
lagesavi
ngsandl oans)

PARTI
CIPATORYLECTUREANDBRAI
NSTORM:METHODSOFCASE-
FINDI
NG.Expl
aint
o
part
ici
pant
sthatanimpor t
antaspectofacommuni
tyout
reachst
rat
egymaybedecidi
nghowcase-
fi
ndingwil
lbeconducted.Defi
nethethr
eemodel
sfoundi
nHandout3.5CommunityOutr
eachSt
rat
egy
:
 House- t
o-housecase-f
indi
ng
 Communi
tycase-
fi
ndi
ng
 Mot
herandf
ami
lycase-
fi
ndi
ng

Askpar t
ici
pantstodescri
besomef actorsthatwoul dsuggestwhi chmodel (
orsequenceorcombi nat
ion)
touse.Possi bl
eanswer si
ncl
ude: t
hedegr eeofacut emal nutr
it
ioninthecommuni ty;
communi ty
awar enessofthesignsofacutemal nutr
it
ion;accessibil
it
yofhomesanddegr eet
owhi chtheyare
clustered;exi
sti
ngnetworksofCHWsandt hei
rwor kloads;ti
meandr esourcesavai
lablefortr
aini
ngand
outreach; whet
herornotcase-f
indi
ngi senvisi
onedasaper manentneedort emporar
ymeasur e.

PRACTI
CE:DETERMI
NINGMETHODSOFCASE-
FINDI
NG.Wi
thpar
ti
cipant
sst
il
li
nwor
kinggr
oups,
referparti
cipantstoExer ci
se3.3Compar isonofCase- Fi
ndingModel s.Takingt hethreemodelsforcase-
fi
ndinginsequence, askgr oupstodiscusst hecategoriesandf ill
inthemat rix.Remi ndthem ofsomeof
thefactorsdiscussedabov e,andifnecessar ygetthem startedbyaski ngwhi choft hemodel sare
appropriateforstart
-upandwhi chforpost-start
-up.Indiscussingt heresponses, notethatther
ear eno
‘
rightanswer s’foreverysit
uati
on.Themosti mportantlessonf rom thi
sexer ciseisthatmanydeci sions
aretrade-offsthatbalanceconvenienceforcommuni tymember sagai nstconv eni
encef ort
heserv i
ce
provider
s.

PARTI
CIPATORYLECTURE:SELECTI ONOFCANDI DATESFORHOUSE- TO-HOUSECASE-
FI
NDING.Expl
aint
opar
ti
cipant
sthatonceadeci
si
onhasbeenmadeconcer
ningthet
ypeofcase-
fi
ndingtoemploy,t
heteam wil
lneedtoseewhocanmosteasi l
yunder
takethi
swork.Insomeset t
ings,
theopti
onsmaybev er
yli
mitedandthechoiceobvi
ous.Wher
etherear
esev er
alopt
ionsavail
abl
e,i
tcan
beausef ul
processtoconsi
dersyst
ematicall
ythest
rengt
hsandweaknessesofeachinordertoarri
veat
thebestcompromise.
Askpar t
ici
pantstolookatHandout3. 6Exampl e:Selecti
onofCandi dat
esforHouse- t
o-HouseCase-
Finding.Theexampl eisfrom theSouthernNati
ons, Nat i
onali
ti
es,andPeople’sRegion(SNNPR)i n
Ethiopia.Themat ri
xranksthecandidatesforhouse-to-housecase-findi
ngwithasimpl ethree-poi
ntscale
acrosseachoft hekeyattri
butes:
Xi sthelow(poor)endoft hescaleandXXXi sthehigh( good)end.The
conclusiondrawni nthi
scasewast hatalt
houghal l
threet ypesofCHWshadat tr
ibutesintheirfavour
,
onlythecommuni tyhealt
hpr omoter(CHP)couldbot hper f
ormt hehouse-t
o-housev i
sit
sandacceptt he
additi
onal workl
oad.

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,2018Ver
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Exer
cise3.
3Compar
isonofCase-
Findi
ngModel
s(wi
thanswer
s)
Model Sui
tabl
efor St
rengt
hs Weaknesses
House-
to- Bot
hst
art
upandpost
-st
art
up Canmor eeasi
lyf
ind“
hidden”caseskept Requi
resamuchl
argernumberoft
rai
ned
House athomeduet ost
igma,misdi
agnosisor vol
unt
eers
Sit
uati
onswher
egoinghouse-
to-
housei
sthemost otherf
actor
s.
Case-
Findi
ng appropr
iat
ewaytoannouncet
henewservi
ce Canbedi ff
icultt
osust
ainoverthelongter
m
Canincr
easethenumberofinf
antsand
Si
tuat
ionswherehouse-
to-houseoutr
eachwor
ker
s(e.
g., chi
l
drendetect
edifi
tisdoneexhaust
iv y Vol
el unteer
s’MUACmeasur ement smightnotbe
CHWs, vol
unt
eers)ar
ereadil
yavai
labl
e accuratewithouthi
ghqual
it
y-t
raini
ng
Sit
uationswheresoci
alf
ragmentati
onorotherfact
ors I
fvisit
saretoofr
equent
,house-
to-
housecase-
preventhousehol
dsfr
om gather
ingtoget
herforcommuni
ty f
indingcanbecomeanintr
usiontothef
amili
es
case-fi
nding
Communi t
y Bot
hst
art
upandpost
-st
art
up Lesseff
ortf
oroutr
eachworker
sthan Gather
ingtoomanyhousehol
dsi
nonelocati
on
Case-
Findi
ng house-
to-
housecase-
fi
ndi
ng cancreat
econfusi
onandwastef
amil
i
es’time.
Sit
uationswher efamili
esar eal
readybringi
nginfant
sand
chil
drentocent r
ali
sedl ocati
onforotherservi
ces(e.
g., Fewerscreenersareneededthanfor Coul
dreproduceexi
sti
ngpatter
nsofaccess,
i
mmuni sat
ion,supplement ar
yfeedingservi
cesor house-t
o-house,al
l
owingemphasi s cat
eri
ngtofamili
eswhoalreadyar
ewell
programmes, screenings) duri
ngtraini
ngonsecuringrel
iabl
eMUAC ser
ved,whil
ethemarginal
i
sedstayhome
measurementf r
om asmal l
ernumberof
Communiti
eswher edi
stancebetweenhousehol
dsmakesi
t tr
ainees Scr
eenerscannotcomeunannounced;people
di
ff
icul
ttoconducthouse-t
o-housevi
si
ts mustbetoldwhenscr eeni
ngteam wi
l
larri
ve,
whi
chrequiresadvanceplanni
ngandsti
cki
ng
Situat
ionswher
ehouse-
to-
housev
olunt
eer
scannoteasi
l
ybe tot
heplan
recrui
ted
Si
tuat
ionswher
etherei
sli
tt
lel
i
keli
hoodofsti
gmaorshame
i
npublicl
ypr
esent
ingaver
ymalnouri
shedchi
l
d
Motherand Bot
hst
art
upandpost
-st
art
up Putsthemot heratthecentreof Itisl
abour
-i
ntensi
veatthestar
t,whichincl
udes
FamilyCase- scr
eeni ng,theref
oreencouragesearly planni
ngandimplementingmasstraini
ng
Fi
nding Sit
uati
onswherecommunityheal
thworker
s(CHWs)exi
stbut i
denti
ficationofnut r
iti
onal
lyvul
nerabl
e campaignsformother
sandf amil
ymember s.
haveahighworkl
oad i
nfantsandchi l
drenwhoar eacutel
y
malnour i
shed. I
trequi
ressour
cingl
argequant
it
iesofMUAC
Theapproachcanbecombinedwithmasscommunit
y t
apes.
tr
aini
ngsandcampaigns. Morer egularscreeningbecausethe
Si
tuat
ionswhereCHWspl ayani mportantrol
eint
rai
ning, motheri
salway
sincontactwit
ht d, Mot
hechi
l hers’MUACmeasur ementsmightnotbe
andaccur
acyofMUA Cme asur
ement accurat
ewi t
houtqual
i
tytr
aini
ngandr out
ine
monit
oring,
andsuppor
tingmot hersandf amil
ymember sand fol
lowu p.
i
ncheckingthemother
’sdiagnosis mayincr
easewit
hrepeateduse.

Si
tuati
onswheredist
ancesbetweenhousehol
dsmakei t Ifal
lmot her
swithinthecat
chmentarea
di
ffi
cul
tforCHWsorv olunt
eer
stoconductregul
arhouse-
to- aretrai
ned,theapproachcangr
eatl
y
housescreeni
ngofchil
dren i
mpr ovethecoverageofCMAM servi
ces.

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,2018Ver
sion

PRACTI
CE:SELECTI
NGCANDI
DATESFORCASE-
FINDI
NG.Br
eakpar
ti
cipant
sint
ogr
oups
accordingtothei
rdist
ri
ctsandaskeachgrouptof i
l
linitsownmat ri
xusingExercise3.4Worksheet:
Selecti
onofCandi dat
esforCommuni t
yOutreach,basedonl ocal
extensionworkersandvol
unteers.Ask
them toli
standconsiderthemeri
tsofatl
eastthreecategor
iesofcandidates:
1. Heal
thextensi
onwor kers(
HEWs)andvolunteer
s(e.
g.,CHWs,communit
y-basedfami
l
ypl
anni
ng
di
str
ibut
ors/educat
ors,home-
basedcar
e[ HBC]vol
unteer
s,v
itami
nAdistr
ibutor
s)
2. Ot
herext
ensi
onworker
sandv
olunt
eer
s(e.
g.,
agr
icul
tur
alext
ensi
onwor
ker
s,soci
alwel
far
eof
fi
cer
s,
NGOproj
ectwor
ker
s)
3. I
mportantcommunityfi
gures(e.
g.teacher,
pri
estorcat
echi
st,
secondar
yschool
leav
ers,
elect
ed
l
eader
s,cult
ural
leader
s,tr
adit
ional
healers)

PARTI
CIPATORYLECTURE:HOMEVI
SITSANDFOLLOW-
UPOFHI
GH-
RISKCASES.Not
eto
parti
cipantst hatbecausefollow-uphomev isitsarerequir
edonlyforhigh-r
iskcases(i.
e.,
thosenot
thri
vi
ngorr esponding,absentees,anddefaulters)
,themaj ori
tyofout
patientcarecases,whichar
enot
highri
sk, caneasi l
ybenegl ected.However,itisimportanttomakeadequat eprovisi
onforthem.

Aswi t
harrangement sforcase-fi
nding,pl
ansforfol
low-
uphomev i
sit
sshouldbemadebef orethefi
rst
outpat
ientcarepati
entsar ereceived.Si
ncetherangeofper
sonnelavai
l
ableforfol
low-uphomev isi
tscan
var
yf r
om oneout pati
entcaresi t
et oanother
,itmi
ghtbeimpossi
blet
omakea“ one-si
ze-f
it
s-al
l
”
arr
angement .I
nstead,responsibi
li
t i
esmightneedtobeworkedoutseparat
elyforeachsit
e.

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Modul
e3Learni
ngObject
ive4:Di
scussConsi
der
ati
onsf
orDev
elopi
ng
andUsi
ngCMAM Messages

TRAI
NER:
Ref
erbackt
oExer
cise3.
1Bar
ri
erst
o
AccessRole-Pl
ayandbecomef amili
arwithHandout St
epOne:
Communi
tyAssessment
3.
7Dev el
opingSimpl
eandSt andardisedCMAM St
epTwo: Formul
ati
onofCommuni
ty
Messages,Handout3.
8Ref er
ence: Handbil
l Out
reachStrat
egy
Messages,andHandout3.9Reference:Visual
CommunicationTool
s. >>St
epThree:Dev
elopmentofMessages
andMater
ial
s
GROUPDISCUSSI
ON:THENEEDFOR St
epFour:
Communi
tyMobi
l
isat
ionand
STANDARDCMAM MESSAGES.Remi
nd Tr
aini
ng
par
ti
cipantsthatthedevel
opmentofmessagesand
materi
alsisthethir
dstepinpr eparationforCMAM
communi t
yout r
each.Inplenary,explainthatthe
mostimpor t
antmessagesar esi mpl e,st
andar di
sedmessagesdescri
bingt
heprogram i
tsel
f.Ask
par
ti
cipantstodescribewhyt hisisimpor tant
.Remi ndthem ofwhatt
heywit
nessedinExerci
se3.1
Bar
rier
st oAccessRol e-
Play.Possi bleanswer sincl
ude:
 Tocl
ari
fyhowt
heser
vicei
sof
fer
edandt
owhom
 Toensur
ethatt
hecommuni
tyi
srel
yi
ngonaccur
atei
nfor
mat
ionandnotr
umour
swhi
chcanhur
t
communi
typar
ti
cipat
ionandser
viceaccessandupt
ake
 Tof
aci
l
itat
ethespr
eadofi
nfor
mat
iont
hroughwor
dofmout
h

BRAI
NSTORM:DEVELOPI
NGSTANDARDCMAM MESSAGES.Askpar
ti
cipant
stot
hinkt
hrough
thekeyinfor
mation(what ?how?who?wher e?when? )t
hatwoul dneedtobeconveyedtomakesurethe
communi ty’
sunderstandingoftheCMAM ser v
icesi
sbot haccurat
eandcompl et
e.Writ
eanswersonaf l
ip
chart
,fi
l
lingingapswi ththety
picalcontentfoundinHandout3. 7Devel
opingSimpl
eandSt andar
dised
CMAM Messages, SectionA.Notef orpart
ici
pantstheimportanceofusi
ngthekeymessagesasan
opport
unitytoaddressconcernsraisedinthecommuni tyassessment.

WORKI
NGGROUPS:DEVELOPI
NGANDUSI
NGHANDBI
LLS.Descr
ibet
hepr
ocessofcr
eat
inga
handbillf
rom thestandardCMAM messages( i.
e.simpli
f yi
ngmessages, t
ranslati
onintolocall
anguage,
back-tr
anslati
on,photocopyi
ng,di
ssemi nati
ng,andtrackingmi sconcept i
onsoncedi sseminat
ed,
reworkingasnecessar y)
.Askparti
ci
pant stoform workinggroupsoft hreeorf ourandt othi
nkofdi f
ferent
venuesandaudi enceswher ethehandbill
scouldbeusedt ospr eadaccur ateandcompl et
einformation
throughoutthecommuni t
y.Al
soaskt hem tothinkoftheirownl ocalci
rcumst ancesandt otrytothinkof
howt hehandbi l
lcoul
dbeusedt ocommuni catethr
oughr adi
o,publ i
caddr esssy st
ems, etc.Discussand
referpart
ici
pantstoHandout3. 7SectionBandHandout3. 8Ref er
ence:Handbi llMessages.Compar e
responses.

PARTI
CIPATORYLECTURE:USI
NGVI
SUALCOMMUNI
CATI
ONTOOLS.Ref
erpar
ti
cipant
sto
Handout3.9Ref erence:Vi
sualCommunicat
ionToolsandexplainthatv
isual
communi cati
ontoolssuch
asposters,
leaf
lets,andfli
erscanpl
ayanimportantr
oleinremindi
ngcommuni t
ies,
famil
ies,mother
s,
andcaregiv
ersofwhat ,where,andwhenser
vicesareavai
labl
e.

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,2018Ver
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Modul
e3Lear ni
ngObject
ive5:Di
scussPr
epar
ati
onsf
orCommuni
ty
Mobi
li
sat
ionandTrai
ning

TRAI
NER:
Becomef
ami
l
iarwi
thHandout3.
10Key
Acti
onsinCommunityMobil
isat
ionandTrai
ningand St
epOne:
Communi
tyAssessment
Handout3.11Pl
anni
ngandImpl ement
ingaMass St
epTwo: Formul
ati
onofCommuni
ty
Trai
ningCampai
gnforMothersandFamily Out
reachStrat
egy
Member s.
St
epThree:
Dev
elopmentofMessagesand
PARTI
CIPATORYLECTURE:PREPARI
NGFOR Mater
ial
s
COMMUNI TYMOBILI
SATI
ONANDTRAI NI
NG. >>StepFour:Communi
tyMobil
isati
onand
Referpar t
ici
pantstoHandout3. 10KeyAct ionsi n Training
Communi tyMobi l
isat
ionandTr ai
ning,r
emi nding
parti
cipantsthatthisi
sthefourthstepinprepar at
ion
forCMAM communi tyoutr
each.Outli
nethef ourkey
acti
onsi nprepari
ngf orcommuni t
ymobi l
isati
onandt r
aini
ng:
 Est abli
shreli
ablecommuni cat
ionsbetweenser v
iceproviders,communi
ty,
mot
hers,
andf amil
i
es.
 Assi
stcommuni
ti
eswi
thsel
ect
ionofout
reachwor
ker
swher
enecessar
y.
 Tr
ainout
reachwor
ker
s(e.
g.,
CHWs,
vol
unt
eer
s)t
oper
for
m case-
fi
ndi
ng.
 Tr
ainmot
her
sandf
ami
l
ymember
stor
egul
arl
yscr
eent
hei
rchi
l
drenf
oracut
emal
nut
ri
ti
on
 Engageci
vi
lsoci
etypar
tner
s.

Foreachofthekeyact
ions,
askparti
cipant
swhytheacti
onisimportantusi
ngthecont
enti
ncol
umntwo
(“
Why ?”
)ofHandout3.10asaguideforthedi
scussi
on.Thendescr
ibethepoint
ersi
ncolumnt
hree
(“
How? ”
).Answeranyquest
ions.

PARTI
CIPATORYLECTURE:PLANNI NGANDI MPLEMENTI NGAMASSTRAI NI
NG
CAMPAIGN.Ref
erpar
ti
cipant
stoHandout3.
11Pl
anni
ngandI
mplement
ingaMassTr
aini
ngCampai
gn
forMot
hersandFamilyMembers.Out
li
net
hesi
xst
epsusedt
opr
epar
eforandi
mpl
ementmasst
rai
ning
campai
gnsformother
sandfamilymember
s:
 Determini
ngthecover
agear
ea
 Det
ermi
ninghumanr
esour
cesneededf
oramasst
rai
ningcampai
gn
 Det
ermi
ningt
hebudget
 Det
ermi
ningwhatt
opr
epar
efort
het
rai
ner
s
 Devel
opi
ngat
rai
ningsessi
on
 Fol
l
owi
ngupwi
tht
hemot
her
s
Foreachstep,rev
iewtheessent
ialact
ivi
ti
est
hatshoul
dbeunder
taken.UseHandout3.
11asagui
def
or
thedi
scussion.Answeranyquesti
ons.

WORKINGGROUPS:USINGMOBILI
SATI
ONANDTRAI NI
NGTOI NCORPORATEBEHAVI OUR
CHANGECOMMUNI CATION(
BCC)INCMAM SERVI
CES.Expl
aint
opar
ti
cipant
sthatt
hrough
expl
or i
ngthecausalfactorsbehindthepr evalenceofacutemalnutri
ti
on, CMAM staf fmaybeabl et
ofind
wayst oint
roduceorreinforceprev
ent i
vemessagesi ntoCMAM rout i
nes.Askpar t
icipantst
of or
m
workinggroupsofthreeorf ourandtodi scusshowef f
ort
sincommuni tymobili
sationandt r
aini
ngcanbe
expandedupont o:i
dentifyrel
evantbehav iourchangemessages; accessinformati
on, educati
onand
communi cati
on(IEC)andBCCmat er
ial
s; andcr eat
eamechanism f ortheirdi
sseminat i
on.
Exampl
esi
ncl
ude:

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 OnceCMAM i
sunderway
,CMAM heal
thcar
epr
ovi
der
sshoul
dtal
kwi
thout
pat
ientcar
epr
ovi
der
sand
out
reachwor ker
stol
ear
nwhatt
hemaj
orcausal
fact
orsappeart
obebasedonadmi
ssi
onst
othe
out
patientcaret
odat
e.
 Thedi
str
ictheal
thmanagementt
eam,
impl
ement
ingagenci
esoper
ati
ngi
nthear
ea,
andl
ocal
heal
th
facil
it
iesar
elikelytohav eaccesstoar angeofBCCandI ECmat er
ial
sonv arioustopi
csaboutf act
ors
contri
buti
ngtoSAM ( e.
g.,complementaryfoods,exclusi
vebreastf
eeding[EBF],di
etar
yv ar
iety
).
 Out r
eachworker sconductingcommuni ty-
lev
elorhouse- t
o-houseMUACscr eeni
ngsmi ghtbenefi
t
from simpl
etraininginthemanagementofdi ar
rhoeai nchil
drensotheycananswerquest ionsabout
thisduri
ngtheirrounds.Or ,out
pati
entcarestaf
forv olunt
eerscouldshareinformati
onaboutf amil
y
planningopt
ionst othemot hers/car
egiver
sgatheredf orCMAM.

56
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e3 Wr
ap-
UpandModul
eEv
aluat
ion

Suggest
edMet
hod:Rev
iewofl
ear
ningobj
ect
ivesandcompl
eti
onofev
aluat
ionf
orm
 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.Thi
smodul
ecov
ered:
1.Thei
mpor
tanceofcommuni
tyout
reacht
oCMAM out
comes
2.Theobst
acl
esandenabl
ersofcommuni
typar
ti
ci
pat
ioni
nCMAM
3.Thear
easofi
nvest
igat
iont
hatmakeupt
hecommuni
tyassessment
4.Thest
epsi
nvol
vedi
nmov
ingf
rom assessmentt
ost
rat
egy
5.Whyi
tisi
mpor
tantt
osi
mpl
i
fyandst
andar
diseCMAM messages
6.Themai
nst
epsr
equi
redt
oini
ti
ateact
iveCMAM out
reach
 Askf
oranyquest
ionsandf
eedbackont
hemodul
e.
 Ref
erpar
ti
cipant
stoHandout3.
12El
ement
sandSequenci
ngofCMAM Communi
tyOut
reach.
 Letpar
ti
cipant
sknowt
hatt
heywi
l
lhav
eanoppor
tuni
tyt
omeetwi
thcommuni
tyl
eader
s,HEWs,
v
olunt
eer
s,andcommuni
tymot
her
s/car
egi
ver
sdur
ingt
hecommuni
tyout
reachf
iel
dvi
sit
.
 Askpar
ti
cipant
stof
il
loutt
hemodul
eev
aluat
ionf
orm.

57
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

FI
ELDVI
SITFORCOMMUNI
TYOUTREACH

Thef i
eldv i
sitisdesi
gnedtoal l
owpar ti
cipantstopr act
icethest epsneededtodevel
opacommuni ty
outreachst r
ategyandanact ionplan.Duringthef i
eldvisi
t,part
icipant
swill
int
ervi
ewoneoft hefoll
owing
fourgroups: communi t
yleaders;exi
stingextensionwor kers,CHWsandv ol
unteer
s;youngercommuni t
y
mot hers/caregiv
ers;
oldercommuni tymot hers/caregiv
ersincludinggrandmother
s.Parti
cipantsthenwill
consolidatefindi
ngsfrom theinter
views,createahandbi ll
(messagest ocommuni cate)andbegin
devisi
ngacommuni t
yout r
eachst r
ategyandanact ionplan.

Itcanbediff
iculttopracti
cer
eali
sti
ccommuni t
youtreachact
ivi
ti
esi
nanar
eathatal
readyhasCMAM
servi
ces.Thev i
sitshouldbedoneatalocat
ionthati
snotservi
cedbyCMAM.

Preparat
ionsi
ncl
udemeet ingwit
hcommuni t
yleader
st oarr
angef orthegroupi
nter
views,sel
ect
ing
communi tymembersforthegroupinterv
iews,l
ini
ngupt r
anslat
ors, ar
rangi
ngtr
ansport
ati
on,and
developi
ngsimpl
einter
viewguides(li
stsofquesti
ons).Trai
nersmi ghtneedtoworkthr
oughcontactsi
n
thecommuni t
ytomakesomeoft hear r
angements.

Theperi
odall
ott
edf orthi
sfiel
dvisi
tisaf
ract
ionoft
heti
meneededtocoveral
laspectsofcommunit
y
out
reach.Thi
spart
icularsi
tevisi
tpl
anemphasisest
hecommuni
tyassessment
,strat
egyandmater
ial
s
components.

Thesenot esareamapofact ivi

tiestobeconduct eddur i
ngthev i
sit
.Theyar enotmeanttosubsti
tutef
or
technicalai
dstoqualit
ati
veresearch,suchasf ocusgroupmanual s,orforthetrai
ner
’sknowledgeand
abili
ti
es.Thetrainermustusehis/herjudgmentoft helocalsett
ingtoadaptt hemodulecont
entforbest
effect.Thetr
ainermustensurethatpar t
ici
pantsareawar eofanycultur
al orcommunitynormssot hey
canadaptt othem asnecessary(e.g.
,ifcert
ainatti
reisexpected).

Note:I
ft hetrai
ningcourseonintegrat
ionofinfantandyoungchi
ldfeedi
ng(I
YCF)supporti
ntoCMAM is
conductedtocompl ementthi
smodul e,addi
ti
onal t
imeshouldbesetasi
defort
headdit
ionalI
YCF
supportfiel
dv i
sitacti
vi
ti
es.Detai
lscanbef oundathttps:
//www.ennonl
i
ne.
net/
int
egrat
ioni
ycfi
ntocmam.

Fi
eldVi
sitObj
ect
ives Handout
stoTaket
oFi
eldVi
sit

Pr
act
iceConduct
ingI
nter
viewswi
thCommuni
ti
es I
ntervi
ewgui
dedev
elopedandpr
ovi
dedby
t
rainer
Consol
i
dat
eFi
ndi
ngsf
rom I
nter
views Handout3.
4Communit
yOut
reach:
From
Assessmentt
oSt
rat
egy
Pr
act
iceDev
elopi
ngaHandbi
l
l
Handout3.
8Ref
erence:
Handbi
l
lMessages
Pr
acti
ceDevel
opi
ngaCommuni
tyOut
reach Handout3.
13Team Checkl
i
stf
orCommuni
ty
St
rat
egyandanActi
onPl
an Outr
eachFi
eldVi
sit

Mat
eri
als
 Spi
ral
-boundnot
ebooks

58
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Adv
ancePr
epar
ati
ons
 Oneweeki
nadv
ance,
makear
rangement
swi
thl
eader
soft
wocommuni
ti
est
ohol
dei
ghtt
wo-
hour
meeti
ngsinthecommuni ti
es.Fourmeetingswi l
lbeheldsimult
aneousl
yineachcommuni ty.Ideal
ly
,
twocommuni t
iesthatareverydiff
erentfr
om eachot her(e.
g.,
envir
onment,
ethnicit
y,accessibil
it
y)
shoul
dbeselected,butthedegreeoflocal het
erogeneit
yandav ai
l
abil
it
yofresources—especi al
ly
tr
anspor
tat
ion—wi l
ldeterminewhetherthisispossibl
e.
 Poi
nter
s:
- Expl
aint
othecommunityleadersthatt
hepurposeoft
hemeeti
ngsistotr
ainhealt
hcare
manager
sandprovi
derstoconsul twi
ththecommunit
yandt
hattheywil
lbeaskingcommuni
ty
membersaboutnut
ri
ti
onpr act
ices.
- Sel
ectsev
enpeopl
eforeachcommuni
tygr
oup.
- Ifpossi
ble,hav
ethemother
/car
egi
vergroupsincl
udewomenwhoar ef
rom di
ff
erentpar
tsoft
he
communi tybutar
eli
kel
ytobecomfort
abletal
kingtoget
her
.Thegr
oupsshoul
dnotendupbeing
dominatedbyoneindi
vi
dual
.
- Theinter
viewsshoul
dbeconduct edwheretheyareunl
ikel
ytobedist
urbedbycur
iousonl
ookers.
Thisneednotnecessari
l
ybei nside.I
tisbesttoavoi
danyspotconnectedwit
hapowerful
force
suchasthecommuni tycouncilorthechurch/mosque.
- Theinter
viewsit
esineachcommunit
yshoul
dbesepar
ateenoughsoasnott
odi
stur
beachot
her
butcloseenoughfort
hefaci
li
tat
ort
ocir
cul
atebet
weenthem.

 Whi
l
emaki
ngar
rangement
sfort
hel
ocat
ions,
secur
etr
ansl
ator
sforeachoft
hei
nter
viewgr
oups,
assumingthatt hepart
ici
pant
sarenotnat ivespeaker
softhelocall
anguage(s).Thi
scanbedi f
ficul
t,
si
ncegoodt ranslat
ionisamatteroftemper amentaswellasoflanguagecompet ence.I
tshouldbe
suff
ici
entfortransl
atorstobecompet entinspokenEngli
sh;
itisnotnecessarytouseprofessi
onal
tr
anslat
orsorindivi
dualswhohav eadv ancedknowledgeofwrit
tenEngli
sh.
 Onet
otwoday
sinadv
ance,
thef
aci
l
itat
orsshoul
dre-
fami
l
iar
iset
hemsel
veswi
tht
hecont
entof
Module3,especi
all
ythesect
ionsonconducti
ngcommuni
tyassessment
,for
mul
ati
nganout
reach
st
rat
egy,anddevelopi
ngmessagesandmat eri
als.
 Onet
otwoday
sinadv
ance,
thef
aci
l
itat
orsshoul
ddev
elopt
hreesi
mpl
eint
erv
iewgui
des(
li
stsof
questi
ons)cov
eri
ngquesti
onsforcommunityl
eaders;ext
ensi
onworker
s,CHWsandvolunt
eer
s;and
thetwocommunitymother
s/caregi
vergr
oups.Faci
l
itator
swil
lneedt
otail
ort
hequest
ionstol
ocal
context
s.
 Theeveni
ngbef
oret
hepr
act
icum,
assi
gneachpar
ti
ci
pantt
ooneoft
heei
ghtgr
oups.Askt
he
part
ici
pant st
odesignatetwomoder ators/i
nterv
iewersandoner ecorderforeachgroup.Dist
ribut
e
theinter
viewguidesandasktheparticipant
st oreviewthem andbecomecomf ort
ablewiththe
contentbefor
etheintervi
ews.Havethemoder ators/i
nter
viewer
sdecidewhi chquesti
onseachwi ll
ask.Makesur edesignat
edrecorder
shav espir
al-boundnotebooksforrecordi
ngthediscussion.
 Thedaybef
ore,
ensur
ethatt
ranspor
tat
ioni
sav
ail
abl
eand,
ifappr
opr
iat
e,sendamessaget
othe
communit
iesconf
irmi
ngt heteam’sarr
ival
time.Ifpossi
ble,
trav
elt
othecommuniti
est
oconf
ir
mthat
arr
angementsf
orthegroupinter
viewsareinplaceandtoansweranyquest
ionst
hecommuni
ty
membersmighthave.

59
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e3FIELDVI
SITACTI
VITY1:PRACTI
CECONDUCTI
NGCOMMUNI
TY
I
NTERVIEWS
SmallWor kingGroups:Conducti
nter
viewswi t
hcommuni t
yleaders;
existi
ngextensi
onworker
s,CHWs
andv olunt
eers;
youngercommuni t
ymot hers/
caregi
ver
s;andoldercommuni tymothers/
car
egi
vers
i
ncludinggrandmothersusingsi
mpleinterv
iewguidesdevel
opedbyt r
ainers.
 For
m smal
lwor
kinggr
oups,
wit
htwopar
ti
ci
pant
sser
vingasmoder
ator
/int
erv
iewer
sandoneser
ving
asr
ecor
der
.
 Tr
anspor
tpar
ti
cipant
stot
het
wocommuni
ti
es.
 Thankcommuni
tyl
eader
sforal
l
owi
ngt
hisl
ear
ningoppor
tuni
ty,
thenhav
epar
ti
cipant
sjoi
nthei
r
assi
gnedgr
oups.
 I
neachcommuni
ty,
atl
eastonef
aci
l
itat
orci
rcul
atesbet
weent
hei
nter
viewgr
oups,
not
ingpr
ogr
ess
andhel
pingcor
rectanypr
obl
emsormi
sunder
standi
ngs.
 I
neachgr
oup,
hav
ethet
wodesi
gnat
edmoder
ator
/int
erv
iewer
staket
urnsaski
ngquest
ionsand
managi
ngt
hei
nter
view.
 Af
tert
hei
nter
view,
ther
ecor
dershoul
dseekcl
ari
fi
cat
ionf
oranyuncer
tai
npoi
nts.Af
tert
hei
nter
view
subj
ect
sleav
e,t
her
ecor
dercompl
etest
hegr
oup’
snot
eswi
tht
hehel
poft
heot
herpar
ti
cipant
s.
 Ref
ert
oHandout3.
13Team Checkl
istf
orCommuni
tyOut
reachFi
eldVi
sit
.

Modul
e3FIELDVI
SITACTI
VITY2:CONSOLI
DATEFI
NDI
NGSFROM
I
NTERVIEWS
Wor
kingGr
oupPr
esent
ati
ons,
Feedback/
Discussi
on:Consol
idat
eandPr
esentFi
ndi
ngs
 Havepar
ti
cipantgr
oupsconsol
i
dat
efi
ndi
ngsf
rom eachcommuni
tygr
oupt
heyi
nter
viewedaccor
ding
t
oquest
ionsf
rom t
hei
nter
viewgui
desandt
hismodul
e’
scommuni
tyassessmentsessi
on.
 Askeachgr
oupt
opr
esenti
tsf
indi
ngsandwr
it
ethem ont
hef
li
pchar
t.Hel
ptot
easeouti
nsi
ght
s
f
rom t
hegr
ouppr
esent
ati
ons.I
nfor
mat
ioni
str
iangul
ated.
 Askpar
ti
cipant
stodi
scusst
hei
rexper
ienceswi
tht
hei
nter
views.Of
feranassessmentbasedon
obser
vat
ionoft
hei
nter
views.
 Leadpar
ti
cipant
sthr
oughapr
ocessofr
evi
si
onoft
hei
nter
viewgui
des,
str
essi
ngt
hatt
hedi
sci
pli
neof
dai
l
yref
lect
ionandr
evi
sionbasedonemer
gingi
nsi
ght
sisani
mpor
tantpar
toft
heassessment
.
 Emphasi
set
opar
ti
cipant
sthati
nsi
ght
sbasedoni
nit
ial
int
erv
iewsmustr
emai
ntent
ati
ve.Thenor
mal
pr
act
icei
stoconductatl
eastonesuchi
nvest
igat
ionf
oreachout
pat
ientcar
esi
te.
 Devel
opashor
tli
stofemer
gingi
nsi
ght
stogui
dedi
scussi
onofst
rat
egy
.
 Ref
ert
oHandout3.
13Team Checkl
istf
orCommuni
tyOut
reachFi
eldVi
sit
.

60
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e3FI
ELDVI
SITACTI
VITY3:DEVELOPAHANDBI
LL
Wor
kingGr
oups:Dev
elopaHandbi
ll
 For
mfi
vewor
kinggr
oups.
 Usi
ngHandout3.
8Ref
erence:Handbi
llMessagesasanexampl
e,hav
eeachgr
oupdev
elopahandbi
l
l,
worki
ngthr oughseveral
stages,i
ncl
uding:discussingandagreeingont hemainmessages;
summar i
singt hesei
nbull
etpoint
s;writ
ingthet extoutinf
ullsentencesandagreei
ngonthewor
ding;
andref
ini
ngt exttot
hesimplestl
anguagepossi blefora“f
inal
”draft.
 I
fti
meal
l
ows,
trai
ner
scanar
rangef
ort
ransl
ator
s(i
deal
l
ytwopergr
oup)t
otr
ansl
atet
hehandbi
l
lint
o
t
helanguageofl
ocalCMAM users.Thetwot
ransl
atorsshoulddothi
sindependent
ly,compar
ethei
r
v
ersi
onsanddiscussdi
ff
erenceswitht
hepar
tici
pantstoselectt
hemostaccuraterenderi
ng.
 Askgr
oupst
oshar
ethei
rhandbi
l
ls.
 Di
scussi
npl
enar
y.

Modul
e3FI
ELDVI
SITACTI
VITY4:PRACTI
CEDEVELOPI
NGA
COMMUNI
TYOUTREACHSTRATEGYANDANACTI ONPLAN
Gr
oupDi
scussi
on:Communi
tyOut
reachSt
rat
egyandAct
ionPl
an
 Usi
ngHandout3.
4Communi
tyOut
reach:Fr
om Assessmentt
oSt
rat
egyasamodel
,hel
p
part
ici
pant
srev
iewi
nsight
sfrom t
hei
nter
viewstodr
awconcl
usi
onsaboutst
rat
egy
.Emphasi
zet
hat
theconcl
usi
onsmustbepracti
cal
andact
ionabl
e.
 St
ruct
uret
hedi
scussi
onbyaski
ngpar
ti
ci
pant
stoconsi
deratl
eastt
hef
oll
owi
ng:
theappr
opr
iat
e
durati
onofoutreach, whetherorhowlongt orelyonact i
vecase-f
indi
ngandwhichmodel t
ouse,t
he
prosandconsofusi ngexisti
ngnetworksofvol unteer
sorextensi
onworkers,
andt heinvol
vementof
ci
v i
lsoci
etyandot herpartnersout
sidetheofficial
healthsect
or.Ifti
meall
ows,tr
ainersmaywishto
addressthesestrategicquesti
onsinsmallergroupsandcompar ethegr
oups’conclusi
ons.
 Summar
iset
heemer
gingst
rat
egyasbul
l
etpoi
ntsont
hef
li
pchar
t,t
aki
ngcar
etor
evi
ewt
he
assessmenti
nsi
ght
sthatl
edt
otheconcl
usi
ons.
 Askpar
ti
cipant
stost
ruct
ureact
ionpl
ansar
oundbui
l
dingacont
inuousr
elat
ionshi
pwi
tht
he
communit
y,assi
sti
ngthecommunit
ywithsel
ecti
ngout
reachwor
ker
s,t
rai
ningv
olunt
eer
stoper
for
m
case-
fi
ndi
ng,andengagi
ngci
vi
lsoci
etypar
tner
s.
 Wi
tht
hei
nsi
ght
sint
othecommuni
tyt
hathav
ebeenaccumul
atedandshar
ed,
askpar
ti
cipant
show
t
heywoul
dal
l
ocat
eti
mef
ordi
ff
erentmobi
l
isat
ionact
ivi
ti
es.

Act
ivi
ty:FeedbackonFi
eldVi
sitSessi
on
Met
hod:Feedback/
Discussi
on
Af
tert
hef
iel
dvi
sit
,conductaf
eedbacksessi
oni
nwhi
chpar
ti
cipant
swi
l
l:
 Pr
ovi
def
eedbackonst
rengt
hsobser
vedi
nthecommuni
tyout
reachact
ivi
ti
es
 Rai
sei
ssuesf
orcl
ari
fi
cat
ionbyf
aci
l
itat
ors
 I
dent
if
ykeygapst
hatneedmor
eobser
vat
iont
ime

61
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

MODULEFOUR:OUTPATI
ENTCAREFORTHE
MANAGEMENTOFSAM WI THOUTMEDI
CAL
COMPLI
CATIONS

Modul
eOv
erv
iew
Thi
smodul ei
ntroducespar t
ici
pant stotheconcept sandprotocolsusedi noutpati
entcareforchi
ldr
en
wit
hsev ereacutemal nutr
iti
on( SAM)wi thoutmedicalcomplicat
ions.Itprovidesanovervi
ewof
admissionanddi schargeprocessesandcr i
teri
a,medicalt
reatmentandnut r
iti
onrehabi
li
tat
ionin
out
patientcare.Emphasi sisplacedont heuseofanact i
onpr ot
ocol,whichhel psheal
thcareprovi
ders
det
ermi newhichchi l
drenrequi
r erefer
raltoinpati
entcareandwhi chchildrenrequir
efol
low-upathome.
Toali
gnwi t
hthe2013Wor l
dHealt
hOrgani
sation(
WHO)gui danceonthemanagementofSAM i
ninfant
s
andchil
dren,t
hismodul
ehasalsobeenupdatedtoprovi
deguidanceonthemanagementofat
-r
isk
mother
sandi nfant
sunder6monthsofage(MAMI )wit
houtmedicalcompl
icat
ionsi
nout
pati
entcar
e.
Themodulecomplementst
heWHO2013updat esonthemanagementofSAM ininf
antsandchil
drenand
theWHOtrai
ningmodulesf
ort
heinpat
ientmanagementofSAM withmedi
calcompli
cati
ons.I
tis
i
ntendedt
obeusedalongsi
denat
ional
guidel
i
nesandnational
treat
mentpr
otocol
sforthemanagement
ofSAM.
Themodulealsoi ncludesaf i
eldvisi
twher eparti
ci
pantswil
lpract
iceassessi
ngandadmi t
tingat-ri
sk
mother
sandi nfantsunder6mont hsaspai r
sandchil
dren6–59mont hswi t
hSAM wi t
houtmedi cal
compli
cat
ionstoout patientcare.Thef i
eldvisi
twil
lal
soenableparti
cipant
stopract
icemanagi nginfant
s
andchi
ldr
eni nanout patientcarefol
low- onsessi
on.Part
ici
pantswil
lalsohavetheopport
unityduring
thi
sfi
eldvi
sittopr acticetheskill
scov eredinModule2.Defini
ngandMeasur i
ngAcuteMalnut r
iti
on.

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises
1.Descri
beOut patientCarefor 15 Power
Poi
nt:
Over
viewofCMAM f
rom Modul
e1(
opt
ional
)
theManagementofSAM minut
es
WithoutMedical
Compl i
cat
ions
2.Descri
beAdmi ssionCri
ter
ia 45 Handout4.
1Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
or
i
nOut pati
entCar e(Inf
ants minut
es CMAM
Under6Mont hsandChi l
dren
Handout4.
2Out
pat
ientCar
e:Admissi
onCr
it
eri
afor
6–59Mont hs)
I
nfant
sUnder6MonthsandChi
ldr
en6–59Months
Exer
cise4.1Out
pati
entCar
eAdmi
ssi
onf
orI
nfant
sUnder
6Mont hsandChi
ldr
en6–59Mont
hs
3.Descr
ibetheProcessfor 1½hour
s Handout4.
3Out
pat
ientCar
e:Admi
ssi
onPr
ocessf
or
Admissi
onsandOut pati
ent Chi
ldr
en6–59Mont
hs
CareFol
low-OnSessionsfor
Handout4.
4Out
pat
ientCar
eTr
eat
mentCar
dfor
Chi
ldr
en6–59Mont hs
Chi
ldr
en6–59Mont
hs
Handout4.
5RUTFRat
ionCar
dforChi
l
dren6–59
Months
Handout4.6Usi
ngOutpat
ientCar
eTreat
mentCar
dand
RUTFRationCar
dforChil
dren6–59Months
Exer
cise4.
2Outpat
ientCar
eTr
eatmentCar
dandRUTF
Rati
onCardforChi
l
dren6–59Months

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orCommuni
ty-
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eMal
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ri
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on(
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,2018Ver
sion

4.ExplainMedicalTr
eatment 1hour Handout4.
7MedicalTreat
mentf
ort
heManagementof
fort
heManagementof SAM i
nOutpat
ientCare
Chil
dr enWithSAM Without
Handout4.
8Rout
ineMedi
cinesf
orSAM i
nOut
pat
ient
Medi calCompli
cat
ionsin
Care
Outpat i
entCar
e
Handout4.9Suppl
ement
alMedi
ci
nesf
orSAM i
n
Outpat
ientCar
e
Handout4.10Medici
neProt
ocol
Rat
ional
efor
Outpat
ientCar
e(Refer
ence)
5.Explai
nNut r
it
ion 30 Handout4.
11Nut
ri
ti
onRehabi
l
itat
ionandRUTFf
or
Rehabil
it
ati
onf ort
he minut
es Chi
ldr
en6–59Months
ManagementofSAM
WithoutMedical
Compl i
cati
onsinOutpat
ient
Care(Chil
dren6–59Mont hs)
6.Descri
betheKeyMessages 30 Handout4.12KeyMessagesf
orIndi
vi
dual
Counsel
li
ng
forMothers/Car
egiv
ersof minut
es forMothers/
Caregi
ver
sofChi
ldr
en6–59Monthsin
Chil
dren6–59Mont hsUsed Outpat
ientCare
i
nOut pat
ientCare
7.Explai
ntheManagementof 1hour Handout4.13C-
MAMIToolVersi
on2.
0:Br
east
feedi
ng
At-
RiskMot her
sandInf
ants Counsel
li
ngandSuppor
tAct
ions
under6Mont hsofAge
Handout4.
14Outpat
ientCare:
Admissi
onPr
ocessf
or
WithoutMedical
At-
RiskMother
sandInfant
sUnder6Months
Compl i
cat
ionsinOut
pati
ent
Care Handout4.15Outpat
ientCar
eTreat
mentCar
dforAt
-
Ri
skMot hersandInf
antsUnder6Mont
hs
8.Recogni
singWhenFurther 45 Handout4.
16Out
pat
ientCar
eAct
ionProt
ocol
for
Acti
onIsNeeded:Ref
erral
to minut
es I
nfant
sUnder6Mont
hsandChil
dren6–59Months
I
npati
entCareandFoll
ow-Up
Handout4.17Refer
ralt
oInpat
ientCar
eorFoll
ow-Up
HomeVi si
ts
HomeVi si
tsforI
nfant
sUnder6Mont hsandChil
dren
6–59Mont hs
Handout4.18Ref
err
alSl
ipf
orI
nfant
sUnder6Mont
hs
andChil
dren6–59Months
Exerci
se4.3Ident
if
yingI
nfant
sUnder6Mont
hsand
Chil
dren6–59Mont hsWhoMayNeedFoll
ow-UpHome
Visi
tsorReferr
alt
oInpati
entCar
e
9.Expl
ainDischar
geCr i
teri
a 30 Handout4.
19Out
pati
entCare:Di
schar
geCri
ter
iaf
orAt-
andProceduresforAt-Ri
sk minut
es ri
skMother
sandI
nfantsUnder6MonthsandChil
dren
MothersandInfantsUnder6 6–59Months
MonthsandChi l
dren6–59
Handout4.
20Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
or
Months
CMAM
Exerci
se4.4Part
ial
l
yCompl
etedOut
pat
ientCar
e
TreatmentCar
ds
10.Descri
beLinkagesBetween 30 Handout1.11Int
egratingCMAM i
ntoRout
ineHeal
th
Outpati
entCareandOther mi nut
es Ser
vicesattheDist
rictLevel
Servi
ces,Pr
ogrammes, and
Ini
ti
ati
ves
Wrap-UpandModul eEval
uati
on 15 Handout4.
21Essent
ial
sofOutpat
ientCar
eforSAM
minut
es Wit
houtMedical
Complicat
ions

63
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ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

(addit
ional Opt
ional
Exer
cise4.
5Out
pat
ientCar
eAdmi
ssi
onsRol
e
15–20 Pl
ay
minutes
forthe
opti
onal
exerci
se)

Fi
eldVi
sitf
orOut
pat
ientCar
e 3day
s Handout4.
22Out
pat
ientCar
eFi
eldPr
act
iceCheckl
i
st

Modul
eDur
ati
on:Ei
ghthour
sincl
assr
oom;
thr
ee-
dayf
iel
dpr
act
ice
Not
e:Dependi
ngont heneedsoft hei
raudi
ence(s),t
rai
ner
smaychooset
oski
porspendmor
eorl
ess
t
imeoncertai
nlear
ningobject
ivesandacti
vit
ies.Themoduledur
ati
oni
sanest
imat
eofthet
imei
ttakes
t
ocompleteal
lthelear
ningobject
ivesandactiv
iti
es.

Mat
eri
als
 Mi
d-upperar
m ci
rcumf
erence(
MUAC)t
apes(
number
ed)andwei
ghi
ngscal
e
 Hei
ghtboar
dandwei
ght
-f
or-
hei
ght(
WFH)z-
scor
echar
t(opt
ional
)
 Packet
sofr
eady
-to-
uset
her
apeut
icf
ood(
RUTF)
 Napki
ns(
forsampl
i
ngRUTF)
 Sci
ssor
s
 Fl
i
pchar
ts
 Mar
ker
s
 Maski
ngt
ape
 Handout4.
13C-
MAMITool
Ver
sion2.
0:Br
east
feedi
ngCounsel
l
ingandSuppor
tAct
ions
 Out
pat
ientcar
etr
eat
mentcar
dsf
orchi
l
dren6–59mont
hs
 C-
MAMIout
pat
ientcar
etr
eat
mentcar
dforat
-r
iskmot
her
sandi
nfant
sunder6mont
hs
 RUTFr
ati
oncar
dsf
orchi
l
dren6–59mont
hs
 Ref
err
alsl
i
psf
rom out
reachwor
ker
s
 Pr
oject
or(
opt
ional
)
 Power
Poi
ntf
rom Modul
eOne(
opt
ional
)

Adv
ancePr
epar
ati
on
 Revi
ewnat
ional
gui
del
i
nesandpr
otocol
sfort
het
reat
mentofSAM i
nthecount
rywher
ethet
rai
ningi
s
bei
ngconduct ed.Deter
minewhatageandcri
teri
aareusedforadmi ssi
on.Det
ermi
newhet herwei ght
-
for
-height(WFH)/weight-
for
-l
ength(
WFL)i
srequiredf
oradmission.IfWFH/WFLisnotrequired,use
onlythebil
ater
alpit
ti
ngoedemaandMUACcr i
teri
aduri
ngthetrai
ning.IfWFH/WFLisr
equi r
ed,
i
ncludeitinthetr
aini
nganduset het
abl
esfortheWFH/ WFLz-scoresoftheWHOstandards( gender
specifi
c).
 Revi
ewt
heHandout4.
13C-
MAMITool
Ver
sion2.
0:Br
east
feedi
ngCounsel
li
ngandSuppor
tAct
ions
anddet
ermi
newhatadapt
ati
onsneedtobemadetoaccommodat
ethemanagementofat-r
isk
mother
sandinf
ant
sunder6monthsofagewi
thoutmedi
cal
compli
cat
ionsi
noutpat
ientcar
e.
 Ensur
ethaty
ouhav
ethebr
east
feedi
ngv
ideosdownl
oadedorav
ail
abl
efort
hedemonst
rat
ion
sessi
onsi
nLearni
ngObject
ive7:Expl
aint
heManagementofAt
-Ri
skMot
her
sandI
nfant
sUnder6
MonthsofAgewit
houtMedical
Complicat
ionsi
nOut
pati
entCar
e.

64
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

 Pr
epar
eset
sofl
ami
nat
edcar
dswi
tht
headmi
ssi
onanddi
schar
gecr
it
eri
aforat
-r
iskmot
her
sand
i
nfant
sunder6mont hsandchi
l
dren6–59mont
hs,
act
ionpr
otocol
,medi
cal
treat
ment
,andnut
ri
ti
on
r
ehabil
it
ati
onpr
otocols.
 Pr
epar
eachar
tofnat
ional
prot
ocol
sforf
ir
st-
li
neant
ibi
oti
ctr
eat
mentf
orchi
l
drenwi
thSAM,
ant
ihel
mint
h,andmal
ari
atr
eat
ment
s.
 Obt
ainl
ocal
ver
sionsofout
pat
ientcar
etr
eat
mentcar
dsandRUTFr
ati
oncar
dsi
fpossi
bleoruset
he
st
andar
dcar
ds.
 I
fopt
ional
Exer
cise4.
5Out
pat
ientCar
eAdmi
ssi
onsRol
ePl
ayi
sdone,
makecar
dswi
tht
her
oles’
descript
ionsaswel lascopiesofbl
ankoutpati
entcaretreat
mentcards,
blankRUTFrati
oncards,
ref
erralsli
psfrom outreachworker
sindi
cati
ngredMUAC, andHandout4.11Nutr
it
ionRehabi
lit
ati
on
andRUTF( speci
fi
callythesect
iononRUTFRat i
on).Also,makesuretohaveMUACt apesandadoll
avai
lable.
 Revi
ewr
elev
antr
efer
encer
esour
cesandf
urt
herr
eadi
ngr
esour
cesl
i
stedbel
ow.

Ref
erenceResour
ces
1. Nat
ional
gui
del
i
nesf
orCMAM

2. WorldHealthOrgani
sati
on(WHO) .2013.Gui
deli
ne:UpdatesontheManagementofSever
eAcute
Malnutr
it
ioninI
nfantsandChil
dren.Geneva:WHO.Availabl
eat:
ht
tp://
www. who.i
nt/
nutri
ti
on/
publicat
ions/
guidel
ines/
updates_
management_
SAM_ i
nfant
andchi
l
dre
n/
en/ .

3. WHO.2014.Int
egrat
edManagementofChi
ldhoodIll
nesses(I
MCI
)ChartBookl
et.Av
ail
abl
eat
:
ht
tp:
//www.who.i
nt/
mater
nal
_chi
l
d_adol
escent/documents/
IMCI
_char
tbookl
et/
en/.

4. EmergencyNutr
it
ionNetwor
k(ENN)
.2018.C-
MAMITool
Ver
sion2.
0.Av
ail
abl
eat
ht
tps:
//www.ennonli
ne.
net
/c-
mami.

5. CoreGr oup.2015.Essenti
alNutri
ti
onActi
onsandEssent
ialHygieneActi
onsFr
amewor k.Avai
labl
e
at
: htt
p://coregr
oup.nonpr
ofi
tsoapbox.
com/r
esour
ces/488-essenti
al-
nut
ri
ti
on-
act
ions-
and-essent
ial
-
hygiene-acti
ons-
framework.

6. EmergencyNutr
it
ionNetwor
k( ENN).2009.I
ntegr
ati
onofI
YCFSuppor
tint
oCMAM.Avai
l
abl
eat
:
ht
tps:
//www.ennonli
ne.
net
/int
egrat
ioniy
cfi
ntocmam.

7. Vali
dInter
nat i
onal.2006.Communi t
y-basedTherapeut
icCare(CTC):AFiel
dManual.Oxfor
d:Vali
d
I
nternat
ional.Avail
ableat:ht
tps:
//www. f
antapr
oject
.or
g/si
tes/
default
/fi
l
es/resour
ces/
CTC-Fi
eld-
Manual-
Oct 2006-508.pdf

Fur
therReadi
ngResour
ces
1. Nat
ional
gui
del
i
nesf
ori
ntegr
atedmanagementofchi
l
dhoodi
l
lness(
IMCI
)

2. WHO.2013.PocketBookofHospi t
alCaref
orChil
dren:Gui
deli
nesforManagementofCommon
Chi
ldhoodI
lnesses.2ndEdi
l t
ion.Avai
labl
eat:
ht
tp:/
/www.who.i
nt/maternal_chi
l
d_adol
escent
/documents/chi
ld_
hospi
tal
_car
e/en/
.

3.Lel
ij
veld,N.etal.2017.ARev i
ewofMet hodstoDetectCasesofSeverelyMalnour
ished
Inf
antsLessthan6Mont hsforThei
rAdmi ssi
onint
oTher apeut
icCare.EmergencyNutri
ti
on
Network.Avail
ableat:ht
tps:
//www.
ennonli
ne.
net
/mamicasedet
ect
ionr
evi
ew.

4. Bai
ley
, .2016.Combi
J.etal nedProt
ocolf
orSAM/MAM Tr
eat
ment
:TheComPASst
udy.Avai
l
abl
eat
:
ht
tps:
//www.ennonl
ine.
net
/fex/
53/t
hecompasst
udy
.

65
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

5. Maust,A.etal
.2015.“
SevereandModerateAcuteMalnutri
ti
onCanBeSuccessf ul
l
yManagedwi
th
anInt
egratedProt
ocoli
nSierr ”Jour
aLeone. nalofNutri
ti
on.Avail
ableat:
ht
tps:
//pdfs.
semanti
cschol
ar.
org/
d5c2/e4bed4e18d6cdfa6d6b3b31f69d0ee347d54.
pdf
.

6.Phil
i
p, T.
J.etal
.2015.“Low-DoseRUTFProt
ocolandImprovedServ
iceDel
iver
yLeadto
GoodPr ogrammeOutcomesi ntheTreat
mentofUncomplicat
edSAM: AProgr
amme
Reportfrom Myanmar”Mat
. er
nal&Chil
dNutr
it
ion.11(
4):
859–69.doi:
10.
1111/mcn.12192.
Epub2015Apr7.Av ail
ableat:
ht
tps:
//www.
ncbi
.nl
m.ni
h.gov
/pmc/
art
icl
es/
PMC4672709/
pdf
/mcn0011-
0859.
pdf
.

66
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module4Learni
ngObjecti
ve1:Descr
ibeOut
pati
entCar
efort
he
ManagementofSAM WithoutMedi
calCompl
icat
ions

TRAI
NER:I
fnecessar
y,r
evi
ewModul
eOnePower
Poi
ntpr
esent
ati
onsl
i
des48t
hrough53onout
pat
ient
car
efort
hemanagementofSAM wi
thoutmedi
cal
compl
i
cat
ions.

GROUPDI
SCUSSI
ON:COMMUNI
TY-
BASEDMANAGEMENTOFACUTEMALNUTRI
TION.Dr
aw
Fi
gur
e1ont
hef
li
pchar
t.Askpar
ti
ci
pant
s:

1. Whati
soutpat i
entcare?Whatdoesitent
ail
?
2. Whorecei
vesout pat
ientcare?
3. Howdoesout pati
entcareforSAM wit
houtmedi
cal
compl
i
cat
ionsdi
ff
erf
rom i
npat
ientcar
eforSAM
wi
thmedicalcompl i
cati
ons?

Di
scussandf
il
li
ngaps.

Fi
gur
e1.Cor
eComponent
sofCMAM

Community
Out
reach
Outpati
entcare
f
ormanagement
ofSAM
WITHOUT
I
npat
ient medical Othernutri
tionandheal th
car
ef or complicati
ons int
erventions,food
mgmtof
SAM WI TH securi
ty,socialprotecti
on
medical andWASH, t
opr event
undernutrit
ion
Management
of
MAM

67
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e4Learni
ngObject
ive2:Descr
ibeAdmi
ssi
onCri
ter
iai
nOut
pat
ient
Car
e(I
nfant
sUnder6MonthsandChildr
en6–59mont
hs)

TRAI
NER:
Becomef
ami
l
iarwi
thHandout4.
1Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
orCMAM,
Handout4.2Outpat
ientCar
e:Admi
ssi
onCrit
eri
aforInf
ant
sUnder6MonthsandChi
ldr
en6–59Mont
hs,
andExerci
se4.1Outpati
entCar
eAdmissi
onforAt-
RiskMother
sandI
nfant
sUnder6Monthsand
Chi
ldr
en6–59Mont hs.

BRAI
NSTORM:ADMI
SSI
ONCRI
TERI
AFOROUTPATI
ENTCARE.Askpar
ti
cipant
stonamet
he
characteri
st i
csofinfant sandchi l
drenwhoshoul dbeadmi tt
edt oout patientcare(i
.e.,
infantsunder6
mont hswhoar enut ri
tionall
yvulnerable[i
.e.
,moder atenut rit
ionrisk]wi thnomedi calcompl icati
onsand
chi
ldren6–59mont hswhohav eSAM, havenomedi calcompl i
cations, haveanappet it
e).Wr it
er esponses
onthef li
pchar t.I
fnotnamedbyt hepar ti
cipants,explai
nt hatt herear eaf ewaddi t
ionalcategoriesof
chi
ldrenwhoshoul dbeadmi tt
ed:
 I nfantsunder6mont hsofagewhoar enut ri
ti
onal l
yv ulnerablewi t
houtmedi calcompl i
cations( i
.e.
,
moder atenutrit
ional ri
sk)orbil
ateralpitt
ingoedemacanbeadmi ttedformanagementi nt he
out pati
entcar e.Managementofbr eastfedinfantsunder6mont hsofageshoul dpriori
tize
establishingorr e-establi
shi
ngef fecti
veexclusivebr eastfeedingbyt hemot herorot herfemal e
caregiv er.I
nfantsunder6mont hswhoar enotbr eastfedwi llalsoneedt obeassessedandpr ovided
targetedf eedingsuppor t
.
 I
nfant
sunder6mont
hswhoar
enut
ri
ti
onal
l
yvul
ner
abl
ewi
thmedi
cal
compl
i
cat
ions(
i.
e.,
high
nut
ri
ti
onal r
isk)andchil
dren6–59mont hswithSAM andmedicalcompli
cat
ionswhose
mother/car
egiverr
efusesinpat
ientcar
edespiteadv
ice.Thei
nfantwi
ll
requi
refol
low-
uphomev
isi
ts
andclosemoni t
ori
ngwhi l
einoutpati
entcar
e.
 Chi
l
drenwhoaheal
thcar
epr
ovi
derhasdet
ermi
nedshoul
dbeadmi
tt
ed,
suchaschi
l
drenov
er5y
ear
s
ofagewi
thbi
l
ater
alpi
tt
ingoedemaorwhoar
esev
erel
ywast
ed.
 I
nfant
sandchi
l
drenwhosemedi
cal
compl
i
cat
ionshav
eresol
vedi
ninpat
ientcar
eandhav
ebeen
r
efer
redt
oout
pat
ientcar
etocompl
etet
hei
rnut
ri
ti
onr
ehabi
l
itat
ion.
 I
nfant
sandchi
ldr
enwhoar
erecuper
ati
ngf
rom SAM andwhor
etur
naf
terdef
aul
ti
ng(
dischar
ged
af
terbei
ngabsentf
ort
hreeconsecut
ivesessi
ons)andneedt
ocont
inuet
hei
rtr
eat
ment
.

Referparti
cipantstoHandout4.1Admissi
onCr i
teri
aandEntr
yCat egori
esforCMAM.Wal kparti
cipant
s
thr
ought heinformationandansweranyquest
ions.Ref
erpar
ti
cipantstoHandout4.2Out
patientCare:
Admi ssi
onCr it
eriaforInf
ant
sUnder6Mont hsandChildr
en6–59Mont hsf
orfutur
eref
erence.

PRACTI
CE:ADMI
SSI
ONCRI
TERI
AFOROUTPATI
ENTCARE.For
m wor
kinggr
oupsoft
hreet
ofour
people.Di
str
ibuteExerci
se4.1Out
patientCareAdmi ssi
onf orI
nfantsUnder6Mont hsandChil
dr en
6–59Mont hs.Askeachwor ki
nggrouptouset heinf
ormat i
onprovidedintheexer
cisetodecidewhet her
thesamplechildr
enshouldbeadmitt
edt ooutpati
entcareandt oexplai
nwhyorwhynot .Hav
egr oups
sharethei
ranswer si
nplenar
y.Di
scussandf i
l
l i
ngaps, r
eferr
ingtoExercise4.
1Out pati
entCare
Admi ssi
onforInfant
sUnder6Mont hsandChi ldr
en6–59Mont hsanswersheet(ont henextpage).

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,2018Ver
sion

Exer
cise4.
1Outpat
ientCar
eAdmi
ssi
onf
orI
nfant
sUnder6Mont
hsandChi
ldr
en6-
59Mont
hs
(Wit
hAnswers)
Bi
lat
eral *
WFH/ WFL
Age MUAC Other
Appet
it
e Pi
tti
ng z-scor
e Admi
tt
edt
oout
pat
ientcar
e?
(mont
hs) i
nmm i
nformat
ion
Oedema (
WHO)
Chi
ld1 7 Yes No 102 -
3≤t
o<-
2 YES,basedonMUACandchil
d
hasappeti
te
Chi
ld2 24 Yes No 117 <-
3 YES,basedonWFHandchi
ldhas
appet
ite
(Note:IfonlyMUACi sused,WFH
wouldnotbeknownandchi ld
wouldnotbeadmi t
tedto
outpatientcar
ebecauseMUAC>
115)
Chi
ld3 20 Yes No 108 <-
3 YES, basedonMUAC
YES, basedonWFL
andchi ldhasappet i
te
Chi
ld4 16 Yes ++ 117 -
3≤t
o<-
2 YES, becausechil
dhasbi lat
eral
pit
ti
ngoedemagr ade++
andchi ldhasappet i
te
Chi
ld5 36 Yes + 118 -
3≤t
o<-
2 YES, becausechil
dhasbi lat
eral
pit
ti
ngoedemagr ade+
andchi ldhasappet i
te
Chi
ld6 12 No No 95 <-
3 NO, becausechildhasSAM and
hasnoappet i
te;r
efertoinpat
ient
care
Chi
ld7 50 Yes No 112 <-
3 YES, basedonMUAC
YES, basedonWFH
andchi ldhasappet i
te
Chi
ld8 45 Yes No 116 NOi fMUAConl yisused
<-
3
YES,basedonWFH
andchil
dhasappet
it
e
Chi
ld9 7 Yes No 107 -
3≤t
o<-
2 YES,basedonMUAC
andchil
dhasappet
it
e
Chi
ld10 5 No,inf
anti
s No 104 -
3≤t 2 Recent
o<- YES,i
nfanti
snutri
ti
onal
ly
refusi
ngto fai
l
uret
o vul
ner
ablewithnomedical
breastf
eed gai
nweight compli
cati
ons(i
.e.
,moderat
e
nut
ri
ti
onalri
sk).
(Note: Thereisgrowi ngev idence
ont heuseofMUACt oidentif
y
nutrit
ionalvulnerabil
ityininfants
under6mont hs.Howev er,
nutrit
ionalclassif
ication
thresholdshav enoty etbeen
established.Iti
sr ecommended
thatMUACdat abecol l
ectedf or
thi
sagegr oupt ohelpbui ldthe
evidencebaseont hresholdsand
casemanagement .
)

Note:I
ncount
ri
eswher
epresenceofbi
l
ater
alpi
tt
ingoedemaandmid-upperarm ci
rcumfer
ence(MUAC)are
usedforadmi
ssi
on,
adj
ustchartt
oremovei
nfor
mationonwei
ght-
for
-height(
WFH) /weight
-for
-l
engt
h(WFL)z-
score.

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,2018Ver
sion

Modul
e4LearningObj
ect
ive3:Descr
ibetheProcessf
orAdmissi
onsand
Out
pat
ientCar
eFoll
ow-
OnSessionsforChil
dren6–59Months

TRAI
NER:Becomef
ami
l
iarwi
thHandout4.
3Out
pat
ientCar
e:Admi
ssi
onPr
ocessf
orChi
l
dren6–59
Months,Handout4.
4Out pat
ientCareTreat
mentCardforChil
dren6–59Mont hs,Handout4.
5RUTF
Rat
ionCardforChil
dren6–59Mont hs,Handout4.6Usi
ngOut pat
ientCar
eTr eatmentCardandRUTF
Rat
ionCardforChil
dren6–59Mont hs,andExerci
se4.2Outpati
entCareTreatmentCardandRUTFRati
on
Car
df orChi
ldr
en6–59Mont hs.

PARTI
CIPATORYLECTURE:ADMI
SSI
ONPROCESSFOROUTPATI
ENTCARE.Ref
er
part
ici
pant
st otheoverv
iewoftheoutpat
ientcareadmissionprocessinHandout4.
3Admi ssionProcess
forOutpat
ientCareforChi
ldr
en6–59Mont hs.Walkparti
cipant
sthrought
hesteps,emphasizingt
he
i
mpor t
antconsider
ati
onstheyneedtotakeintoaccount.Respondtoquesti
ons.

PRACTICE:FILLINGOUTANOUTPATI ENTCARETREATMENTCARDANDRUTFRATI ON
CARD.Dist
ri
butealocal
out
pat
ientcar
etr
eatmentcar
difonei
sav
ail
abl
e.Ot
her
wise,
useHandout4.
4
OutpatientCareTreatmentCardf orChil
dren6–59Mont hs.Notet
hatALLchi l
drenadmit
tedtoCMAM at
theoutpatientcar
esiterecei
veanout pat
ientcaret
reatmentcar
d,i
ncludi
ngthosebeingrefer
redto
i
npatientcare.Expl
ainthegeneralcol
umnandr owdetail
sontheoutpati
entcaretr
eatmentcardandthe
i
nformat i
onneededt ofil
loneout.Reviewthecontentbel
owandonHandout4. 6UsingOutpati
entCare
Treat
mentCar dandRUTFRat i
onCar dforChil
dren6–59Mont hs.
 Admi
ssi
oni
nfor
mat
ionpr
ovi
dedont
heout
pat
ientcar
etr
eat
mentcar
dincl
udes:
- Name,
ageandsexofchi
l
d,nameofpar
ent
s,pl
aceofor
igi
n
- Dat
eofadmi
ssi
on,
admi
ssi
onchar
act
eri
sti
cs
- Nameofheal
thf
aci
l
itywi
thout
pat
ientcar
esi
te
- Regi
str
ati
onnumber
- Gener
alf
ooddi
str
ibut
ionaccess
- Br
east
feedi
ngst
atus
- Ant
hropomet
ryuponadmi
ssi
on,
admi
ssi
oncr
it
eri
aexami
ned
- Medi
cal
hist
ory
- Phy
sical
exami
nat
ion
- Vacci
nat
ionst
atus
- Rout
ineadmi
ssi
onmedi
cat
ion
- Ot
hermedi
cat
ion

 Fol
l
ow-
upi
nfor
mat
ionpr
ovi
dedont
reat
mentcar
dincl
udes:
- Ant
hropomet
ry
- Medi
cal
hist
ory
- Phy
sical
exami
nat
ion
- RUTFappet
it
etest
- NumberofRUTFpacket
spr
ovi
ded
- Tr
eat
mentout
come
- Act
iontaken
Referparti
cipantst
oHandout4.
5RUTFRati
onCardforChi
ldr
en6–59Monthsandrev
iewthe
i
nformationf oundont
her
e.Askpar
ti
ci
pant
stofor
m pair
sandpassoutcopi
esoft
heOutpati
entCar
e

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eMal
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CMAM)
,2018Ver
sion

Tr
eat
mentCar
dsandRUTFRat
ionCar
ds.Havepart
ici
pant
scompl
eteExerci
se4.2:Outpat
ientCar
e
Tr
eat
mentCar
dandRUTFRati
onCardforChi
ldr
en6–59Months.Respondtoquesti
ons.

Brai
nstor
m: WeeklySessionsatOutpat
ientCare.Ref err
ingbacktot heprocessinHandout4.3,ask
part
ici
pantstosuggestwhichacti
vi
ti
esandpr ocedur esoccurinoutpati
entcarefol
low-onsessi
ons.
(Answer:Al
lacti
vit
iesandprocedur
esshouldbei ncludedexceptforassigningaregist
rat
ionnumber,
whichoccursonlyatadmissi
on,andmeasuringhei ght/l
ength,
whichoccur sonlyoncepermonthi f
WFH/ WFLisused).

Emphasi
zethatdur
ingeachsessi
on,
iti
sessent
ial
todet
ermi
newhet
herr
efer
ral
orf
oll
ow-
uphomev
isi
ts
ar
enecessar
yandexplai
nthefoll
owi
ngpoi
nts:
 Themot
her
/car
egi
verandchi
l
dshoul
dret
urnt
oaheat
hfaci
l
ityt
hatpr
ovi
desout
pat
ientcar
eforSAM
withoutmedicalcompli
cati
onsonaweeklybasis.I
fthereisapr obl
em wit
hattendancedueto
distanceorotherr
easons,i
tmightbenecessar
ytoaskt hemot her/
car
egivert
ocomet oout
pati
ent
careev er
ytwoweeks;ifthi
sisthecaset
hemot her
/caregivershoul
drecei
veat wo-weeksuppl
yof
RUTF.
 Bi
l
ater
alpi
tt
ingoedemai
sassessedandMUACandwei
ghtar
etakenateachweekl
yout
pat
ientcar
e
f
oll
ow-
onsessi
on.Hei
ght/l
engt
hismeasuredoncepermont
hifi
tisnecessar
ytocal
cul
ate
WFH/WFLz-
scoret
oreassessant
hropometr
icst
atus.
 Theappet
it
etesti
sdoneatev
erysessi
on.
 Anut
ri
ti
onandmedi
cal
assessment(
i.
e.ant
hropomet
ry,
medi
cal
hist
ory
,br
east
feedi
ngassessment
f
orchi
l
dren6–23mont
hs,
phy
sical
exami
nat
ion)i
sdoneatev
eryout
pat
ientcar
efol
l
ow-
onsessi
on.
 Compl
etedosesofr
out
inemedi
ci
nesar
egi
venaccor
dingt
orout
inemedi
cal
prot
ocol
s(t
hisi
s
cov
eredi
nLear
ningObj
ect
ive4)
.
 Anout
pat
ientcar
eact
ionpr
otocol
isf
oll
owedt
odet
ermi
newhet
herr
efer
ral
oraf
oll
ow-
uphomev
isi
t
i
sneeded(
thi
siscov
eredi
nLear
ningObj
ect
ive8)
.
 Addi
ti
onal
medi
cat
ionsgi
vendur
ingout
pat
ientcar
efol
l
ow-
onsessi
onsshoul
dbenot
edont
he
out
pat
ientcar
etr
eat
mentcar
d.
 RUTFi
spr
ovi
dedaccor
dingt
othechi
l
d’swei
ght
,andt
hemot
her
/car
egi
veri
scounsel
l
edoni
tsuse.
 Themot
her
/car
egi
veri
saskedwhet
hert
hechi
l
dhaseat
enal
ltheRUTF.I
fther
ear
esomepacket
s
l
eftoverfr
om theprevi
ousweek, t
hehealthcareprov
iderreducestheamountofRUTFgiv
enbyt hat
numberofpackets.Forexample,i
fthemot her
/car
egiverhasthreepacket
slef
tfr
om a14-
packet
rat
ion,11packet
sareprovidedforthenextweek.Thehealthcareprovi
deral
soshoul
dcoll
ectempty
RUTFpackets.
 Theheal
thcar
epr
ovi
dercompl
etest
heout
pat
ientcar
etr
eat
mentcar
dandRUTFr
ati
oncar
d.

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,2018Ver
sion

Module4LearningObject
ive4:Expl
ainMedicalTreatmentf
orthe
ManagementofChil
drenWi t
hSAM Wi thoutMedicalCompli
cat
ionsi
n
Out
patientCar
e

TRAI
NER:
Becomef
ami
l
iarwi
thHandout4.
7Medi
cal
Treat
mentf
ort
heManagementofSAM i
n
Out
pat i
entCar
e,Handout4.8Routi
neMedici
nesforSAM i
nOutpat
ientCare,Handout4.9Supplemental
Medici
nesforSAM i
nOut pat
ientCar
e,andHandout4.
10Medici
nePr ot
ocolRational
eforOutpati
entCare
(
Reference)
.

PARTI
CIPATORYLECTURE:ROUTI
NEMEDI
CALTREATMENTI
NOUTPATI
ENTCARE.Ref
er
par
ti
cipant
stoHandout4.7MedicalTr
eat
mentfortheManagementofSAM i
nOut
pat
ientCar
eand
di
scuss,emphasi
sing:
 Whenchi l
drenshouldNOTrecei
vemalar
iat
reat
ment
 Whyi
ronandf
oli
caci
d,andVi
tami
nAar
eNOTgi
venr
out
inel
y
 Whi
cht
reat
ment
sar
egi
vendur
ingt
hechi
ld’
sfi
rstsessi
onatout
pat
ientcar
e(i
.e.
,amoxi
cil
li
n,
malar
iatest
ingortreat
mentifappropr
iate)andwhicharegivenl
ater(
e.g.
,dewor
ming,
measl
es
vacci
nat
ionifnecessar
y,t
reatmentforanaemiaifnecessar
y )

Answeranyquest i
onsandr eferpart
ici
pant
stoHandout4.8Rout i
neMedi
cinesforSAM i
nOutpati
ent
Care.Inplenary,
expl ai
nthedet ai
l
softhemedicalt
reat
mentpr ot
ocol
sastheyappeari
neachcolumnand
row.Relaytoparticipant
sanyadapt ati
ons/
dif
fer
encesthatshoul
dbemadei naccor
dancewi
thcountr
y-
specif
icnationaldrugprotocols.

PRACTI
CE:ROUTI
NEMEDI
CALTREATMENTOFSAM.Askpar
ti
cipant
stof
orm gr
oupsoft
hree.
Onaflipchart
,wri
tethebasi
cinfor
mationofanumberofchil
dreni
noutpati
entcar
e(bel
ow).Ask
par
ti
cipantstodet
erminewhichmedicati
onsanddosageseachchi
ldneedsbasedonwhetherthechi
l
dis
anewcase, whatmedicat
ions/hehasalr
eadyrecei
ved,
his/
hermedical
condit
ion,
andhis/
herage.

 Pat
ient1: Girl,
age2y ears
 Ref erredfrom inpati
entcar eaft
er10day sofstabil
isati
onofmedi calcompl i
cat
ions,
which
includedey esi gnsofvitaminAdef i
ciency.Thegirli
snowcl i
nical
lywel l
,hasagoodappetit
e,and
receivedt wodosesofv itaminAonDay1and2ofi npati
entcareforthetreatmentofvi
tami
nA
def i
ciency.Ithasbeen5day ssi
nceshewasdi schargedfrom i
npatientcare.
 Bi lateralpit
tingoedema: Grade+
 Par acheck: Negative
 Vacci nati
onr ecord:Alluptodat e
 Vi tami nA: Day1and2ofi npati
entcare

Answer:Gi
veamoxi ci
l
li
n3t i
mesperdayfor7days;
donotgivemal
ariatr
eat
ment;donotgi
ve
measlesvacci
nati
on(givenaft
er4weeks)
.Giv
ethethi
rddoseofvi
taminA(onday15)tocompl
ete
thet
reatmentofeyesigns.

 Pat
ient2:Boy, age18mont hs
 Newadmi ssion
 Bi l
ateral
pittingoedema:No
 Par acheck: Posi
ti
v e
 Vacci nati
onr ecord:I
ncompl
ete
 Vi t
ami nAl astgiv
en: 6mont
hsago

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,2018Ver
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Answer:Gi
veamoxici
ll
in3ti
mesperdayf or7days;gi
vemalari
atreatmentaccor
dingt
oprotocol
;gi
ve
measlesvacci
nat
iononweekf ourorassoonaspossibl
e,pl
usothervacci
nesasperexpanded
pr
ogrammeofi mmunisat
ion(EPI);
donotgivev
itaminAbecauseitisal
readyint
heRUTF.

 Pat
ient3:Girl,15mont hs
 Secondvi sittoout pati
entcare
 Bi l
ateralpitt
ingoedema: grade+
 Par acheck: Negat ive
 Vacci nati
onr ecord:Incomplet
e
 Vi t
ami nAl astgi v
en: 4mont hsago
 Amoxi ci
l
linl astgiven:Weekoneonadmi
ssi
on

Answer:Gi
vemedendazol
eorot
herdeworming;gi
vemeaslesvacci
nat
iononweekf
ouraswellas
otherv
acci
nesasperEPI;
donotgi
vemalari
at r
eat
ment;donotgivevi
tami
nAbecausei
tisal
readyi
n
theRUTF.

REVI
EW ANDREFERENCE:Di
rectpar
ti
ci
pant
stoHandout4.
9Suppl
ement
alMedi
cinesf
orSAM i
n
OutpatientCare.Revi
ewbriefl
ythesupplement
almedicinesonHandout4. 9andinwhatcircumst
ances
theywoul dbegiven.Answeranyquesti
ons.Dir
ectpar
ticipant
st oHandout4.10MedicineProt
ocol
RationaleforOutpati
entCare(Refer
ence)tobeusedfort hei
rrefer
encei
nt hefut
ure.

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eMal
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,2018Ver
sion

Module4Learni
ngObjecti
ve5:Explai
nNutri
ti
onRehabil
it
ationfort
he
ManagementofSAM WithoutMedicalCompl
icat
ionsi
nOut pati
entCar
e
(
Chil
dren6–59Months)

TRAI
NER:Becomef
ami
l
iarwi
thHandout4.
11Nut
ri
ti
onRehabi
li
tat
ionandRUTFf
orChi
ldr
en6–59
Mont
hs.

DEMONSTRATI
ON:TASTI
NGRUTF.For
m smal
lgr
oupsanddi
str
ibut
eonepacketofRUTFand
napki
nstoeachgroup.Expl
ainhowt
oopent
hepackageandaskpar
ti
cipant
stot
ast
etheRUTF.Askf
or
anyfeedbackf
rom t
hegroups.
Askgroupstodescri
bewhatt
heyt
hinkt
heRUTF’
singr
edi
ent
sar
eandt
henwr
it
eRUTF’
sty
pical
composit
iononaf l
i
pchart
.
 Composit
ionofli
pid-
basedRUTF
25%peanutbut
ter
26%milkpowder
27%sugar
20%oil
2%combinedmineralandvi
tami
nmi
x(CMV)

GROUPDI
SCUSSI
ON:USI
NGRUTF.Wi
thpar
ti
ci
pant
sst
il
li
nsmal
lgr
oups,
askt
hem t
odi
scuss:
 HowRUTF’
scomposit
ioncompareswithF100(
simi
l
ari
ncomposi
ti
onbutRUTFhasi
ronandi
sabout
f
ivet
imesmor
eenergy-nut
ri
entdense)
 WhyRUTFcanbeusedforoutpat
ientcar
e(itcanbeeatenathomeanddoesn’
trequi
recooki
ngor
mi
xingwi
thwat
er,
whichpreventsgrowthofbacter
ia)
Di
scussf
urt
heri
npl
enar
y,f
il
li
nanygaps,
andansweranyquest
ions.

PARTI
CIPATORYLECTURE:NUTRI
TIONREHABI
LITATI
ONANDRUTF.Di
rectpar
ti
cipant
sto
Handout4.
11Nut
ri
ti
onRehabi
li
tat
ionandRUTFf
orChi
ldr
en6–59Mont
hs.Poi
ntoutt
opar
ti
cipant
sthe
tabl
esenti
tl
ed“RUTFRati
onsinOutpat
ientCar
e”deali
ngwit
hPlumpy’
nutandlocall
yproducedRUTFin
packet
s,andexpl
ainhowtousethem.Wr i
tedi
ffer
entwei
ghtsonthef
li
pchartthenaskparti
cipant
show
manypacketstogi
v et
oachil
dofeachwei ght
.

PRACTI
CE:DETERMI
NINGRUTFRATI
ONSI
ZE.Askpar
ti
cipant
stor
egr
oupi
ntosmal
lgr
oups.Ask
t
hem t
ouseHandout4.
11todet
ermi
nehowmuchRUTFt ogi
veeachchi
l
dint
heexampl
esbel
ow.Ask
f
orvol
unt
eer
stowrit
eanswer
sonthefl
i
pchar
t.Di
scussandf
il
li
ngaps.

RUTFRATI
ONPRACTI
CE.
Exampl
e1:92gpacketsofRUTFar
edi
stri
butedt
hroughout
pat
ientcare.Chi
ld1weighs6.
8kgand
comestoout
pat
ientcar
eeveryt
woweeks.HowmuchRUTFdoy ougiv
et hechi
ld?(
Answer:36packet
s)
Example2:Chil
d3weighs7.
2kgandwi
llr
etur
ntoout
pat
ientcar
enextweek.Howmanypacket
sofy
our
l
ocall
yproducedRUTFwil
lyougi
vet
hechi
ld?(
Answer
:18packets)
Whenf i
nishedwithpract
ice,pointoutt
otheparti
cipantsthatther
eisongoi
ngresear
chont hecombi
ned
protocolforSAM andMAM t reatmentt
otestal
ternativet
reatmentprot
ocol
sbyreducingtheRUTFdoses.
Referpartici
pantstotheevidencefrom Si
err
aLeone, revi
ew,andanswerquesti
ons.Detai
l
sont he
combi nedpr ot
ocolforSAM andMAM t reat
mentwi llbecoveredinModule6:ManagementofMAM int he
Cont extofCMAM.

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,2018Ver
sion

Module4Learni
ngObject
ive6:Descr
ibet
heKeyMessagesf
or
Mothers/
Car
egiv
ersofChil
dren6–59MonthsUsedi
nOutpat
ientCar
e

TRAI
NER:Becomef
ami
l
iarwi
thHandout4.
12KeyMessagesf
orI
ndi
vi
dual
Counsel
l
ingf
or
Mot
her
s/Car
egi
ver
sofChi
l
dren6–59Mont
hs.

GROUPDI
SCUSSI
ON:KEYMESSAGESFORMOTHERS/
CAREGI
VERS.Expl
aint
opar
ti
cipant
s
thatout
patientcareincl
udesindiv
idualcounselling,healt
handnutriti
oneducation,
andbehaviourchange
communi cati
on( BCC)ateachsession.Thei ni
tialcounselli
ngsessionshouldfocusonlyonaf ewkey
messagessot hatthemother/car
egivercl
ear l
yunder standsthepracti
cesthatareessent
ial
tomanagi ng
SAM inachi l
d.Ast hechi
ld’
sconditi
oni mproves, ot
hermessagesshoul dbegiven.

I
ntheinit
ial
counsel
l
ingsessi
on,
heal
thcar
epr
ovi
der
scounsel
themot
her
/car
egi
verwi
thkeymessages
onthefol
lowingt
opi
cs:
1.Howtof eedRUTFtot hechil
d
2.Whenandhowt ogivethemedici
nest
othechil
d
3.Whentor et
urntooutpati
entcare
4.Under
standingdangersignsandmaki
ngsurethechi
l
disbr
oughtt
otheheal
thf
aci
l
ity
i
mmedi atel
yifhi
sorherconditi
ondet
eri
orat
es

WORKI
NGGROUPS:DEVELOPI
NGKEYMESSAGESFORMOTHERS/CAREGI
VERS.Ask
worki
nggroupstowr i
tesixkeymessagestogivet
othemother
/car
egi
verduri
nghis/heri
nit
ialsessionin
out
pati
entcare.Haveonegr ouppr
esentandtheot
hergr
oupsaddaddi
ti
onalmessages.Discuss,clari
fy,
andfi
lli
ngaps.Alsodiscusswhataddi
ti
onalmessageswoul
dbeimport
antinsubsequentoutpati
ent
car
efoll
ow-onsessions.

ROLE-
PLAY:I
NDI
VIDUALCOUNSELLI
NG.I
nwor
kinggr
oups,
hav
eonepar
ti
cipantactasa
mother/
caregiv
erwhohascomet ooutpati
entcareforthefi
rstti
meandanot heractastheCMAM
counsel
lor
;therestoft
heworkinggroup’
sparti
cipantsshoul
dobser ve.Havet heactor
spract
ice
counsel
li
ngwiththemostimpor t
antkeymessages.Askt heobser v
ersforfeedback.Havethe
mother/
caregiv
erandcounsel
lorswitchrol
esandcont i
nuepr act
ici
ngifti
meal l
ows.

BRAI
NSTORM:HEALTHANDNUTRI
TIONEDUCATI
ON.Askpar
ti
cipant
stot
hinkofkeyheal
thand
nut
ri
ti
ontopi
cst
hatshoul
dbemadeapartofi
ndivi
dualcounsel
l
inginoutpat
ientcar
efol
l
ow-
onsessi
ons.
Wri
teanswer
sonthefl
ipchar
tandf
il
li
nanygaps.Possibl
eanswersincl
ude:
 Hygiene
 Cont
inuat
ionofr
ecommendedbr
east
feedi
ngbehav
iour
s(especi
all
ywi
thi
nfant
sandy
oungchi
l
dren
ages6-
23mont
hs)
 Thei
mpor
tanceoff
requentandact
ivef
eedi
ng
 Whatl
ocal
foodst
ogi
vey
oungchi
l
dren(
whi
l
erei
nfor
cingt
hemessaget
hatt
hechi
l
dinout
pat
ient
car
eMUSTf
ini
sheat
ingal
lRUTFbef
oreot
herf
oodsar
egi
ven)
 I
dent
if
yingunder
nut
ri
ti
on(
whent
obr
ingchi
l
drent
oout
pat
ientcar
e)
 Managi
ngdi
arr
hoeaandf
ever
 Recogni
singdangersi
gns

ROLE-
PLAY:HEALTHANDNUTRI
TIONMESSAGES.Wi
thpar
ti
cipant
sint
hesamewor
kinggr
oups,
askt
heobserversintherol
e-pl
ayabovet
onowbr eaki
ntopai
rst
oplayt
herol
esofmother/car
egi
verand
CMAM counsell
or.Askthem topr
acti
cecounsel
l
ingwi
thheal
thandnut
ri
ti
onmessages.Askobser
verst
o

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,2018Ver
sion

pr
ovi
def
eedback.Swi
tchr
olesandcont
inuepr
act
ici
ngi
fti
meal
l
ows.

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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module4Lear ningObject
ive7:Expl
aint
heManagementofAt
-Ri
sk
MothersandInfantsUnder6Mont hsofAgeWi
thoutMedi
cal
Compli
cationsinOutpati
entCare

TRAI
NER:
Becomef
ami
l
iarwi
thHandout4.
13C-
MAMITool
Ver
sion2.
0:Br
east
feedi
ngCounsel
l
ingand
Suppor
tAct
ions,
Handout4.
14Admissi
onPr
ocessf
orOut
patientCar
ef orAt
-Ri
skMother
sandI
nfant
s
Under6MonthsofAge,
andHandout4.
15C-
MAMIOutpat
ientCareTreatmentCar
d.

PARTI
CIPATORYLECTURE:ADMI
SSI
ONPROCESSFOROUTPATI ENTCAREFORAT- RI
SK
MOTHERSANDI NFANTSUNDER6MONTHSOFAGE.Ref
erpar
ti
cipant
stot
heout
pat
ientcar
e
admissionprocessforat
-r
iskmother
sandinfant
sunder6monthsofagei
nHandout4.14Admissi
on
ProcessforOutpati
entCareforAt
-Ri
skMothersandI
nfant
sUnder6MonthsofAge.Walkt
he
part
ici
pantsthroughthest
eps,emphasi
zi
ngtheimport
antconsi
der
ati
onstheyneedt
otakei
ntoaccount
.
Respondt oquesti
ons.

PRACTI
CE:FI
LLI
NGOUTAC-
MAMIOUTPATI
ENTCARETREATMENTCARD.Di
str
ibut
ea
l
ocalC-MAMIout pati
entcaretreatmentcardifoneisav ail
able.Otherwise,
useHandout4. 15C-MAMI
Outpati
entCareTr eat
mentCar d.Not ethatALLpairsofat -r
iskmot hersandinf
ant sadmi ttedfor
managementi ntheout pat
ientcar esi
terecei
veanout patientcaretreatmentcard,includi
ngt hosebei
ng
ref
erredtoinpat
ientcare.Onet reatmentcardshouldbei ssuedtoonemot her-
infantpair.Explai
nthe
generalcol
umnandr owdet ai
lsont heC-MAMIout pati
entcar etreatmentcardandt heinformati
on
neededt of
ill
oneout .

PARTI
CIPATORYLECTURE.Askpar
ti
ci
pant
stor
efert
otheHandout4.
13,
expl
ainr
ecommended
breastf
eedingpracti
cesaswellascounsell
i
ngandsuppor
tf oref
fect
ivebreast
feedi
ngcover
ingthe
fol
lowingfourareas:goodat
tachment,ef
fecti
vesuckl
i
ng,
frequencyofbreastf
eeds,andr
eceiv
ingother
l
iquidsandf oods.Respondt
oquestions.

DEMONSTRATI ON:GOODATTACHMENT.I fpossibl

e,showthef ol
lowi
ngv i
deos.Aft
erthevideo
sessi
on,discussandrespondtoquestions(sel
ectt heappr
opriat
evideodependingonaudience:healt
h
workertr
ainingandcounsel
li
ng/helpi
ngmot hers)
.
 Br eastfeedi
ngatt
achment:https:
//global
healthmedia.
org/port
fol
io-i
tems/at
tachi
ng-y
our-
baby -
at-
the-
br
east
/?por
tfol
i
oID=10861
 Br
east
feedi
ngposi
ti
ons:
htt
ps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
posi
ti
ons-
for
-
br
east
feedi
ng/
?por
tfol
i
oID=10861
 Ef
fect
ivesuckl
i
ngandbr
east
feedi
ngf
requency
:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
is-
y
our
-baby
-get
ti
ng-
enough-
mil
k/?
por
tfol
i
oID=10861

PARTICI
PATORYLECTURE:COUNSELLI NGANDSUPPORTFOREFFECTI VE
BREASTFEEDI
NG.Askpar
ti
ci
pant
stor
efert
otheHandout4.
13.Expl
aint
her
ecommended
breast
feedi ngpracti
cesaswellascounsel
li
ngandsuppor
tforef
fect
ivebr
east
feedi
ng.Ensur
ethaty
ou
coverthef oll
owingareas:
 Per ceptionof“notenough”br
eastmilk
 Br
eastcondi
ti
onssuchasengor
gement
;sor
eorcr
ackedni
ppl
es;
pluggedduct
sandmast
it
is;
flat
,
i
nver
ted,
lar
ge,
orl
ongni
ppl
es;
thr
ushi
nthei
nfantandmot
her
 Lowbi
rt
hwei
ghti
nfant
;kangar
oomot
hercar
e(KMC)
 Br
eastmi
l
kexpr
essi
on,
cupf
eedi
ng,
andst
orageofbr
eastmi
l
k
 Rel
act
ati
on

77
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on(
CMAM)
,2018Ver
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 Ot
herbr
east
feedi
ng-
rel
atedconcer
nsi
ncl
udi
ng:Mot
herexpr
essesconcer
naboutdi
et,
mot
her
expr
essesconcer
naboutwor
kingorbei
ngawayf
rom heri
nfant
,twi
ndel
iver
y,adol
escentmot
her
,
motherHIVorTBinf
ect
ed

DEMONSTRATI ON:COUNSELLI NGANDSUPPORTFOREFFECTI VEBREASTFEEDI NG.I f

possi
ble,showthefol
l
owingvideos.Af
tert
hev i
deosessi
on,discussandr
espondtoquest
ions.(
Select
theappropri
atevi
deodependi
ngonaudience:heal
thworkert
raini
ngandcounsel
li
ng/
helpi
ngmot hers.
)
 Per
cept
ionof‘
notenough’
breastmi
l
k:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
incr
easi
ng-
your
-
mil
k-suppl
y/?
por
tfol
i
oID=10861
 Ni
ppl
epai
n:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
what
-t
o-do-
about
-ni
ppl
e-
pai
n/?
por
tfol
i
oID=10861
 Br
eastpai
n:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
what
-t
o-do-
about
-br
east
-
pai
n/?
por
tfol
i
oID=10861
 Br
eastengor
gement
:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
breast
-
engor
gement
/?por
tfol
i
oID=10861
 Thr
ush:
htt
ps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
thr
ush/
?por
tfol
i
oID=5638
 Howt
oexpr
essbr
eastmi
l
k:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
how-
to-
expr
ess-
br
east
mil
k/?
por
tfol
i
oID=10861
 St
ori
ngbr
eastmi
l
ksaf
ely
:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
stor
ing-
breast
mil
k-
saf
ely
/?por
tfol
i
oID=10861
 Cupf
eedi
ngasmal
lbaby
:ht
tps:
//gl
obal
heal
thmedi
a.or
g/por
tfol
i
o-i
tems/
cup-
feedi
ng-
your
-smal
l
-
baby
/?por
tfol
i
oID=13325

PARTI
CIPATORYLECTURE:COUNSELLI
NGANDSUPPORTACTI
ONSFORTHEMOTHER.
Askparti
cipantstoref
ertoHandout4.
13.Explai
ntherecommendedcounsell
ingandsuppor
tpr
act
ices
coveri
ngthefollowi
ngareas:
nutr
it
ion;
healt
hcareservi
ces;water
,sani
tat
ion,
andhygi
ene(WASH);
healt
h
educati
on/inf
ormati
on;andsoci
alsuppor
t.Respondtoquesti
ons.

WORKI
NGGROUPS.Askpar
ti
ci
pant
stof
orm gr
oupsof4–5peopl
e.Eachgr
oupshoul
ddi
scussand
wri
tedownt hei
nfor
mat i
ontheywouldgivethemotherandcommunitytohel
pexpl
aintheprocesst
hey
wil
lexper
iencewhenadmi t
tedi
ninpati
entcare.Haveonegr
ouppresentandtheot
hergroupsadd
addi
ti
onalpoint
s.Discussandcl
ari
fyanypoi nt
s,r
efer
ri
ngtoHandout4.13.

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orCommuni
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eMal
nut
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ti
on(
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,2018Ver
sion

Module4LearningObjecti
ve8:Recogni
singWhenFur
therActi
onI
s
Needed:Ref
err
altoInpati
entCareandFollow-
UpHomeVisit
s

TRAI
NER:Revi
ewHandout4.
16Out
pat
ientCar
eAct
ionPr
otocol
forI
nfant
sUnder6Mont
hsand
Chi
ldr
en6–59Months;Handout4. 17Referr
altoInpat
ientCareorFoll
ow-UpHomeVi sit
sforI
nfant
s
Under6Mont
hsandChi l
dren6–59Mont hs; Handout4.18Referr
alSl
ipforInf
ant
sUnder6Mont hsand
Chi
ldr
en6–59Months,andExercise4.3Identi
fyi
ngInfantsUnder6Mont hsandChi
l
dr en6–59Months
WhoMayNeedReferralt
oI npat
ientCar
eorFol l
ow-UpHomeVi si
ts.

BRAI
NSTORM:ACTI
ONPROTOCOLFORREFERRALANDFOLLOW-
UP.Not
etopar
ti
cipant
sthat
anacti
onprot
ocol (inl
inewit
hintegratedmanagementofchildhoodil
l
ness[I
MCI ]gui
deli
nes)hasbeen
dev
elopedtohelphealthcareprovidersdet
ermine:
 Whet heri
nfantsunder6mont hsandchildr
en6–59mont hsshouldberefer
redtoinpati
entcar
e(e.
g.,
duetomedical compli
cati
ons, noappet
ite,
deter
ior
ati
ngconditi
on,orpr
esenceofanydangersign,
i
ncludi
nginfantfeedi
ngdiff
iculti
es)
 Whet
herchi
l
drenr
equi
ref
oll
ow-
upv
isi
tsathomebet
weenout
pat
ientcar
efol
l
ow-
onsessi
ons(
e.g.
,
weightl
oss,det
eri
orat
ingcondi
ti
on,
noteati
ngenoughRUTF,absentfr
om out
pati
entcar
efoll
ow-on
sessi
on),whi
chmaybedonebyanout reachwor
ker(e.
g.,
communi t
yheal
thworker[CHW],
volunt
eer)
Inplenary ,
askpar t
ici
pant stonamedangersi gns,feedingdi ff
icult
ies,andmedi cal compl i
cati
onsthat
woul drequireref
erral t
oinpatientcar e.Wr it
et hem ont hef l
ipchart.Thenaskwhatmedi calcomplicati
ons
orsy mpt omsmi ghtrequireaf ollow-uphomev i
sit
.Referpar ti
cipantst oHandout4. 16Out pat
ientCare
ActionPr otocolforInfantsUnder6Mont hsandChi ldren6–59Mont hsandcompar eresponsesont he
fl
ipchar ttothoseint hesecondcol umnoft heactionpr otocol
.Descr ibesymptomst hatwouldrequire
eit
herr eferr
alorfoll
ow- upv i
sit
s( e.g.
, bi
l
at eralpitt
ingoedema+++, weightl
ossf ortwoconsecut i
veweeks)
andaskwhatact ioni sdictat
edbyt hepr otocol :
referr
al toinpati
entcar eorfoll
ow- uphomev i
sit
s.
Cont i
nueaski ngquest i
onsunt ilparti
cipant sseem comf ortabl
eusi ngt heact
ionpr ot ocol
.
PARTI
CIPATORYLECTURE:PROCEDURESFORREFERRI
NGPATI
ENTS.Expl
aint
opar
ti
cipant
s
theinpat
ientcar
erefer
ralsy
stem, useofref
erralsli
ps,
ref
err
altot
erti
arycar
eandkeypointsr
elat
edt
o
ref
erri
ngforfoll
ow-
uphomev i
sit
s.Referpart
icipantst
oHandout4.17Refer
ralt
oInpat
ientCar
eor
Foll
ow-UpHomeVi si
tsforI
nfantsUnder6Mont hsandChil
dren6–59Mont hs.

PRACTI
CE:I
DENTI
FYI
NGANDREFERRI
NGCHI
LDREN.Di
rectpar
ti
cipant
stoExer
cise4.
3
Ident
if
yingInfantsUnder6Mont hsandChi ldren6–59Mont hsWhoMayNeedRef err
altoInpati
entCar
e
orFoll
ow-UpHomeVi sits.Havepar t
ici
pantsform groupsofthr
eeorf ourandaskthem toreadthe
descri
pti
onsoft hechi
ldrenanddet erminewhatact i
ont ot
ake:refer
ral
,fol
low-
uphomev i
sitor
conti
nuati
oninout pat
ientcare(seeExer ci
se4. 3answersbel
ow) .Askpart
ici
pant
stor ef
ertoHandout
4.16Outpati
entCar eActionProtocolforInfantsUnder6Mont hsandChi l
dren6–59Mont hs.Hav e
groupspresentandexplainthei
ranswer s.
Dist
ri
but
eHandout4.
18Referr
alSli
pforI
nfantsUnder6MonthsandChi
ldr
en6–59Mont hsand
demonstr
atehowt
ofil
li
toutusingasamplechil
dfr
om Exer
cise4.
3whorequi
redi
npat
ientcar
e.

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Exerci
se4.3I
denti
fyi
ngInf
ant
sUnder6Mont
hsandChi
ldr
en6–59Mont
hsWhoMayNeed
Referr
alt
oInpat
ientCar
eorFoll
ow-
UpHomeVisi
ts(
wit
hanswers)

Chi
ldA
Questi
on: Chil
dAi s2y earsold,
hasaMUACof111mm andhasbeenr eferredbyt heCHW toCMAM
ser
vices.Onadmi ssi
on, t
hechil
drefusestoeattheRUTFduri
ngtheappet it
et est
.Youaskhi s
mother/caregi
v ertomov etoaquietareaandtryagai
n.Af
terahalf
-hour,
t hechi l
dstil
lref
usestoeatthe
RUTF.Dur i
ngt hemedi calexami
nati
on, y
oudiscovert
hatt
hechil
dhasbeenv omitingfort
woday s.What
act
ionisneeded?
Answer
:Refertoi
npat
ientcar
eformedi
cal
car
eandsuppor
tbecauset
hechi
l
dhasaser
iousdangersi
gn
ofnoappet
ite.

Chil
dB
Questi
on:Chi
l
dBispr
esent
edattheoutpat
ientcaresi
tewit
hbil
ater
alpi
tt
ingoedema+andaMUACof
117mm.Thechil
dhasgoodappeti
teandnoot hersi
gnsofmedical
complicat
ions.Whatact
ioni
s
needed?
Answer
:Admi
ttoout
pat
ientcar
easabi
l
ater
alpi
tt
ingoedemaadmi
ssi
on.

Chi
ldC
Quest
ion:
Chil
dCwasadmi t
tedtooutpat
ientcarewit
haMUACof109mm andwei ghtof10kg.Thechi
ld
di
dnotgainanyweighti
nthefir
stt
hreeweeks, andbythef
our
thweekhasact
ual
l
yl ostwei
ght;
thechi
ld
nowweighs9.5kg.Whatacti
onisneeded?
Answer :Thischildisnotgainingwei ghtaf terfourweeksi ntheCMAM ser vi
ce;youmustr eferhi
m/ herto
i
npat i
entcaref orfurthermedical assessmentandt reatment.Ideallythischil
dshoul dhavehadaf oll
ow-
uphomev i
sitaft
ert hei
routpatientcar efoll
ow- onsessiont hepr eviousweek( afterthethi
rdweek),
accordingtoout patientcar
eact ionpr otocols.Ref ertothechild’soutpat i
entcar
et reat
mentcar d(orto
theCHW orv olunteerwhov isi
tedt hehomei fnot hingwaswr i
ttenont hecar d)t
oseehowt hechil
dwas
doingathomeandwhatt hepossi blereasonsf ornotgai ni
ngwei ghtare,basedont hefoll
ow-uphome
visi
t.Discussthiswi ththemot her/caregiverandt henreferthechi l
dt oinpati
entcare.

Chi
ldD
Quest
ion:
Chi
l
dDispresent
edattheout
pat
ientcar
esi
tewi
thbi
l
ater
alpi
tt
ingoedema++andaMUACof
110mm.Whatact
ioni
sneeded?
Answer
:Refert
oinpat
ientcar
eformedicalcar
eandsuppor
tbecausethechi
ldhasmar
asmi
c
kwashi
orkor
.Al
lmarasmickwashior
korcasesshoul
dberef
err
edtoinpati
entcar
e.

Chi
ldE
Questi
on:
Chil
dEi sathree-mont
h-ol
dgirl
.Hermot
herwasil
lwi
tht
hefl
uandstoppedbreast
feedi
ngone
weekago.Theinf
antisbeingfedteaandcow’smi
lk,
appear
snott
obegai
ningweight
,andiscli
nical
l
y
well
.Whatact
ionisneeded?
Answer :Themot her-
infantpairshouldbeenr olledinoutpatientcaretore-est
abli
shexclusive
breastf
eeding.Expl ai
nt hebr east
feedingbasics—goodat tachment ,
effect
ivesuckl
ing,fr
equencyof
breastf
eeding, gr
adual eli
mi nati
onoft eaandcow’ smil
k, supplyanddemand—bui l
dingherconfidence
alongtheway .Discussbui l
dinguphermi lksupply:whatittakes,howl ongitmighttake,whatisthe
l
ikeli
hoodofsuccess, whatmi ghtbeot heroptions,andwhatwoul dbet heupside/
downsi deofrelact
ati
on
vs.otheroptions.Addr essherquest ions:Willsheneedt oeatmor e?Isherdietsuff
ici
ent
(quanti
ty/qualit
y)?Mot herneedst obel inkedtof amil
yandcommuni tysupport.

Chi
ldF

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Question:Chi
ldFispresentedattheoutpat
ientcar
esitewit
hbil
ater
alpi
tt
ingoedema+++.Youwantto
ref
erthechildtothehospit
al.Despi
teyourbesteff
ort
st oper
suadethemother
,herf
amil
yrefusest
olet
hertakethechil
dt ot
hehospi t
al.Whatacti
onisneeded?
Answer :
Allcasesofbil
ateralpit
ti
ngoedema+++shoul dber eferr
edtoinpati
entcareformedicalcare
andsuppor t
.Howev er
,ifamot her/car
egiverr
efusestotaket hechil
dtoinpat
ientcare,t
hechil
dshouldbe
admitt
edt ooutpati
entcareandr eceiv
et hesyst
ematictreatment.Thechil
dshouldreceiver
egularfol
low-
uphomev i
sit
sdur i
ngthefirstweekstomoni t
orhis/herconditi
on,andthemot her/
caregi
vershouldbe
encouragedtobringthechildbackt otheheal
thfaci
lit
yifhis/hercondi
ti
onwor sensatanytime.Thechild
shoul
dagai nbereferr
edtoi npati
entcareifhi
s/herconditi
onwor sens.

Chil
dG:
Questi
on:Chi
ldGisabove6monthsandwasadmi tt
edwit
haMUACof109mm andawei ghtof5kg.The
chi
ldgainedali
tt
lewei
ghtthef
ir
stweekbuthasnotgai
nedweightforthepastt
woweeks.Hismedical
assessmentdoesnotshowanysignsofi
l
lnessormedi
calcompli
cati
ons.
Answer
:Theheal
thcar
eprovi
dershouldt
alkwit
hthemother/
caregi
verabouthowt hechil
diseat
ingthe
RUTFandobser
vetheappet
it
etest
.Thehealt
hcareprovi
dershoul
daskwhet hert
hechildhashad
di
arr
hoea,
vomiti
ngorf
everandshouldgi
vecounsel
li
ng.Thechi
ldal
sor equi
resafoll
ow-uphomev i
sit
.

Chil
dH
Question:Chil
dHisa2-week-ol
dboywhosemot heri
sbreast
feedi
ng.Theinfanthasnowregai
nedhi
s
bi
rthwei ght
.Themotherthi
nkssheisnotproducingenoughmilkf
orhim andwant st
ogiv
ehim some
di
lutedcow’smi l
k.Whatact
ionisneeded?
Answer :Themot her
-i
nfantpai
rshouldbeenr ol
ledinoutpatientcar
e.Counselandsupportthemot her
(andf amil
y)toconti
nuetobreast
f eed.Rev
iewbr eastf
eedingbasics:goodatt
achment;effect
ivesuckli
ng;
frequencyofbreastf
eeds;notgi
vinganyplainwat er,l
i
quids,orsoli
ds.Talkwi
ththemot heraboutwhyshe
thinksshedoesn’thaveenoughbr eastmil
k,explai
nsuppl yanddemand, andbuil
dherconf i
dence.
Connectt hemothertoanycommuni tyorf
acili
tybreastf
eedingsupport.Askt
hemot hertoreturnwithher
sont hefoll
owingweek.

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Module4Lear
ningObj
ecti
ve9:Expl
ainDi
schar
geCri
ter
iaandPr
ocedur
es
f
orAt-Ri
skMot
hersandInf
ant
sUnder6Mont hsandChi
ldr
en6–59
Months

TRAI
NER:Revi
ewHandout4.
16Out
pat
ientCar
eAct
ionPr
otocol
forI
nfant
sUnder6Mont
hsand
Chil
dren6–59Monthsandbecomefamili
arwi
thHandout4.
19Outpat
ientCare:
Dischar
geCr i
ter
iaforAt
-
RiskMother
sandInfant
sUnder6MonthsandChil
dren6–59Months,
Handout4.20DischargeCrit
eri
a
andExitCat
egor
iesforCMAM,andExerci
se4.
4Partial
l
yCompl
etedOutpati
entCareTreat
mentCar ds.

PARTI
CIPATORYLECTURE:DI
SCHARGEFROM OUTPATI
ENTCARE.Usi
ngt
het
exti
nHandout
4.
19Outpati
entCare:DischargeCr i
teri
aforAt-RiskMothersandInfantsUnder6Mont hsandChi l
dren
6–59Monthsasar efer
ence, r
eviewt hecri
ter
iafordi
schargefrom outpat
ientcare,noti
ngt hat
:
 Achildisdi
schargedf rom outpati
entcarewhens/hehasr ecoveredfr
om bilateral
pitt
ingoedemaor
l
owweightand,ther
ef ore,
nol ongerhasSAM.
 Thedeci
siont
odi
schar
get
hechi
l
disbasedonhi
s/herr
ecov
eryf
rom t
hei
nit
ial
SAM condi
ti
on,
consi
stent
lygai
ningwei
ghtandbei
ngcl
i
nical
l
ywel
landal
ert
.
 Di
schar
ger
ulesdi
ff
erbasedont
hecr
it
eri
ausedt
oadmi
tthechi
l
d.

Ref
erpart
ici
pantstoHandout4.
20DischargeCri
ter
iaandExi
tCat
egor
iesf
orCMAM,
whi
chdeal
swi
th
out
pat
ientcaredischar
gecr
it
eri
aandexitcat
egori
es.

PRACTICE:USINGOUTPATI ENTCARETREATMENTCARDSTODETERMI NEACTION

NEEDED.Dir
ectpar
ti
cipant
stoExer
cise4.
4Par
ti
all
yCompl
etedOut
pat
ientCar
eTr
eat
mentCar
dsand
tor ef
erbackt oHandout4.16OutpatientCareActionPr ot
ocol .Askthem t
ousetheoutpat
ientcare
actionprotocoltodetermi
newhatact ionisneeded(discharge, f
oll
ow-uphome,r
efer
ral
)andt ofi
ll
outthe
treatmentcardaccordingl
y.I
nplenary, di
scusswhattheydeci dedtodoandanyissueswithcompleting
theout pat
ientcaretr
eatmentcards.Discussandfill
ingaps.

Exer
cise4.
4Par
ti
all
yCompl
etedOut
pat
ientCar
eTr
eat
mentCar
ds(
wit
hanswer
s)
Example1(JemmaBanda) :Chil
dIsReadyforDi
scharge
Thepre-
fi
ll
edout
pat
ientcaretreat
mentcard(t
othe12thweek)showsthatt
hechil
dwasadmit
tedwit
ha
MUACof109mm.Thechi l
dhashadsust ai
nedweightgai
nforthepasttwoweeksandi
scl
ini
cal
lywell
.
(
Part
ici
pant
sshoulddeter
minet
hatt
hechi
l
disr
eadyf
ordi
schar
geandf
il
loutt
heout
pat
ientcar
e
t
reat
mentcardaccor
dingl
y).

Example2( Adam Ali)

:Chil
dRequiresFoll
ow-
Up
Thepre-f
il
ledoutpati
entcaretr
eatmentcard(
tothefourt
hweek)showsthatt
hechil
dhasnotgai ned
weightf
ort hepasttwoweeksandwei ghs5kg.Atthenextout
pati
entcar
efoll
ow-onsessi
on,thechil
d
sti
l
l ghs5kg.(
wei Part
ici
pantsshoulddet
ermi
nethatthechi
ldr
equir
esafoll
ow-uphomevisitandfil
lout
t
heout
pati
entcar
etr
eat
mentcar
daccor
dingl
y,not
ingwhatact
ionwoul
dbet
aken[
inf
ormt
heout
reach
wor
ker
])
.

Example3( Fl
orencePhiri
):I
nfantUnder6Mont hsRequi
resReferr
altoInpati
entCare
Thepre-fi
l
ledC- MAMIout pati
entcaretr
eatmentcard(
tothethi
rdweek)showst hatt
heinfantisnot
breast
feedingeffect
ivel
y,andnotgaini
ngweight.Thei
nfantwasreferr
edt oi
npati
entcar
eont hesecond
weekbutmot herref
usedr ef
err
al.Onthethi
rdweekofoutpati
entcarefol
low-
onsession,t
hei nfantst
il
l
weighs3.4kg, i
sunwel l
andnotbr east
feedi
ng.
(
Par
ti
cipant
sshoul
ddet
ermi
net
hatt
hei
nfant
srequi
resr
efer
ralt
oinpat
ient
,themot
herwi
l
lneed

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i
nt ensi
vecounsel
l
ingandsupportonwhattoexpectandexper
ienceini
npat
ientcar
e.Par
ti
cipant
sshould
fi
llouttheC-MAMIoutpati
entcar
etreat
mentcardaccordi
ngl
y,noti
ngwhatacti
onwouldbetaken[r
efer
ral
,
counselli
ngandsupport
])
.

GROUPDI
SCUSSI
ON:DI
SCHARGEPROCESS.Askpar
ti
cipant
stot
hinkt
hroughspeci
fi
cact
ionst
o
t
akeinthepr
ocessofdi
schar
gefrom outpat
ientcare.Writ
eanswersont
hef
li
pchar
t.I
fpar
ti
cipant
shav
e
t
roubl
enamingacti
ons,
provi
decoachingtoeli
citt
her esponses,
bel
ow:
 Thechi
l
d6-
59mont
hsi
sgi
venar
ati
onofRUTFt
osuppor
ttr
ansi
ti
ont
ofami
l
yfood.(
Thi
susual
l
y
consi
stsofappr
oxi
mat
elysev
en92-
gram packet
sofRUTF.
)
 Thei
mmuni
sat
ionst
atusi
scheckedandupdat
ed.
 Makesur
ethei
nfantorchi
l
dhasr
ecei
vedal
lrequi
redmedi
cines(
e.g.
,ant
ibi
oti
cs)
.Gi
veany
v
acci
nat
ions(
e.g.
,measl
es,
otherEPI
)thatwer
enotpr
ovi
dedear
li
er.
 Themot
her
/car
egi
veri
sgi
vengui
danceoncar
epr
act
icesandaskedt
oret
urni
fthei
nfant
’sorchi
l
d’s
condi
ti
ondet
eri
orat
es.

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Modul
e4Lear
ningObjecti
ve10:Descr
ibeLi
nkagesBet
weenOut
pat
ient
Car
eandOt
herServ
ices,Pr
ogrammes,andIni
ti
ati
ves

TRAI
NER:Revi
ewHandout1.
11I
ntegr
ati
ngCMAM i
ntoRout
ineHeal
thSer
vicesatt
heDi
str
ictLev
el.I
f
t
hiscont
entwascov
eredi
ndept
hinModul
eOne,
itcanbebr
ief
lyr
evi
ewedher
e.

WORKI
NGGROUPS:LI
NKI
NGOUTPATI
ENTCARETOOTHERSERVI
CES.Not
etopar
ti
cipant
s
thatoutpati
entcar eprovi
desagoodoppor t
unitytol
inkthemanagementofSAM t ootherser
vices,
i
ncludingpr event
ionprogrammessuchasgr owt hmonitor
ingandpromot i
on(GMP).Li
nkagescanand
shouldbemadewi thIMCI,post
natalcare,
nationall
evelornongovernmental
organi
sati
on(NGO)f ood
dist
ri
butionpr ogrammes, progr
ammest omanageMAM, i
mmuni sat
ionsandVit
aminAsupplement at
ion,
famil
ypl anning,waterandsanitat
ion,heal
thandnutrit
ioneducati
on,malar
iaandHIVtreat
ment ,f
ood
securi
tyandl ivel
ihoodsprogrammes, andothersupportserv
ices.

Askpar ti
cipant
stoform workinggr
oupsofthreeorf our,bydist
rictorregi
onifpossi
ble,anddistri
but
e
cards.Askeachgr ouptowriteonacardallthehealthservices,
pr ogr
ammesandi nit
iati
vesint hei
r
dist
rictandexplai
nhowt hesecanlinktooutpati
entcare( mapping).Askgroupstoposttheircardsand
explaintheirpr
escr
ibedl
inkstooutpati
entcare.Discuss.Leavethecar dspostedf
orther emainderofthe
tr
aining.

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Modul
e4Wr
ap-
UpandModul
eEv
aluat
ion

TRAI
NER:
Becomef
ami
l
iarwi
thHandout4.
21Essent
ial
sofOut
pat
ientCar
eforSAM Wi
thoutMedi
cal
Compl
i
cat
ionsand,
ifappl
i
cabl
e,Opt
ionalExer
cise4.
5Out
pat
ientCar
eAdmi
ssi
onsRol
e-Pl
ay.

OPTI
ONALROLE-
PLAY:PRACTI
CINGADMI
SSI
ONTOOUTPATI
ENTCARE.Topr
epar
efort
his
role-
play,
makecopi
esofbl
ankoutpati
entcaret
reat
mentcar
ds,blankRUTFrati
oncards,r
efer
ralsl
ips
from outr
eachwor
kersi
ndi
cat
ingredMUAC, andHandout4.
11Nut ri
ti
onRehabil
it
ati
onandRUTFf or
Chi l
dren6—59Months(
speci
fi
cal
l
yt hesecti
ononRUTFRation)
.MUACt apesandadol l
arealsoneeded.
Askf ortwov olunteer
s:onet oplayamot herwit
hasmal l
chil
d,andtheot
hertoplayanursei
nchargeof
outpati
entcar e.Giveeachv olunt
eeracardwi t
hthedescri
pti
onofhis/
herrol
e,asexpl
ainedi
nExerci
se
4.5Out pat
ientCar eAdmi ssionsRole-Pl
ay,bel
ow,andaftert
hevolunt
eer
shav ehadafewmi nut
esto
revi
ewt hei
rrol es,
beginther ole-
play
.
Oncefini
shed,di
scusst
herole-
playi
nplenary,
askingpar
tici
pant
stofi
ll
inanygapsandt
omake
suggesti
onsonhowt okeepassessmentsrunningsmoothly
.Ift
imeper
mits,
repeatt
her
ole-
playwi
th
othervol
unteer
s.

Exer
cise4.
5Out
pat
ientCar
eAdmi
ssi
onsRol
e-Pl
ay

Mot
herwi
thaSmal
lChi
ld:
 Useadol
ltosi
mul
atey
ourchi
l
d.Gi
vet
hechi
l
daname(
ifcul
tur
all
yaccept
ed)
.
 Yourchi
l
disabout10mont
hsol
d(y
oudonotknowex
act
ly)
,andi
syoury
oungest
.Youhav
efi
ve
ot
herchi
l
dren.Yourhusbanddi
edaboutay
earagoaf
teral
ongi
l
lness.
 Youbr
east
feedher
,buty
oudonotf
eel
ver
ywel
lyour
sel
fandt
hebabydoesnotseem t
ogetanymi
l
k.
Yougiv
ehermai
zepor
ri
dgeandsomet
imescow’
smi
l
k,butshedoesnothav
emuchappet
it
eandi
s
nowthi
n.
 Shehashadr
unnydi
arr
hoeaf
ort
hepastweek,
andt
hisi
snott
hef
ir
stt
ime.Ev
eryt
imeshehas
di
arr
hoea,
youst
opbr
east
feedi
ng.
 TheCHW i
nyourv
il
lagemeasur
edy
ourchi
l
dwi
that
apeandpr
essedherf
eet
.Het
oldy
out
haty
our
chil
dwasthi
n.Hesai
dyoumustgot othecli
niconThur
sday,andtheywouldgiveyousomespeci
al
foodandmedici
nef
oryourchi
l
d.Hegav eyouapieceofpaperwit
hsomet hingwri
tt
enonitandt
old
youtogi
veitt
othenur
se,butyoudonotknowwhatitsaysexactl
y,becauseyoucannotr
ead.
 Youar
ewi
l
li
ngt
ogot
othecl
i
nicev
ent
houghi
tisat
hree-
hourwal
kbecausey
ouhear
dfr
om ot
her
mothersinyourvi
ll
agethatthecli
nici
sgi v
ingaspecialpeanutpastefoodfort
hinandswol l
en
chi
ldren.Youhopeyourvi
sittothecli
nicwill
beworthitthi
stime.Youhav ebeentherebefor
eand
neverhadagoodexperience.Youhopet hatthenur
sewi l
lmakey ourchil
dwellandthatyouwil
lget
somef ood.
 Youshoul
dwai
tfort
henur
set
oasky
ouquest
ionsabouty
ourchi
l
dandhercondi
ti
on.I
fthenur
se
doesnotask,
youcant
ell
him/
heraf
ewt
hingsandhopet
hiswi
l
lleadt
omor
equest
ions.

Out
pat
ientCar
eNur
se:
 Youar
eanur
se,
andr
unt
heCMAM out
pat
ientcar
eser
vicesaty
ourcl
i
nicev
eryThur
sday
.
 Amot
herpr
esent
swi
that
hinbaby
.
 Youaskf
ort
her
efer
ral
sli
pfr
om t
heCHW,
whi
chshowsar
edMUAC.Thechi
l
dhasal
readybeen
wei
ghedandi
s4.
5kg.
 Yout
aket
heMUACagai
nandf
indi
ttobe109mm.Thent
akeamedi
cal
hist
oryandaskt
hemot
her
quest
ionsaboutherchi
l
d’scondi
ti
on.

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,2018Ver
sion

 Fol
l
owt
heout
pat
ientcar
etr
eat
mentcar
dandmakesur
eyouconductat
hor
oughassessment
,
i
ncl
udi
ngamedi calexaminat
ionandRUTFappet it
etest,
sot haty
oucancompletel
yfil
lint
he
out
pat
ientcaretreat
mentcar dwi
tht henecessar
yinf
ormation.Fi
lli
ntheout
pat
ientcaretr
eat
ment
car
dand,ifnecessary,askt
hemot herquesti
onstohelpfi
ll
inanygaps.
 Det
ermi
newhatact
ioni
sneeded:
admi
ssi
ont
oout
pat
ientcar
e,r
efer
ral
toi
npat
ientcar
e,orr
efer
ral
to
suppl
ement
aryf
eedi
ng.
 I
fyoudeci
det
oadmi
tthechi
l
dtoout
pat
ientcar
e,makesur
etodi
scusskeymessageswi
tht
he
mother
.Takenoteofwhatt
hemot
hertel
l
syouwheny
oudi
scussherchi
l
d’scondi
ti
on;
thi
swi
l
lhel
p
youtoknowwhichmessagest
oemphasi
se.
 I
fyougi
veRUTF,
det
ermi
nehowmuchi
sneededaccor
dingt
othechi
l
d’swei
ght
.Fi
l
lint
heRUTF
r
ati
oncar
dwi
thal
lappl
i
cabl
einf
ormat
ion.
 Tel
lthemot
heraboutt
hei
mpor
tancet
ocont
inuebr
east
feedi
ng,
andbef
oreev
eryRUTFf
eedi
ng.
Di
recthertoincr
easet henumberofbr
eastf
eedswhent
hebabyhasdi
arr
hoea.Pr
ovi
degui
danceon
st
rengtheni
nglactat
ion.

Suggest
edMet
hod:Rev
iewofl
ear
ningobj
ect
ivesandcompl
eti
onofev
aluat
ionf
orm
 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.I
nthi
smodul
e,wehav
e:
1. Descr
ibedout
pat
ientcar
efort
hemanagementofSAM wi
thoutmedi
cal
compl
i
cat
ions
2. Descr
ibedout
pat
ientcar
eadmi
ssi
oncr
it
eri
a(i
nfant
sunder6mont
hsandchi
l
dren6–59mont
hs)
3. Descr
ibedt
hepr
ocessf
oradmi
ssi
onsandweekl
yout
pat
ientcar
efol
l
ow-
onsessi
onsf
orchi
l
dren
6–59mont
hs)
4. Expl
ainedmedi
cal
treat
mentf
ort
hemanagementofchi
l
drenwi
thSAM wi
thoutmedi
cal
compl
i
cat
ionsi
nout
pat
ientcar
e
5. Expl
ainednut
ri
ti
onr
ehabi
l
itat
ionf
ort
hemanagementofSAM wi
thoutmedi
cal
compl
i
cat
ionsi
n
out
pat
ientcar
e(chi
l
dren6–59mont
hs)
6. Descr
ibedt
hekeymessagesgi
vent
omot
her
s/car
egi
ver
sofchi
l
dren6–59mont
hsdur
ing
out
pat
ientcar
e
7. Expl
ainedt
hemanagementofat
-r
iskmot
her
sandi
nfant
sunder6mont
hsofagewi
thoutmedi
cal
compl
i
cat
ionsi
nout
pat
ientcar
e.
8. Usedanact
ionpr
otocol
todet
ermi
newhenaddi
ti
onal
act
ioni
sneeded
9. Expl
aineddi
schar
gecr
it
eri
aandpr
ocedur
esf
orat
-r
iskmot
her
sandi
nfant
sunder6mont
hsand
chi
l
dren6–59mont
hs
10.Descr
ibedl
i
nkagesbet
weenout
pat
ientcar
eandot
herser
vices,
progr
ammes,
andi
nit
iat
ives

 Askf
oranyquest
ionsandf
eedbackont
hemodul
e.Di
str
ibut
eHandout4.
21Essent
ial
sofOut
pat
ient
Car
eforSAM Wi
thoutMedi
cal
Compl
i
cat
ionsasasummar
yofModul
e4.
 Letpar
ti
cipant
sknowt
hatt
heywi
l
lhav
eanoppor
tuni
tyt
opr
act
icedur
ingt
heout
pat
ientcar
efi
eld
v
isi
t.
 Askpar
ti
cipant
stof
il
loutt
hemodul
eev
aluat
ionf
orm.

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orCommuni
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eMal
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CMAM)
,2018Ver
sion

Modul
e4Out
pat
ientCar
eFi
eldPr
act
ice

Ov
erv
iew
Amaximum off
ivepar
ti
cipant
sshouldbeateachoutpat
ientcar
esi
teonagivenday
.Coordi
nat
ewi
thas
manyout
pati
entcar
esitesasnecessar
ytokeepthenumberofpart
ici
pant
satfi
veorfewer
.
Anexperiencedhealthcareprov
ider
,ideal
lysomeoneaf fi
l
iat
edwi t
htheout pat
ientcar
esite,shoul
d
ment ort
heparti
cipants,f
ir
stbydemonst r
ati
ngt heacti
vi
ti
es,thenbyinv
iti
ngpar t
ici
pantstotakeonmore
responsi
bil
it
y.Parti
cipant
smustcompl eteallacti
vi
ti
esunderthesupervi
sionofanexper i
encedhealt
h
careprovi
der.
Becertainthatparti
cipantsbri
ngtheircopiesofal l
handout sdeal
i
ngwi t
hadmi ssi
onanddischar
ge
cr
iteri
aandact ion,medicaltr
eatment,andnut r
it
ionr ehabil
i
tat
ionprot
ocols(l
i
stedbel
ow),aswellasany
ot
hert oolstr
ainersdeem necessary.Thef i
eldpracticeforModule2:Defi
ningandMeasuringAcute
Malnutrit
ionwillbedonedur i
ngthisvisi
t,sopartici
pant sal
soshouldbri
ngHandout2.4AssessingAge,
Bi
lateralPit
ti
ngOedema, MUAC, WeightandHei ght/ Lengt
h.
Pai
rpar
ti
cipant
swi
thsomeonewhospeakst
hel
ocal
language.

Pr
epar
ati
onofOut
pat
ientCar
eFi
eldPr
act
ice
Referpar
tici
pant
stoHandout4.22Outpat
ientCareFi
eldPract
iceCheckl
istanddi
scussandr
evi
ewt
he
procedur
esandstepst
hatpart
icipant
swil
lundert
akeatthecommunity-
basedsit
es:
 Ant
hropomet
rymeasur
ement
s(f
ourchi
l
dreni
ncl
udi
ngonei
nfantunder6mont
hs,
ifpossi
ble)
 Assessmentofnut
ri
ti
onal
vul
ner
abi
l
ityofmot
her
sandi
nfant
sunder6mont
hsofage(
thr
eemot
her
-
i
nfantpai
rs,
ifpossi
ble)
 Admi
ssi
on(
fourchi
l
dren,
ifpossi
ble)
 Out
pat
ientcar
efol
l
ow-
onsessi
on(
fourchi
l
dren,
ifpossi
ble)
 Di
schar
ge(
thr
eechi
l
dren,
ifpossi
ble)
 Accept
ingr
efer
ral
sfr
om i
npat
ientcar
e
 Tal
ki
ngwi
thst
affandmot
her
s/car
egi
ver
swhocomet
oout
pat
ientcar
e

Part
ici
pantsmightneedtoseeasmanycasesaspossibl
etounderst
andthedif
fer
entscenar
iosof
deci
sion-
makingduringadmissi
on,
out
pat
ientcar
efol
low-onsessi
onsanddischar
ge.

Lear
ningObj
ect
ives Handout
stoTaket
oOut
pat
ientCar
eFi
eldPr
act
ice
1.AssessandAdmitaChi
l
d
Handout2.4AssessingAge,
Bil
ater
alPi
tt
ingOedema,
MUAC,
Wei
ghtand
toOutpati
entCar
e
Hei
ght(fr
om Modul e2)
Handout4.
1Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
orCMAM
Handout4.2Out
pat
ientCar
e:Admi
ssi
onCr
it
eri
aforI
nfant
sUnder6Mont
hs
andChil
dren6–59Months
Handout4.
3Out
pat
ientCar
e:Admi
ssi
onPr
ocessf
orChi
l
dren6–59Mont
hs

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,2018Ver
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2.AssessandTreataChil
d Handout4.
7Medi
cal
Treat
mentf
ort
heManagementofSAM i
nOut
pat
ient
DuringanOutpat
ient Care
CareFoll
ow-OnSession Handout4.
8Rout
ineMedi
cinesf
orSAM i
nOut
pat
ientCar
e
Handout4.
9Suppl
ement
alMedi
ci
nesf
orSAM i
nOut
pat
ientCar
e
Handout4.
10Medi
cinePr
otocol
Rat
ional
eforOut
pat
ientCar
e(Ref
erence)
Handout4.
11Nut
ri
ti
onRehabi
l
itat
ionandRUTFf
orChi
l
dren6–59Mont
hs
3.AssessandManagean Handout4.12KeyMessagesf
orIndi
vi
dual
Counsel
l
ingatOut
pat
ientCar
e
At-Ri
skMot herand f
orMot her
s/Caregi
ver
sofChi
ldr
en6–59Months
Inf
antUnder6Mont hsof
Agewi t
houtMedi cal 4.
13C-MAMITool
Ver
sion2.
0:Br
east
feedi
ngCounsel
l
ingandSuppor
t
Compl i
cat
ionsin Act
ions
Outpati
entCare Handout4.
14Out
pat
ientCar
e:Admi
ssi
onPr
ocessf
orAt
-Ri
skMot
her
sand
I
nfant
sUnder6Mont
hs
Handout4.
15Out
pat
ientCar
eTr
eat
mentCar
dforAt
-Ri
skMot
her
sand
I
nfant
sUnder6Mont
hs
Handout4.16Out
pat
ientCar
eAct
ionPr
otocol
forI
nfant
sUnder6Mont
hs
andChil
dren6–59Months
Handout4.
19Out
pat
ientCar
e:Dischar
geCr
it
eri
aforAt
-r
iskMot
her
sand
I
nfant
sUnder6Mont
hsandChildren6–59Months
Handout4.
20Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
orCMAM
Handout4.
22Out
pat
ientCar
eFi
eldPr
act
iceCheckl
i
st

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orCommuni
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eMal
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ti
on(
CMAM)
,2018Ver
sion

Modul
e4Fi el
dPract
iceLear
ningObj
ect
ive1:AssessandAdmi
taChi
ld
t
oOutpat
ientCar
e

Hands-
OnPr act
iceatsit
e:Pract
iceadmissi
onofchi
ldr
ent
oout
pat
ientcar
e(admi
t
f
ourchil
drenduringhands-
onpracti
ce)
(
NOTE:THI
SINCLUDESCHI
LDRENREFERREDFROM I
NPATI
ENTCARE)

Ant
hropomet
ry
 Assesschi
l
drenf
orbi
l
ater
alpi
tt
ingoedema
 Measur
eMUAC,
wei
ght
,hei
ght
/lengt
h
 Cl
assi
fynut
ri
ti
onal
stat
us
 Recor
dnut
ri
ti
oni
ndi
cat
orsonout
pat
ientcar
etr
eat
mentcar
dsandRUTFr
ati
oncar
ds

NewAdmi
ssi
ons
 Obt
ainr
egi
str
ati
ondet
ail
sfr
om mot
her
/car
egi
verandchi
l
d’sr
ecor
d
 Takemedi
cal
hist
ory
 Conductphysi
cal
exami
nat
ion
 Testappet
it
e(washhandsbef
orehandl
i
ngt
heRUTF)
 Deci
de:
ref
err
alt
oinpat
ientcar
eifamedi
cal
compl
i
cat
ionexi
sts,
admi
ssi
ont
oout
pat
ientcar
e
 Cal
cul
atedosesandgi
ver
out
inemedi
ci
nest
ochi
l
d
 Expl
ainmedi
cal
treat
mentt
omot
her
/car
egi
ver
 Cal
cul
ateamountofRUTFf
orchi
l
d,r
ecor
ditandgi
ver
ati
on(
basedonchi
l
d’swei
ghtandf
requency
ofv
isi
t)
 Checkbr
east
feedi
ngst
atusf
orchi
l
dren6–23mont
hs
 Di
scusskeymessageswi
thmot
her
s/car
egi
ver
s
 Fi
l
loutRUTFr
ati
oncar
dsf
orchi
l
dreni
ntheser
vice
 Askmot
her
/car
egi
vert
orepeati
nst
ruct
ionsongi
vi
ngmedi
cineandRUTF
 Li
nkwi
thout
reachwor
ker

Accept
ingRef
err
alsf
rom I
npat
ientCar
e
 Revi
ewr
efer
ral
sli
pfr
om i
npat
ientcar
eandr
ecor
drel
evanti
nfor
mat
iononout
pat
ientcar
etr
eat
ment
car
d(i
ncl
udi
ngmedi
cines)
 Revi
ewi
nfor
mat
ionandmedi
cat
ionspr
ovi
dedi
ninpat
ientcar
e,conf
ir
m medi
cinesr
ecei
vedt
odat
e
wi
thmot
her
/car
egi
ver
,andadj
ustout
pat
ientcar
emedi
cinesf
oradmi
ssi
on
 Fol
l
owadmi
ssi
onpr
otocol
s(i
.e.t
estappet
it
e,cal
cul
ateRUTFr
ati
on,
breast
feedi
ngst
atus,
discuss
keymessages/
pract
ices,
fil
loutRUTFr
ati
oncar
d,l
i
nkwi
thout
reachwor
ker
)

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orCommuni
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eMal
nut
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ti
on(
CMAM)
,2018Ver
sion

Module4Fi
eldPr
acti
ceLear
ningObj
ecti
ve2:AssessandTr
eataChi
ld
Dur
inganOut
pati
entCar
eFoll
ow-OnSessi
on

Hands-
OnPract
ice:Pr
acti
ceconducti
nganoutpati
entcarefol
low-
onsessi
on(conduct
vi
sitwi
tht
hreemother-
inf
antpai
rsandfourchi
ldr
enduringhands-
onpract
ice)

Ant
hropomet
ry
 Assesschi
l
drenf
orbi
l
ater
alpi
tt
ingoedema
 Measur
eMUAC,
wei
ght
,lengt
h
 Cl
assi
fynut
ri
ti
onal
stat
us
 Recor
dnut
ri
ti
oni
ndi
cat
orsonout
pat
ientcar
etr
eat
mentcar
dsandRUTFr
ati
oncar
ds

Rev
iewPr
ogr
essandDet
ermi
neNextSt
eps
 Pr
act
icer
evi
ewi
ngi
nfor
mat
ionont
reat
mentcar
dtodat
eandi
nter
pret
ingpr
ogr
ess(
Aret
hechi
l
dren
i
mpr
ovi
ng?Ar
etheynoti
mpr
ovi
ng?Why
?)
 Useact
ionpr
otocol
toassessneedf
orf
oll
ow-
uphomev
isi
t,r
efer
ral
toi
npat
ientcar
eordi
schar
ge,
andmakeanyar
rangement
s,i
fnecessar
y
 Di
scusschi
l
d’spr
ogr
esswi
thmot
her
/car
egi
ver

Di
schar
ge
 Compl
etet
heout
pat
ientcar
etr
eat
mentcar
dupondi
schar
ge
 Pr
ovi
deappr
opr
iat
einf
ormat
iont
omot
her
/car
egi
veraboutchi
l
d’sdi
schar
ge(
e.g.
,whent
ocome
backwi
tht
hechi
l
d,dangersi
gns)
 Gi
vedi
schar
ger
ati
onofRUTF
 I
nfor
m mot
her
/car
egi
veraboutl
i
nki
ngwi
thot
herser
vicesand/
orpr
ogr
ammesasappr
opr
iat
e(e.
g.,
gr
owt
hmoni
tor
ingandpr
omot
ion[
GMP]
)

90
Modul
e4Fi el
dPracticeLear
ningObj
ect
ive3:AssessandManageanAt
-
Ri
skMotherandInf
antUnder6Mont hsofAgewithoutMedi
cal
Compl
icat
ionsi
nOut pati
entCare

Hands-OnPract
ice:Pract
icemanagi
ngat
-r
iskmothersandinfant
sunder6monthsof
agewithoutmedicalcompli
cat
ionsi
nout
pati
entcare(conductvi
sitwi
tht
hreemother
-
i
nfantpair
s)

AssessandCl
assi
fyt
heMot
herandI
nfantPai
r
 Assesst
hemot
her
-i
nfantpai
r:Tr
iaget
hei
nfant
;conductant
hropomet
ry,
breast
feedi
ng,
andcl
i
nical
assessment
 Cl
assi
fynut
ri
ti
onal
stat
us(
ant
hropomet
ry)
 Assesst
hemot
herf
ordepr
essi
on,
anxi
ety
,and/
ordest
ress
 Recor
dinf
ormat
ioni
ntheC-
MAMIt
reat
mentcar
d

Management
 Obt
ainr
egi
str
ati
ondet
ail
sfr
om mot
her
/car
egi
verandchi
l
d’sr
ecor
d
 Takemedicalhi
story
 Conductphysi
calexami
nat
ion
 Conductfeedi
ngassessment
 Deci
de:refer
ralt
oinpat
ientcar
eifamedi
cal
compl
i
cat
ionexi
stsoradmi
ssi
onf
ormanagementi
n
out
pat
ientcar
e
 Pr
ovi
def
eedi
ngsuppor
t:Counsel
l
ingf
ort
hemot
her
,and/
orf
ami
l
yorcommuni
tycounsel
l
ingand
suppor
t
 Li
nkwi
thout
reachwor
ker

Act
ivi
ty:FeedbackonFi
eldPr
act
iceSessi
ons
Met
hod:Feedback/
Discussi
on
Af
tereachf
iel
dpr
act
ice,
conductaf
eedbacksessi
oni
nwhi
chpar
ti
cipant
swi
l
l:
 Pr
ovi
def
eedbackonst
rengt
hsobser
vedateachheal
thf
aci
l
ity
 Rai
sei
ssuesf
orcl
ari
fi
cat
ionbyt
rai
ner
s
 I
dent
if
ykeygapst
hatneedmor
epr
act
iceorobser
vat
iont
ime

91
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

MODULEFIVE:I
NPATIENTCAREFORTHEMANAGEMENT
OFSAM WI
THMEDI CALCOMPLICATI
ONSI
NTHE
CONTEXTOFCMAM

Modul
eOv
erv
iew
Thismodul eprov i
desanorientat
ionofinpati
entcar efort
hemanagementofsev ereacut
emal nutr
iti
on
(SAM)wi thmedi calcompl
icati
onsandnot est heissuesthatshouldbeconsi
dered.Themodul ebri
efly
outl
ineswhoshoul dbeadmi t
tedtoinpati
entcar eandwhy .I
talsocoversadmissionanddischarge
processesandcr iter
iaaswellasthebasicprinciplesofmedicaltr
eatmentandnut r
it
ionr
ehabili
tat
ion.
Emphasi sisplacedonensur i
ngasmoot href
er r
alprocessbetweenoutpati
entcareandinpati
entcare,i
n
bothdirecti
ons.
Thi
smodul eisNOTagui detosettingupormanagi ngi npati
entcare.Forthi
stypeofguidance,aseparat
e
seven-dayWor ldHealthOrgani
sation(WHO)t raini
ngcour sehasbeendesi gnedforhealt
hcaremanager s
andheal t
hcar eprovi
derswhowi l
lbemanagi ngchi ldr
enwi thSAM wi t
hmedi calcompli
cati
onsin
i
npatientcare.Howev er,
parti
cipantsinthetrainingofthismodul ewillpar
takeinahalf-
daysitevi
sitt
oan
i
npatientcaresitetogivethem abet t
erunder standingofCMAM, thecompr ehensiv
etreat
mentofSAM,
andther efer
ralprocessbetweent heinpat
ientandout pati
entcomponent s.
Thi
smodul eisint
endedtobeusedal
ongsi
detheWHOguideli
nesf
orthemanagementofsever
e
malnutr
it
ion(1999)
,theWHOupdateonthemanagementofSAM i
ninf
ant
sandchil
dren(2013)
,and
nat
ionalgui
deli
nesandtreat
mentpr
otocol
s.
Inpati
entcareisprovi
dedinahospitalorhealt
hf aci
l
itywith24-hourcareforchil
drenwithSAM without
appetit
eorwi thmedicalcompl
icati
onsuntilt
heirmedi calcondi
ti
onisstabil
isedandt hecompli
cationis
resolv
ing.Treatmentthencont
inuesinoutpati
entcareunt il
thechil
drecoverssuffi
cientwei
ght.For
certai
ncases, i
npati
entcaresi
tescanprovidecar ef
ort hemanagementofSAM unt i
l t
hechil
disfully
recovered.

Dur
ati
on Handout
sandExer
cises
Learni
ngObj ect
ives
1.Outl
inet heManagementof 15 Handout5.
1Essent
ial
softheManagementofSAM Wi
th
Childrenwi t
hSAM wi t
h minut
es Medical
Compli
cati
onsinI
npat
ientCar
e
Medi cal Complicat
ionsin
InpatientCare
2.DescribeAdmi ssionand 30 Handout5.
2Admi
ssi
onPr
ocedur
esi
nInpat
ientCar
e
Dischar geforthe minut
es
Handout5.
3Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
or
ManagementofSAM Wi t
h
CMAM
Medi cal Complicat
ionsin
InpatientCare Handout5.
4Di
schar
gePr
ocedur
esi
nInpat
ientCar
e
Handout5.
5Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
or
CMAM
3.ReviewMedicalandDi et
ary 30 Handout5.
6MedicalandDi
etar
yTr
eat
mentofSAM Wi
th
TreatmentinInpat
ient minut
es Medical
Compl
icati
ons
Care
4.Practi
cetheReferr
al 30 Handout5.
5Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
or
ProcessBetweenI npati
ent minut
es CMAM
CareandOut pati
entCare
Handout5.
7Pract
ical
Impl
i
cat
ionsi
nDi
schar
gesFr
om
I
npati
entCare
Exer
cise5.
1Ref
err
alf
rom I
npat
ientt
oOut
pat
ientCar
e

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ngGui
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orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Fi
eldVi
sitt
oInpat
ientCar
e ½day Handout5.
1Essent
ial
sfortheManagementofSAM Wi
th
Si
te Medical
Compli
cati
onsinInpat
ientCar
e
Handout5.
8Inpat
ientCar
eFi
eldVi
si
tCheckl
i
st
Local
Inpat
ientCar
eTr
eat
mentCar
d
Wrap-
UpandModul
e 15
Ev
aluat
ion minut
es

Dur
ati
on:Twohour
sofcl
assr
oom t
imef
oll
owedbyahal
f-
daysi
tev
isi
t
Not
e:Dependi
ngont heneedsoft hei
raudi
ence(s),t
rai
ner
smaychooset
oski
porspendmor
eorl
ess
t
imeoncertai
nlear
ningobject
ivesandacti
vit
ies.Themoduledur
ati
oni
sanest
imat
eofthet
imei
ttakes
t
ocompleteal
lthelear
ningobject
ivesandactiv
iti
es.

Mat
eri
als
 Ref
err
alsl
i
ps(
forr
efer
ral
from i
npat
ientcar
etoout
pat
ientcar
eandv
icev
ersaorf
orr
efer
ral
for
f
urt
hermedi
cal
inv
est
igat
ion)
 Copi
esofal
ocal
inpat
ientcar
etr
eat
mentcar
d
 Nat
ional
gui
del
i
nesf
ormanagementofSAM
 Handout
sandexer
cises

Adv
ancePr
epar
ati
on
 Room set
up,mater
ials,
fli
pchart
s,mar
ker
s,maskingt
ape
 Checknat
ional
protocolsfort
hemanagementofSAM
 Obtai
nandmakecopi esofal
ocali
npati
entcaret
reatmentcard
 DownloadandmakecopiesoftheupdatedWHOj obaidsonthemanagementofSAM i
ninf
ant
sand
chi
l
dren(Note:Expect
edtobepubl
ishedin2018)
 Downl
oadandmakecopi sUpdat
esofWHO’ esont
heManagementofSAM i
nInf
ant
sandChi
l
dren
(
2013)(
seel
i
nki
nref
erencer
esour
cesbel
ow)
 Downl
oadandmakecopi
esofWHO’ sManagementofSev
ereMal
nut
ri
ti
on:AManualf
orPhysi
cians
andOt
herSeni
orWor
kers(1999)
,(av
ail
abl
eat
http:
//www.who.i
nt/
nutri
ti
on/
publ
icat
ions/
en/
manage_sev
ere_
malnut
ri
ti
on_eng.
pdf
)andWHO’s
Guideli
nesfort
heInpat
ientTr
eat
mentofSeverel
yMal
nouri
shedChi
ldr
en(2003)(
seeli
nki
nref
erence
resourcesbel
ow)
 Pr
epar
eset
sofcar
dswi
thanadmi
ssi
onanddi
schar
gecr
it
eri
onwr
it
tenoneach
 Col
l
ectorpr
epar
eref
err
alsl
i
ps
 Revi
ewr
elev
antr
efer
encer
esour
cesandf
urt
herr
eadi
ngr
esour
cesl
i
stedbel
ow.

Ref
erenceResour
ces
1. WorldHeal
thOr
ganisat
ion(
WHO) .2002.Tr
aini
ngCourseontheManagementofSever
eMal
nut
ri
ti
on.
Genev WHO.(
a: Note:Updat
eexpectedtobepubli
shedin2018)

93
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ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

2. WHO.2013.Gui deli
ne:UpdatesontheManagementofSevereAcut
eMal nut
ri
tioni
nInfant
sand
Chi
ldren.Avai
lableat:
ht
tp:/
/ www.who.i
nt/nutr
it
ion/publ
i
cati
ons/
gui
del
ines/
updates_management_SAM_inf
antandchi
l
dren/
e
n/
3. WHO.2013.PocketBookofHospi t
alCaref
orChil
dren:Gui
deli
nesforManagementofCommon
Chi
ldhoodI
lnesses.2ndEdi
l t
ion.Avai
labl
eat:
ht
tp:/
/www.who.i
nt/maternal_chi
l
d_adol
escent
/documents/chi
ld_
hospi
tal
_car
e/en/
.
4. WHO.2003.Guidel
inesf
ortheInpati
entTr
eat
mentofSeverel
yMal
nouri
shedChil
dren.Geneva:WHO.
Av
ail
abl
eat:htt
p://
www. who.
int/nut
ri
ti
on/
publi
cat
ions/
sev
eremal
nut
ri
ti
on/9241546093/en/.
5. WHO.1999.ManagementofSev
ereMal
nut
ri
ti
on:AManualforPhysi
ciansandOt
herSeni
orHeal
th
Wor
kers.Geneva:WHO.Avai
l
abl
eat:
www.who.
int
/nut
/publ
i
cations.

Fur
therReadi
ngResour
ces
1. Nat
ional
gui
del
i
nesf
orCMAM
2. Nat
ional
gui
del
i
nesf
ori
ntegr
atedmanagementofchi
l
dhoodi
l
lness(
IMCI
)
3. EmergencyNutri
ti
onNet work,I
nternat
ionalBabyFoodAct i
onNetwork,Terr
edesHommes, Unit
ed
Nati
onsHighCommi ssionerforRefugees,UNICEF, Worl
dFoodProgramme, WHO.2004. 
“TheYoung
Sever
elyMalnour
ishedI nfant”(
chapter8)inInfantFeedi
nginEmergencies,
Modul
e2, Ver
sion1.0
forHeal
thandNut ri
ti
onWor ker
sinEmer gencySi t
uati
ons.Avai
l
abl
eat :
htt
p:/
/www.unhcr.org/45f6cc4e2.pdf
4. Woodruff
,B.andDuf fi
el A.2000.Adol
d, escents:AssessmentofNutr
it
ionalSt
atusi
nEmergency
Aff
ectedPopulat
ions.UnitedNationsAdmi ni
strati
veCommi t
teeonCoor di
nat
ionSub-
Committeeon
Nutr
it
ion(ACC/SCN) .Avai
labl
eat :
ht
tps:
//www.unscn.org/web/archives_
resources/fi
les/
adol
escent
rni
ssup.pdf

94
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module5Lear
ningObject
ive1:Outl
inetheManagementofChi
ldr
enWi
th
SAM Wit
hMedicalCompli
cati
onsinInpati
entCar
e

TRAI
NER:Becomef
ami
l
iarwi
thHandout5.
1Essent
ial
sfort
heManagementofSAM wi
thMedi
cal
Compl
icat
ionsi
nInpat
ientCar
e.

BRAI
NSTORM:I
NPATI
ENTCARE.Dr
awt
hegr
aphi
cbel
owont
hef
li
pchar
tandaskpar
ti
cipant
s:
 Whyi
sthei
npat
ientcar
ecomponenti
nCMAM ser
vicessmal
l
ert
hant
heot
hercomponent
s?
 Howdoest
hei
npat
ientcomponenti
nCMAM di
ff
erf
rom r
esi
dent
ial
orcent
re-
basedcar
e?(
Answer
s:
onl
ythemostat -
riski
nfant
sandchi l
drenar
eadmi t
tedwhileothersaretreat
edinoutpat
ientcar
e;
i
nfant
sandchildrenarerel
easedwhent hei
rmedicalcondi
tionisstabi
li
sedandtheirmedical
compli
cati
onisresolv
ing,r
atherthanful
lyr
ecov
ered;chil
dren6–59mont hscantakeRUTFi n
i
npati
entcarei
ftheyhav eappeti
te)

Fi
gur
e1.Cor
eComponent
sofCMAM

Community
Out
reach
Outpati
entcare
f
ormanagement
ofSAM
WITHOUT
I
npat
ient medical Othernutri
tionandheal th
car
ef or complicati
ons int
erventions,food
mgmtof
SAM WI TH securi
ty,socialprotecti
on
medical andWASH, t
opr event
undernutrit
ion
Management
of
MAM

GROUPDI
SCUSSI
ON:ESSENTI
ALSOFI
NPATI
ENTCARE.Di
rectpar
ti
cipant
stoHandout5.
1
Essenti
alsfortheManagementofSAM Wit
hMedicalCompl i
cat
ionsinInpati
entCare.Askparti
cipant
s
torevi
ewt hehandoutandanswert
hef
oll
owingquest
ions.Revi
ewr esponsesi
nplenaryanddiscuss.
 Whyi
sinpat
ientcar
esuchanessent
ial
componentofCMAM?
 Whor
ecei
vest
reat
menti
ninpat
ientcar
e?
 Howl
ongi
str
eat
mentpr
ovi
ded?
 Howi
sinpat
ientcar
ebesti
mpl
ement
ed?Wi
thi
nwhi
chst
ruct
ures?

95
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module5Learni
ngObjecti
ve2:Descri
beAdmissi
onandDischargefort
he
ManagementofSAM WithMedicalCompl
icat
ionsi
nInpat
ientCare

TRAI
NER:Becomef
ami
l
iarwi
thHandout5.
2Admi
ssi
onPr
ocessi
nInpat
ientCar
e,Handout5.
3
Admissi
onCri
ter
iaandEnt
ryCategor
iesforCMAM, Handout5.
4Di
schar
gePr
ocessi
nInpat
ientCar
e,and
Handout5.
5Dischar
geCri
ter
iaandExitCategor
iesf
orCMAM.

PARTI
CIPATORYLECTURE:PROCESSFORADMI
SSI
ONTOI
NPATI
ENTCARE.Descr
ibet
o
par
ti
cipant
sthebul
l
etpoi
ntsout
li
nedi
nthef
ir
stsect
ionofHandout5.
2:Admi
ssi
onPr
ocessi
nInpat
ient
Car
e.

ELI
CITATI
ONANDGROUPDI
SCUSSI
ON:ADMI
SSI
ONCRI
TERI
AFORI
NPATI
ENTCARE.Ask
part
ici
pant stonamecr it
eriaforadmi ssi
ont oinpat i
entcare.Manyoft hecrit
eriawil
lbethose
encounteredinModul e4r equir
ingreferral t
oinpat ientcare.Wri
teresponsesonaf l
ipchart.Refer
part
ici
pant stoHandout5. 2Admi ssionPr ocessi nI npati
entCar
eandHandout5. 3Admi ssionCri
ter
ia
andEntryCat egor
iesforCMAM.Rev iewt hetextandt hetabl
e,makingnoteofanydi scr
epancieswit
hthe
answersont hefli
pchar t
.Emphasi zet hedi ff
eringadmi ssi
oncri
teri
aforinfantsunder6mont hsand
bri
efl
ypr esentadmissioncrit
eriaforadol escent s,adultsandHIV-posi
tiv
eadul ts.Di
scussandf il
li
ngaps.

PARTICI
PATORYLECTURE:PROCEDUREANDCRI TERI
AFORDI SCHARGEI NINPATIENT
CARE.Descr
ibet
opar
ti
cipant
sthebul
l
etpoi
ntsout
li
nedonHandout5.
4Dischar
gePr
ocessi
nInpat
ient
Care,
Secti
onAandHandout5.
5DischargeCri
teri
aandExi
tCategor
iesf
orCMAM.Answerany
quest
ionst
henbr
ief
lyr
evi
ewthedi
schargecri
teri
ainbot
hthet
extandthetabl
eont
hesamehandout
.

PRACTICEANDGROUPDI SCUSSION:DETERMI NEAPPROPRI ATENESSOFI NPATI

ENT
CARE.Ref
erpar
ti
cipant
stot
hetabl
esinbot
hHandout5.
3andHandout5.
5.Tel
lthem y
ouwi
l
lgi
ve
examplesofchi
l
dreneit
herpr
esent
ingatoralr
eadyi
ninpati
entcar
eandaskthem t
odeter
mineifthe
chil
dshoul
dbeadmi t
ted,r
emaini
ninpat
ientcar
eorbedischar
gedtoout
pati
entcar
e.Askthem t
o
explai
nwhy.
Exampl
es:
1. I
nfanti
sunder6mont hsandisbroughttoi
npati
entcar
ewi t
hbil
ater
alpi
tt
ingoedemagr
ade+.
(
Answer:admitt
oinpati
entcarebecauseofbi
lat
eralpi
tt
ingoedema.)

2. Chil
dwasadmi t
tedtoinpati
entcarewi t
hami d-upperarm ci
rcumf er
ence(MUAC)<115mm andno
appeti
tebutnoot hermedicalcomplicat
ions.Chil
dnowpassest heappeti
tetestandiscl
ini
cal
l
ywel
l
andalert
.
(Answer:di
schargetooutpatientcar
ebecauseappet it
ehasr eturnedandall
othercri
ter
iamet)
.
3. Chil
disbroughttoinpati
entcar ewit
hbilat
eralpit
ti
ngoedemagr ade++andMUAC<115mm.
(Answer:admittoinpat
ientcarewithfortr
eatmentofmar asmickwashi or
kor.)

4. Inf
antisunder6mont hsandwasbr oughttoinpat
ientcar
eunabl et
obreastf
eedandwithprol
onged
weightl
oss.Inf
antisnowef f
ecti
velygaini
ngweightonexclusiv
ebreast
feedi
ng,andt
hemot heri
s
confi
dentwiththeinf
ant’
sbreastf
eedingstat
us.
(Answer:di
schargetooutpat
ientcaretocont
inuewithfol
low-upandbreastf
eedi
ngsupport
.)

Chil
dwasbr oughttoinpati
entcarewit
hmar asmickwashior
kor.Bi
l
ater
alpi
tt
ingoedemahasbeen
reducedfr
om grade+++t ograde+.
(Answer:
keepchildininpati
entcareunt
ilbi
l
ateralpi
tt
ingoedemaresol
ved.
)

96
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module5Learni
ngObj
ect
ive3:Rev
iewMedi
cal
andDi
etar
yTr
eat
menti
n
I
npat
ientCar
e

TRAI
NER:
Becomef
ami
l
iarwi
thHandout5.
6Medi
cal
andDi
etar
yTr
eat
mentofSAM Wi
thMedi
cal
Compl
i
cat
ions.

REVI
EW:MEDI
CALCOMPLI
CATI
ONSREQUI
RINGI
NPATI
ENTCARE.Askpar
ti
cipant
stoname
t
hemedi
cal
compl
i
cat
ionst
hat
,coupl
edwi
thSAM,
woul
drequi
rei
npat
ientcar
e:
 Anor
exi
aornoappet
it
e,i
nfantunder6mont
hsunabl
etof
eed
 I
ntr
act
abl
evomi
ti
ng
 Convul
sions
 Let
har
gy,
notal
ert
 Unconsci
ousness
 Lowerr
espi
rat
oryt
racti
nfect
ion
 Hi
ghf
ever
 Dehydr
ati
on
 Per
sist
entdi
arr
hoea
 Sever
eanaemi
a
 Hypogl
ycaemi
a
 Hypot
her
mia
 Eyesi
gnsofv
itami
nAdef
ici
ency
 Ski
nlesi
ons

Addi
ti
onal
compl
i
cat
ionsf
ori
nfant
sunder6mont
hs:
 Cl
eftl
i
porpal
ate
 Abnor
mal
toneorpost
ure
 Excessi
vel
yopenorcl
enchedj
aw
 Unabl
etosuppor
theadorcont
rol
trunk
 Whenhel
d,i
nfant
’sar
msandl
egsf
all
tot
hesi
des
 I
nfant
’sbodyst
il
l,
har
dtomov
e
 Notwi
l
li
ngorabl
etosuckl
eatt
hebr
eastorf
eedbycuporbot
tl
e
 Coughi
ngandey
etear
ing(
signsofunsaf
eswal
l
owi
ng)whi
l
efeedi
ng

READINGANDGROUPDI SCUSSION:MEDICALANDDI ETARYTREATMENTI NI NPATIENT

CARE.Expl
aint
opar
ti
cipant
sthatt
hemedi
cal
anddi
etar
ytr
eatmentofSAM i
ninpat
ientcar
efol
l
owsthe
WHOtreat
mentpr
otocolf
orthetr
eat
mentofSAM unt
ilthemedicalcondi
ti
oni
sst
abi
l
ised,
themedi
cal
compl
i
cati
oni
sresol
vingandthechi
l
disr
efer
redt
oout pati
entcare.

Ref erparti
cipantst
oHandout5. 6MedicalandDiet
aryTreat
mentofSAM Wi thMedi calCompli
cati
ons.
Inpl enary
,discussthefi
gureshowingstabi
li
sat
ionandrehabil
it
ationphases.Notethataft
erfourto
sev enday soft r
eat
ment,themedicalcondi
ti
onshouldbestabil
isedandt hemedicalcompli
cati
on
resol vi
ng.Reviewthehandouttoget
herandansweranyquestionsr egar
dingnut
ri
tionrehabi
li
tat
ionfor
i
nf antsunder6mont hsandchil
dren6–59mont hs.

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orCommuni
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,2018Ver
sion

Referparti
cipantstotheWHOupdat esonthemanagementofSAM ininfantsandchi
l
dren(2013)
,WHO
Gui
delinesfortheI npat
ientTr
eatmentofSever
elyMal
nour
ishedChil
dren(2003),
andothergui
dance
l
ist
edi ntheRef erenceResourcesandFurt
herReadi
ngResourcesSecti
onoft hi
smodule.

Giveeachpar
ti
cipantacopyofal
ocal
inpat
ientt
reat
mentcar
dandexpl
aint
hei
nfor
mat
iont
hatcanbe
foundonit
:
 Per
sonal
inf
ormat
ion:
namesandl
ocat
ionsofmot
her
s/car
egi
ver
stoal
l
owf
orf
oll
ow-
uphomev
isi
ts
af
terdi
schar
ge
 Resul
tsofdai
l
ybi
l
ater
alpi
tt
ingoedemachecks
 Ant
hropomet
ry:
MUAC,
wei
ght
,andhei
ght
/lengt
hrecor
dedonadmi
ssi
on;
wei
ghti
sal
someasur
ed
dai
l
y
 Cl
i
nical
dat
a/f
indi
ngs:
resul
tsofdai
l
ymedi
cal
assessment
s(becausedet
eri
orat
ioncanoccurqui
ckl
y,
i
tisessent
ial
torecor
dmedi
cal
findi
ngsandot
heri
nfor
mat
iont
omakeacor
rectdi
agnosi
sand
pr
ovideti
melytr
eatment
)
 Medi
cines:
themedi
cinesgi
venandwhent
heywer
egi
venar
erecor
ded(
Not
e:medi
cal
staf
fshoul
d
di
rect
lyobser
vet
hemedi
cinebei
ngt
aken,
thechi
l
d’sr
esponset
othemedi
cineandt
heout
come)
 Feedi
ngi
nfor
mat
ion:
typeandpr
opor
ti
onoft
het
her
apeut
icf
oodt
hechi
l
dconsumesandany
i
nst
ancesofv
omi
ti
ng

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,2018Ver
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Module5Learni
ngObj
ecti
ve4:Pract
icet
heRef
err
alPr
ocessBet
ween
I
npat
ientCar
eandOutpat
ientCar
e

TRAI
NER:
Becomef
ami
l
iarwi
thHandout5.
5Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
orCMAM,
Handout
5.
7Pr acti
cal
Implicat
ionsi
nDi
schar
gesf
rom I
npat
ientCar
e,andExer
cise5.
1Ref
err
alf
rom I
npat
ientt
o
Outpati
entCare.

REVI
EW:REFERRALSFROM I
NPATI
ENTCARE.I
npl
enar
y,askpar
ti
cipant
stonamedi
schar
ge
cr
it
eriathatwouldindicateadischar
gefrom i
npat
ientcar
etooutpat
ientcar
e.I
fpar
ti
cipantshave
di
ff
icult
yr espondi
ng,remindthem toref
ertoHandout5.5Di
schargeCrit
eri
aandExitCategor
iesforAt
-
Ri
skMot hersandInfantsUnder6Mont hsandChildr
en6–59Mont hs.

PARTI
CIPATORYLECTURE:REFERRALSBETWEENI
NPATI
ENTANDOUTPATI
ENTCARE.
Explaintopar ti
cipantsthatthemai nfocusofthesemodul esisonoutpati
entcare,whichincludes
refer
ralsfrom inpat i
enttooutpati
entcare.Howev er,
therearesever
alcaseswher epatient
swi l
lbe
dischargedt ootherset t
ings.Outl
inetoparti
ci
pant sthekeypoint
sregardi
ngdischargesf rom i
npati
ent
caret oter
tiarycar eanddischargesthatexi
tCMAM ser v
icesasfoundinHandout5. 7Pr acti
cal
Implicati
onsi nDi schargesfrom Inpati
entCare.
Remindpar ti
cipant
sthataneffectiv
er ef
err
alsyst
em betweeninpat
ientcareandoutpat
ientcarei
s
essenti
alforthesmoot hfunct
ioningofCMAM ser vi
ces.Notethati
tishelpf
ulfori
npati
entcarestaf
fto
vi
sitoutpati
entcaresit
esandv iceversa.Outl
i
nethekeypointsinHandout5.7.Askparti
cipant
sifthey
haveanyot herkeypointstoadd.

BRAI
NSTORM:REFERRALSFROM I
NPATI
ENTTOOUTPATI
ENTCARE.Askpar
ti
cipant
stot
hink
ofkeyacti
onsthatshouldaccompanythedi
schargeofpati
ent
sfrom i
npat
ientcar
etooutpat
ientcar
e.
Writ
eresponsesonaf l
ipchart
.Fi
lli
nthegapinresponseswit
hthekeypoi
ntsoutl
inedi
nHandout5.7,
Secti
onD.

PRACTI
CE:REFERRALSFROM I
NPATI
ENTTOOUTPATI
ENTCARE.Askpar
ti
cipant
stof
orm
pai
rs.Referthem t oExer cise5. 1Referr
alfrom I
npati
enttoOutpati
entCar e.Wri
tethefol
lowingdetailsof
achil
donf li
pchar tandaskpai rstofil
louttheref
err
alcardfr
om inpat
ienttooutpati
entcare.(Note:usea
l
ocall
yappr opriatenamef orthechi l
dandt henameofal ocalcommuni t
y.)Movewi t
hinandamongt he
pai
rsandanswerquest ions.Di scusswhatchangesoccurredinthechil
d’shealt
ht opermi
tr ef
erralt
o
out
patientcar eandf il
l i
ngaps.
Admissiondat a:
Dateofadmi ssi on: 09/Feb/2018
I
npat i
entsi te: XXX
Registrationnumber :113/OC/ZAL
Age: 26mont hs
Sex:Femal e
Height/lengt h: 78. 5cm
Weight :7.2kg
Bil
ateral pit
tingoedema: ++
MUAC: 117mm
WFH/ WFL: <-3z- score

Di
schar
gedat a:
-Dateofdischar
ge:15/
Feb/ 2018
-Weight:
7.0kg
Bil
ater
alpit
ti
ngoedema: none
MUAC: 118mm

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WFH/
WFL:
<-3z-
scor
e

Tr
eat
ment
:F75,
someRUTF
Amoxici
ll
i
n: 125mg(5ml)3x/dayfor7day
s
Ar
tesunate:Days1-
3,1t
abletperday

Exer
cise5.
1Ref
err
alf
rom I
npat
ientt
oOut
pat
ientCar
e(wi
thanswer
s)

Nameofchi
ld (
local
name) Communi
ty (
local
name)
Age 26mont
hs Sex F
Dat
eof
admi
ssi
on
09/
Feb/
18

ADMI
SSI
ONDATA Si
te #

ght 7.
Wei 2kg MUAC 117mm Ref
err o Out
alt pat
ientCar
e
WFH/
WF Regi
str
ati
on 113/
OC/
ZAL
ght 78.
Hei 5cm <-
3z-
scor
e
L No

Bi
lat
eralpi
tt
ingoedema(
cir
cle) NONE + ++ +++

I
NFANTSUNDER6MONTHSOFAGE
I
sinf
antexcl
usi
vel
ybr
east
feedi
ng?(
cir
cle) Y N

I
fnotbr
east
feedi
ng,
isi
nfantf
eedi
ngwel
landexcl
usi
vel
yonr
epl
acementf
eed?(
cir
cle) Y N

Dat
eofr
efer
ral 15/
Feb/
18

Cr
it
eri
aforr
efer
ral
Wei
ght
:7.
0kg Bi
l
ater
alPi
tt
ingOedema:
None
MUAC:
118mm WFH:<-
3z-
scor
e

Tr
eat
mentgi
ven
F75,
someRUTF
Amoxi
cil
l
in:
125mg(
5ml
)3x/
dayf
or7day
s
Ar
tesunat
e:Day
s1-
3,1t
abl
etperday

Comment
s

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,2018Ver
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Modul
e5Wr
ap-
UpandModul
eEv
aluat
ion

Suggest
edMet
hod:Rev
iewl
ear
ningobj
ect
ivesandcompl
eteev
aluat
ionf
orm.
 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.I
nthi
smodul
eyouhav
e:
1. Out
li
nedt
hei
npat
ientcar
ecomponentofCMAM
2. I
dent
if
iedadmi
ssi
onanddi
schar
gecr
it
eri
afori
npat
ientcar
efort
hemanagementofSAM wi
th
medi
calcompl
i
cat
ions
3. Rev
iewedmedi
cal
anddi
etar
ytr
eat
mentusedi
ninpat
ientcar
e
4. Pr
act
icedt
her
efer
ral
processbet
weeni
npat
ientcar
eandout
pat
ientcar
e

 Askf
oranyquest
ionsandf
eedbackont
hemodul
e.

 Askt
hef
oll
owi
ngr
evi
ewquest
ions:
Whatar
ethemai
nreasonsf
orr
efer
ri
ngi
nfant
sandchi
l
drent
oinpat
ientcar
e?
Aboutwhatper
cent
ageoft
het
otal
casel
oadofchi
l
drenwi
thSAM wi
l
lrequi
rei
npat
ientcar
e?
Aboutwhatper
cent
ageoft
het
otal
casel
oadofi
nfant
swi
l
lrequi
rei
npat
ientcar
e?
Howlong(onaverage)i
sachil
dwit
hSAM wit
hmedi
calcompl i
cati
onsexpect
edt
ost
ayi
n
i
npat
ientcar
ebeforeconti
nui
ngontot
reat
menti
nout
patientcare?
Whatar
ethedi
schargecr
it
eriaf
rom i
npat
ientcar
etooutpati
entcare(i
.e.howdoy
ouknowwhen
achi
ldwit
hSAM wit
hcomplicat
ioni
sreadytogotooutpati
entcare)
?

 Letpar
ti
cipant
sknowt
hatt
heywi
l
lhav
eanoppor
tuni
tyt
oobser
vepr
ocedur
esanddi
scusst
hem wi
th
st
affdur
ingt
hei
npat
ientcar
efi
eldv
isi
t.

 Askpar
ti
cipant
stof
il
loutt
hemodul
eev
aluat
ionf
orm.

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Modul
e5I
npat
ientCar
eFi
eldVi
sit

Ov
erv
iew
 I
deal
l
y,amaxi
mum off
ivepar
ti
ci
pant
sshoul
dbeateachi
npat
ientcar
esi
teonagi
vendayt
oal
l
ow
parti
cipant
senoughtimetoobserveandi nt
eractdirectl
y.Coor dinat
ewi thasmanyinpatientcar
e
sit
esasnecessarytokeept henumberofpar t
ici
pant satfiveorf ewer.Ensur
ethattheinpati
entcar
e
faci
li
ti
eswherethefiel
dv i
si
twillt
akeplaceprov i
de24- hourcar eandar eful
l
yequippedtomanage
severeacutemalnut
rit
ionaccordi
ngtheWHOt reatmentpr otocol.
 Pai
rpar
ti
cipant
swi
thsomeonewhospeaksbot
hthepar
ti
cipant
slanguageandt
hel
ocal
language.
 I
ntr
oducepar
ti
cipant
stot
heheadoft
hewar
dorot
herper
soni
nchar
ge.

Lear
ningObj
ect
ives Handout
stoTaket
oInpat
ientCar
eFi
eldVi
sit
ReviewAdmi
ssi
on,Tr
eatment,
andDi
schar
ge
Procedur
esf
orI
npati
entCar
e Handout5.1Essenti
alsfortheManagementofSAM
WithMedicalComplicati
onsinInpati
entCare
Obser
veandDiscussAdmi
ssi
on,Tr mentand Handout5.
eat 8Inpat
ientCareFiel
dVi si
tCheckl
ist
Di
schargePr
oceduresf
orI
npat
ientCar
e LocalI
npati
entCareTr eat
mentCar d

Module5FI
ELDVISI
TLEARNINGOBJECTI
VE1:REVI
EW ADMI
SSI
ON,
TREATMENT,ANDDISCHARGEPROCEDURESFORINPATI
ENTCARE
READI
NGTHEEVENI
NGBEFORE:Admi
ssi
onandDi
schar
gePr
ocedur
esf
orI
npat
ientCar
e
I
nprepar
ati
onfort
heinpati
entcar
efiel
dvi
sit
,askpart
ici
pantstorevi
ewHandout5.
1Essent
ial
sfort
he
ManagementofSAM WithMedicalCompl
icati
onsinI
npatientCare.

Module5FI
ELDVISI
TLEARNINGOBJECTI
VE2:OBSERVEANDDISCUSS
ADMISSI
ON,TREATMENT,ANDDISCHARGEPROCEDURESI
NINPATIENT
CARE
Tr
ainer:Becomefamil
iarwi
thHandout5.
8Inpat
ientCar
eFi
eldVi
sitCheckl
istanddi
rectpar
ti
cipant
sto
br
ingthiswitht
hem t
ot hef
iel
dvi
sit
.

Dur
ingt
hef
iel
dvi
sit
,obser
vet
hef
oll
owi
ng:
 Thepat
ientr
egi
str
ati
onpr
ocess
 Admi
ssi
onanddi
schar
gecr
it
eri
a
 Dai
l
ynut
ri
ti
onassessmentandmoni
tor
ing
 Dai
l
ymedi
cal
assessment
,moni
tor
ing,
andmedi
cal
treat
ment
 Foodpr
epar
ati
onandst
orage
 Feedi
ngandf
eedi
ngr
out
ines
 Re-
est
abl
i
shi
ngbr
east
feedi
ngi
ninf
ant
sunder6mont
hsofage(
suppl
ement
arysuckl
i
ngt
echni
que)

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 Recor
dingont
hei
ndi
vi
dual
chi
l
d’si
npat
ientcar
etr
eat
mentcar
d(e.
g.,
thei
nfor
mat
ioncol
l
ect
ed,
the
chi
l
d’spr
ogr
ess)
 Thef
lowofact
ivi
ti
es
 Ther
efer
ral
process

Dur
ingt
hef
iel
dvi
sit
,askt
hest
aff
:
 Howt
her
efer
ral
bet
weeni
npat
ientcar
eandout
pat
ientcar
eiswor
king
 Howt
henumber
s/t
ypesofi
nfant
sandchi
l
dreni
ninpat
ientcar
enowcompar
ewi
tht
he
number
s/t
ypesbef
oreout
pat
ientcar
ewasav
ail
abl
e
 Whatt
hechal
l
engest
omanagi
ngt
hei
rwor
kloadar
e

Act
ivi
ty:Feedback0nI
npat
ientCar
eFi
eldVi
sitSessi
ons
Met
hod:Feedback/
Discussi
on
Af
tert
hei
npat
ientcar
efi
eldv
isi
t,conductaf
eedbacksessi
oni
nwhi
chpar
ti
cipant
swi
l
l:
 Pr
ovi
def
eedbackonst
rengt
hst
heyobser
vedatt
heheal
thf
aci
l
itywi
thi
npat
ientcar
e
 Rai
sei
ssuesf
orcl
ari
fi
cat
ionbyt
rai
ner
s
 I
dent
if
ykeygapst
hatr
equi
remor
eobser
vat
iont
imeatt
heheal
thf
aci
l
iti
eswi
thi
npat
ientcar
e

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MODULESIX:MANAGEMENTOFMODERATEACUTE
MALNUTRI
TION(MAM)INTHECONTEXTOFCMAM

Modul
eOv
erv
iew
Themoduleout
li
nesthei
ssuesthatshoul
dbeconsi
der
edwhenprogr
ammesorser
vicesf
orthe
managementofmoderat
eacutemalnutr
it
ion(
MAM)arepar
tofcommuni
ty-
basedmanagementofacut
e
malnut
ri
ti
on(CMAM)servi
ces.
Themodul efocusesonsuppl ement aryf
eeding.Becausemostexper i
enceinmanagementofMAM i n
CMAM hasbeeni nemer gencysituati
onstodate,part
icularfocusi
sgiventosupplement ar
yfeedi
ng
programmes( SFPs)asani nterventi
onforthemanagementofMAM i nemer gencies.Themodule
addresseswhoi sadmit
t edandbr iefl
ydescri
besthetypesofmedi calt
reat
mentandnut ri
ti
on
rehabil
i
tat
ionthatareprov i
ded.Themodul ealsodescribeshowt hemanagementofMAM f i
tsi
nasa
componentofCMAM ser v
ices.Emphasisisplacedonensur ingasmoot href
erralprocessamongCMAM
component s(e.
g.,f
rom supplement aryf
eedingtooutpatientcareori
npati
entcare).
hi
smoduleshoul
dbeusedal ongsidenat
ionalgui
deli
nesf
orthemanagementofMAM andt he
ManagementofAcuteMalnutr
it
ion:ADecisi
onToolforEmergencies,av
ail
ableat
ht
tp:
//nut
ri
ti
oncl
uster
.net
/?get
=002086%7C2014/ 07/MAM-Deci
sion-Tool-
fi
nal
-June-
2014-
cor
rect
ed.
pdf
.
Themodul
eincl
udesahal
f-
daysi
tev
isi
ttoasuppl
ement
aryf
eedi
ngsi
te.

Not
es:
Programmesandser vi
cest omanageMAM ar eevol
vingwi t
hongoingr esear chonef f
ecti
venessof
tr
eatmentopt ions,approaches, andmet hodstosimplif
yandi mproveimpactatt heindiv
idual and
populationlev
els(seeRef erenceResour cesandFurtherReadi ngResourcesbel owf ormor edetai
ls).I
tis
i
mpor tantthatMAM ser vicesorpr ogrammedesi gnandappr oachesaret ailoredbasedont hecont ext
,
underlyi
ngcausesofmal nutrit
ion,andresourcesavail
able.TheMAM deci siontoolforemer genci
esnot ed
abovecanbeusedt ohelpident i
fythemostappr opr
iateandf easi
bleprogr ammet oaddr essMAM i na
part
icularcontext.
Progr
ammesandser vi
cestomanageMAM shoul dnotbei mplementedinisolati
on.Theyshouldbepart
ofabroadermult
isectornut
ri
ti
onprogrammei ncl
udi
nginfantandy oungchildfeedi
ng(IYCF)supporti
n
emergenci
es;l
i
velihoods;f
oodsecuri
ty;heal
th;
andwater,
sanitati
on,andhy giene(WASH)inter
venti
ons.
Inexcepti
onal emer gencyset t
ingswher eglobalacutemal nutri
ti
on(GAM)i shi gh(above15per centinthe
absenceofaggr av
at i
ngfactorsorabov e10per centint hepresenceofaggr avati
ngf actors)andt her
ei s
noSFPand/ oroutpatientcaref ort
hemanagementofsev ereacutemalnutrit
ion(SAM)wi thoutmedi cal
compl i
cati
ons, gui
danceont heuseofcombi nedprotocol forSAM andMAM t reat
menti sprovided(see
Handout6. 1ManagementofModer at
eAcut eMal nutrit
ion[MAM]i nEmer gencies).Becauser esear chis
ongoingont hecombi nedprotocolforSAM andMAM, guidanceprovi
dedint hismodul eisat empor ary
opti
onf oremer gencysettings.Thegui danceshouldbeseenasacompl ementt onat i
onal gui
delinesto
supportthetreatmentofchi ldrenuntil
f ul
lserv
ices/programmesar esetup.

104
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises

1.Descr
ibeSomeTy pesof 40mi
nut
es Handout6.
1ManagementofModer
ateAcut
eMal
nut
ri
ti
on
Progr
ammest oManage (
MAM)i nEmer
gencies
MAM andHowt his
Handout6.
2Pri
nci
plesofSuppl
ement
aryFeedi
ngf
ort
he
ComponentFit
sWi thi
n
ManagementofMAM
CMAM
2.Descr
ibeAdmissionto 25mi
nut
es Handout6.
3Admi
ssi
onPr
ocedur
esi
nSuppl
ement
ary
andDischar
gefrom the Feedi
ng
ManagementofMAM
Handout6.
4Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
ies
CMAM
Handout6.
5Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
or
CMAM
Handout6.
6Cl
assi
fi
cat
ionofAcut
eMal
nut
ri
ti
onf
orCMAM
Handout6.
7Suppl
ement
aryFeedi
ngTr
eat
mentCar
dCar
ds
3.DiscussMedical 20mi
nut
es Handout6.
8Medi
cal
Treat
mentPr
otocol
sforManagement
TreatmentandNutri
ti
on ofMAM
Rehabil
it
ati
onforthe
Handout6.
9Nutr
it
ional
Rehabi
l
itat
ionPr
otocol
sfort
he
managementofMAM
ManagementofMAM
Handout6.
10FoodCommodi
ti
esUsedf
ort
he
ManagementofAcut
eMal
nut
ri
ti
on
Handout6.
11Suppl
ement
aryFeedi
ngRat
ionCar
d
4.Pract
iceMaki
ngReferral
s 20mi
nut
es Handout6.
12Ref
err
alSl
ip
fr
om Suppl
ementary
Exer
cise6.
1Ref
err
alsi
nCMAM
Feedi
ngtoOutpat
ientor
I
npati
entCare
5.Suppl
ementar
yFeedi
ng ½day Handout6.
2Pr
inci
plesofSuppl
ement
aryFeedi
ngf
or
Fi
eldVi
sit t
heManagementofMAM
Handout6.
4Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
or
CMAM
Handout6.
5Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
or
CMAM
Handout6.13Suppl
ement
aryFeedi
ngFi
eldVi
sit
Checkl
ist
Wrap-
UpandModul
e 15mi
nut
es
Ev
aluat
ion

Modul
eDur
ati
on:Twohour
sofcl
assr
oom f
oll
owedbyahal
f-
daysi
tev
isi
t
Not
e:Dependi
ngont heneedsoft hei
raudi
ence(s),t
rai
ner
smaychooset
oski
porspendmor
eorl
ess
t
imeoncertai
nlear
ningobject
ivesandacti
vit
ies.Themoduledur
ati
oni
sanest
imat
eofthet
imei
ttakes
t
ocompleteal
lthelear
ningobject
ivesandactiv
iti
es.

105
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Mat
eri
als
 Nat
ional
gui
del
i
nesandpr
otocol
sforsuppl
ement
aryf
eedi
ngwher
eav
ail
abl
e
 Copi
esofl
ocal
suppl
ement
aryf
eedi
ngt
reat
mentcar
dsandsuppl
ement
aryf
eedi
ngr
ati
oncar
ds
 Copi
esofHandout6.
12Ref
err
alSl
ip
 Handout
sandexer
cises
 Car
dswi
thadmi
ssi
oncr
it
eri
a
 Fl
i
pchar
ts
 Mar
ker
s
 Maski
ngt
ape

Adv
ancePr
epar
ati
on
 Room set
up,
mat
eri
als
 Pr
epar
ati
onofasetofcar
dswi
thanadmi
ssi
oncr
it
eri
onf
rom i
npat
ientcar
e,out
pat
ientcar
eor
suppl
ement
aryf
eedi
ngwr
it
tenoneach
 Revi
ewr
elev
antr
efer
encer
esour
cesandf
urt
herr
eadi
ngr
esour
cesl
i
stedbel
ow

Ref
erenceResour
ces
1. GlobalNutri
ti
onCl ust .2017.Moder
er at
eAcuteMalnut
ri
ti
on:ADeci
sionToolforEmergenci
es.
Avail
ableat:htt
p://nutr
it
ioncl
ust
er.
net/
?get
=002086%7C2014/
07/MAM-Decision-
Tool
-fi
nal
-June-
2014-corr
ected.pdf.
2. TheSpherePr
oject
.2017r
evi
si
on.Humani
tar
ianChar
terandMi
nimum St
andar
dsi
nDi
sast
er
Response.
3. GlobalNutr
it
ionCluster
,EmergencyNut
ri
ti
onNetwor
k( .2010.Har
ENN)etal monisedTrai
ning
Package–Ver si
on2.Modul e12.ManagementofModer
ateAcut
eMalnutr
it
ion.Avai
labl
eat:
ht
t ps:
//www.ennonli
ne.
net/
htpv2modul
e12.
4. WorldFoodPr ogr
amme( WFP)andUni tedNati
onsHi ghCommi ssi
onerforRefugees( UNHCR) .2011.
Gui
delinesforSel
ecti
veFeedi ng:TheManagementofMal nutr
it
ioninEmer gencies.Avail
ableat:
ht
tps:/
/ cms.emer
gency .
unhcr.org/
documents/11982/32558/Guideli
nes+for+select
ive+feedi
ng.+The
+management +of+malnutr
it
ion+in+emergenci
es/117faa46-7f
a4-446b-8104-10f5a4c763e1.
5. ENN.2009.I
ntegr
ati
onofI
YCFSupporti
ntoCMAM.Avai
l
abl
eat
:
ht
tps:
//www.ennonl
i
ne.
net
/int
egr
ati
oniy
cfi
ntocmam.
6. UNHCR/ UNI
CEF/WFP/ WHO.2003.FoodandNut r
it
ionNeedsinEmergenci
es.
ht
tp:
//apps.
who.i
nt/
iri
s/bi
tst
ream/handl
e/10665/
68660/a83743.
pdf
;j
sessi
onid=807AFEFCE35FFF1A
A581AFC85A0C4C15?sequence=1.

Fur
therReadi
ngResour
ces
1. Bai
ley
,J.et
. .2016.Combi
al nedProt
ocolf
orSAM/MAM Tr
eat
ment
:TheComPASst
udy.Avai
l
abl
eat
:
ht
tps:
//www.ennonl
ine.
net
/fex/
53/t
hecompasst
udy
.
2. Maust,A.et.
al.2015.“Sev
ereandModer ateAcuteMal nut
ri
ti
onCanBeSuccessf ul
l
yManagedwi
than
I
ntegr
atedProt ocoli
nSierr
aLeone.”JournalofNutr
it
ion.Avail
abl
eat:
ht
tps:
//pdfs.
semant i
cscholar
.or
g/d5c2/e4bed4e18d6cdfa6d6b3b31f
69d0ee347d54.
pdf
.
3. USAID.2016.Multi
-Sect
oralNutr
iti
onStrat
egy—TechnicalGui
danceBr
ief
:Community-
Based
ManagementofAcut eMal nut
ri
ti
on( CMAM) .Avai
l
abl
eat :
ht
tps:/
/www. usai
d.gov/
sit
es/defaul
t/f
il
es/documents/1864/
CMAM- t
echni
cal
-gui
dance-
bri
ef-
508-

106
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

r
evFeb2017.
pdf
.
4. WHO.2012.TechnicalNote:Supplementar
yFoodsfortheManagementofModer ateAcute
Malnutr
it
ioninI
nfantsandChildr
en6–59Mont hsofAge.Availableat:
ht
tp:/
/www. who.
int/
nutri
ti
on/publi
cat
ions/moder
ate_
mal nut
ri
tion/9789241504423/en/
.

107
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module6Lear
ningObj
ect
ive1:Descr
ibeSomeTypesofPr
ogr
ammest
o
ManageMAM andHowThisComponentFitsWi
thi
nCMAM

TRAI
NER:Becomef
ami
l
iarwi
thHandout6.
1ManagementofModer
ateAcut
eMal
nut
ri
ti
on(
MAM)i
n
Emer
genci
esandHandout6.
2Pr
inci
plesofSuppl
ement
aryFeedi
ngf
ort
heManagementofMAM.

WORKI
NGGROUPS:THEROLEOFPROGRAMMESTOMANAGEMAM I
NCMAM.For
m
worki
nggroupsoffi
vepar
ti
ci
pant
s.Dr
awFi
gur
e1onaf
li
pchar
t.Askpar
ti
cipant
stoanswert
hef
oll
owi
ng
quest
ionsi
ngroups:
 Whati
smanagementofMAM i
nthecont
extofCMAM?
 Whyar
eser
vicesorpr
ogr
ammest
omanageMAM necessar
y?
 Whyar
eser
vicesorpr
ogr
ammest
omanageMAM t
hel
argestCMAM component
?

Askgr
oupst
oshar
einpl
enar
y.Di
scussandf
il
li
ngaps.

Fi
gur
e1.Cor
eComponent
sofCMAM

Community
Out
reach
Outpati
entcare
f
ormanagement
ofSAM
WITHOUT
I
npat
ient medical Othernutri
tionandheal th
car
ef or complicati
ons int
erventions,food
mgmtof
SAM WI TH securi
ty,socialprotecti
on
medical andWASH, t
opr event
undernutrit
ion
Management
of
MAM

108
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

PARTICI
PATORYLECTURE:MANAGEMENTOFMAM–PURPOSEANDTYPESOF
SUPPLEMENTARYFEEDING.Expl
aint
opar
ti
ci
pant
sthatsuppl
ement
aryf
eedi
ng,
asi
mpl
ement
edi
n
theemer gencycont ext,wil
l bethepr i
maryfocusofdiscussionforthemanagementofMAM i nCMAM.
Aski fanyonecandef i
newhatsuppl ementaryfeedi
ngisandwhet heranyonehasexper i
encewor kingwith
wor ki
nginsuppl ement aryfeeding.Fil
lint
hegapswi ththedef i
nit
ionforsupplementaryfeedingin
Handout6. 1ManagementofModer ateAcut eMalnut
ri
tion(MAM)i nEmer genci
es.Explainthe
diff
erencebet weenbl anketsuppl ementaryfeedi
ngandt ar
getedsuppl ementaryfeedi
ng,stressi
ngt hat
thesupplement aryfeedingdi scussedinthismoduleaspar tofCMAM ar etar
getedsupplement ar
y
feeding.Referparti
cipantst oHandout6. 1andt oHandout6. 2Princi
plesofSuppl ementaryFeedingf or
theManagementofMAM f orreferenceinthefutur
e.

Conti
nuecoveri
ngthemainpoint
sinHandout6.
1,Sect
ionsBandCt oexplai
nsuppl
ementar
yfeedingas
anemergencyint
ervent
ioni
nthecont
extofCMAM, obj
ecti
vesofanSFP,andwhentost
artandclosean
SFP.Emphasizethefol
l
owingkeypoi
nts:
 Suppl
ement
aryf
eedi
ngmi
ghtbepar
tofi
ntegr
atedCMAM ser
vices.I
tmaybeoper
atedbyt
hesame
agencyorbyadi
ff
erentone.
 Ef
fect
ivemoni
tor
ingandcl
osecoor
dinat
ionamongsuppl
ement
aryf
eedi
ng,
out
pat
ientcar
eand
i
npat
ientcar
ear
ecri
ti
calforensur
ingasmoot
href
err
alpr
ocess,
especi
all
ywher
edi
ff
erentagenci
es
ar
esupporti
ngt
hedi
ffer
entcomponentsofCMAM.
 Bi
l
ater
alpi
tt
ingoedema,
mid-
upperar
m ci
rcumf
erence(
MUAC)andwei
ghtshoul
dbecheckedat
ev
erysessi
ontoident
if
ychil
drenwhoneedt
oberefer
redtoout
patientori
npati
entcar
e.Wher
e
wei
ght-
for-
hei
ght(WFH)/wei
ght-
for
-l
engt
h(WFL)i
sused,hei
ght
/lengthismeasuredev
erymonth.

GROUPDI
SCUSSI
ON:MANAGI
NGMAM I
NTHEABSENCEOFSUPPLEMENTARYFEEDI
NG.
Expl
aintoparti
cipant
st hatt
hereareinst
anceswheret her
eisnoSFPav ail
able.Thisisl
ikel
ytobethe
casewhenonl ythemanagementofSAM ( i
npati
entcareandoutpati
entcare)ispartofrouti
neheal
thcar
e
i
nanon- emergencysituati
onorinafood-secureenvi
ronment.I
talsomightbet hecaseaf t
eran
emergencywhenr esourcesarenolongeravail
ablef
orSFPsand/ orwherethepr ev
alenceofacute
malnutr
it
ionhasbeensi gnif
icant
lyr
educed.

Expl
ainPoint1f
rom Handout6. 1,
SectionD.Askpart
icipant
showr ati
onscanbeusedtoensurethe
samegoals.Tel
lpart
ici
pantsthattheywil
lrev
iewaddi
tionalopt
ionsforexcept
ional
CMAM programming
i
nemer genci
esl
ateron.DiscussPoints2and3f r
om Handout6. 1,
SectionDinthesamecontext.

WORKI
NGGROUPS:LI
NKI
NGTOPREVENTI
ONPROGRAMMES.Askpar
ti
cipant
stof
orm
wor
kinggr
oupsbyregion/
dist
ri
ct.I
ntr
oducePoi
nt4f
rom Handout6.
1,Sect
ionD.Askpar
ti
cipant
sto
r
efl
ectont
hefol
lowingquesti
ons:
 I
sther
eongoi
ngsuppl
ement
aryf
eedi
ngi
nyourdi
str
ict
?
 Whatot
herpr
ogr
ammesexi
standhowcoul
dli
nkagesbeest
abl
ishedbet
weent
hese
pr
ogr
ammesandout
pat
ientcar
e?

Askonegr
oupt
oshar
ethei
rresponsesandot
hergr
oupst
oaddnewi
nfor
mat
ion.Di
scussandf
il
li
ngaps.

PARTI
CIPATORYLECTURE:HANDOUT6.
1.MANAGEMENTOFMODERATEACUTE
MALNUTRITI
ON(MAM)INEMERGENCIES,SECTI
ONE.Expl
aint
opar
ti
cipant
sthatt
her
ear
e
opti
onsfortr
eat
mentofacutemalnutrit
ionintheabsenceofanSFPand/ oroutpatientcar
eforthe
managementofSAM wit
houtmedi calcomplicati
ons.Explai
nthatthethreeopt i
onsar edescr
ibedfurt
her
i
nSectionEofHandout6.
1.Clari
fythattheopt i
onsprovidedaretemporar yandar emeanttobeusedas
agap-f
ill
i
ngmeasureunt
ilbot
hout pat
ientcareandSFPar esetup.Pointoutt heevidenceontheuseof
thecombinedSAM andMAM protocolinSierr
aLeoneandexpl ainthataddi t
ionalstudi
esareongoing.

Ref
ert
hepar
ti
cipant
stoTabl
e1:Opt
ionsf
orExcept
ional
CMAM Pr
ogr
ammi
ngi
nEmer
genci
esi
n

109
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Handout6.
1.Revi
ewwiththepar
ti
cipant
stheadmissi
onanddischar
gecr
it
eria,
organi
sati
on,
RUTFor
RUSF,t
hesystemat
ict
reat
ment,andthedischar
gecri
ter
iaf
orr
ecommendationsA,B,andC.

110
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Modul
e6LearningObj
ect
ive2:Descr
ibeAdmissi
ontoandDi
schar
ge
f
rom t
heManagementofModerat
eAcuteMalnutr
iti
on(
MAM)

TRAI
NER:Becomef
ami
l
iarwi
thHandout6.
3Admi
ssi
onPr
ocedur
esi
nSuppl
ement
aryFeedi
ng,
Handout
6.
4Admi ssi
onCrit
eri
aandEntryCat
egoriesforCMAM, Handout6.
5DischargeCr
it
eri
aandExit
Categori
esf
orCMAM, Handout6.6Classif
icat
ionofAcut
eMalnutr
it
ionforCMAM andHandout6.
7
Supplement
aryFeedi
ngTreat
mentCar d.

PARTI
CIPATORYLECTURE:ADMI
SSI
ONPROCEDURESI
NSUPPLEMENTARYFEEDI
NG.
Descr
ibet
oparti
cipant
sthebull
etpoi
ntsoutl
inedi
nHandout6.
3Admi
ssi
onPr
ocedur
esi
n
Suppl
ementar
yFeeding,Sect
ionA.Answeranyquest
ions.

ELI
CITATI
ONANDGROUPDI SCUSSION:ADMISSIONANDDI SCHARGECRI TERI
AFOR
SUPPLEMENTARYFEEDI
NG.Askpar
ti
ci
pant
stonamecr
it
eri
aforadmi
ssi
ont
osuppl
ement
ary
feedi
ng.Manyoft hecr iter
iawil
l ref
lectthoseencount er
edinModul e4asdi schargecr i
ter
iaf r
om
outpatientcare.Wr i
ter esponsesont hefli
pchart.Referpart
icipantst oHandout6. 3Admi ssion
Procedur esinSupplement aryFeedingandHandout6. 4Admi ssionCr it
eri
aandEnt ryCategor i
esf
or
CMAM.Rev i
ewt het extandt het able,makingnoteofanydi screpanci eswitht
heanswer sont hefl
i
pchart.
Brief
lynot etheadmi ssi oncri
teri
af orpregnantwomenandl act ati
ngwomen( withinfantsunder6mont hs)
andal sonot ethatchildrenwi t
hMAM whohav emedi calcomplicationsaresti
lladmi t
tedto
supplement aryfeedingbutar ereferredtomedicaltreatmentandr eturnwhenthemedi calcompli
cati
onis
resol
v ed.Discussandf illi
ngaps.
Br
ief
lyrevi
ewHandout6.
5Di schargeCr
it
eri
aandExi
tCategor
iesf
orCMAM, andHandout6.
6
Cl
assif
icat
ionofAcut
eMalnutri
ti
onforCMAM wit
hpart
ici
pant
s.Answeranyquest
ions.

PRACTICE:ADMI
SSI
ONCRITERI
AFORI NPATI ENTCARE,OUTPATI ENTCAREAND
SUPPLEMENTARYFEEDI
NG.Tel
lpar
ti
ci
pant
sthatyouwi
l
lbehol
dingupacar
dwi
thacr
it
eri
onf
or
admissiont oinpati
entcare,
outpat
ientcareorsuppl
ementaryfeeding.Askthem t
oi dent
if
ywhichser
vice
theadmi ssioncri
teri
onisrel
evanttoandwhy .Repeatunt
ilpar
ti
cipantsarecomfortableanswer
ingor
usingther efer
encetablesasnecessary.

REVI
EW:SUPPLEMENTARYFEEDI
NGRATI
ONCARD.Ref
erpar
ti
cipant
stoHandout6.
7
Supplement
aryFeedingTreatmentCar
dandbri
efl
yrev
iewtheinf
ormati
onrecor
dedonit
.Di
scusshow
thesuppl
ementaryfeedi
ngtreat
mentcarddi
ff
ersfr
om theout
pati
entcar
etreat
mentcar
d.

111
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aini
ngGui
def
orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module6LearningObj
ect
ive3:Di
scussMedi
cal
Treat
mentandNut
ri
ti
on
Rehabi
li
tat
ionf
ortheManagementofMAM

TRAI
NER:Becomef
ami
l
iarwi
thHandout6.
8Medi
cal
Treat
mentPr
otocol
sfort
heManagementofMAM,
Handout6.9Nutri
ti
onRehabi
l
itat
ionPr
otocol
sfort
heManagementofMAM,Handout6.10Food
CommoditiesUsedfort
heManagementofAcuteMalnut
ri
ti
on,
andHandout6.
11Supplementar
yFeedi
ng
Rat
ionCard.

PARTI
CIPATORYLECTURE:MEDI
CALTREATMENTI
NSUPPLEMENTARYFEEDI
NG.Expl
ain
topart
ici
pantsther
outi
nemedici
nesforMAM,al
soinaccor
dancetothenati
onalgui
del
i
nes:Vi
tami
nA,
anti
hel
minths,i
ron,
fol
i
cacid,
andothertr
eat
ments.Ref
erpart
ici
pant
st oHandout6.
8Medical
Treat
mentPr ot
ocolsf
ortheManagementofMAM.Answeranyquestions.

READI
NGANDDI
SCUSSI
ON:NUTRI
TIONREHABI
LITATI
ON.Askpar
ti
cipant
stoqui
etl
yrev
iew
Handout6.9Nutr
it
ionRehabi
li
tat
ionPr
otocol
sfort
heManagementofMAM andHandout6.
10Food
Commodi t
iesUsedfort
heManagementofAcuteMalnut
ri
ti
on.Answeranyquest
ions.

REVI
EW:SUPPLEMENTARYFEEDI
NGRATI
ONCARD.Ref
erpar
ti
cipant
stoHandout6.
11
Suppl
ementaryFeedingRati
onCar
dandrev
iewwhatinf
ormati
onisrecor
dedonthecard.Discusswhat
i
sdiff
erentf
rom aready-
to-
uset
her
apeut
icf
ood(RUTF)rat
ioncar
d,usedinout
pat
ientcare,
andwhyt he
twocardsar
ediff
erent.

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Module6Learni
ngObjecti
ve4:Practi
ceMaki
ngRef er
ral
sfr
om
Suppl
ement
aryFeedi
ngt oOutpat
ientorI
npat
ientCare

TRAI
NER:
Becomef
ami
l
iarwi
thHandout6.
12Ref
err
alSl
i
pandExer
cise6.
1Ref
err
alsi
nCMAM.

REVI
EW:USI
NGREFERRALSLI
PS.Ref
erpar
ti
ci
pant
stoHandout6.
12Ref
err
alSl
ip,
not
ingt
hatt
his
i
sthesamerefer
ral
sli
ptheyhaveencount
eredi
nthemodul
esaddr
essi
ngout
pat
ientandi
npat
ientcar
e.
Aski
fther
eareanyquesti
ons.

PRACTI
CE:MAKI
NGREFERRALSFROM SUPPLEMENTARYFEEDI
NG.Askpar
ti
cipant
stof
orm
pai
rs.Dir
ectthem t
oExer cise6.1Referr
alsinCMAM anddi stri
butecopiesofrefer
ral
sli
ps.Ask
part
ici
pantst
or eadtheexampl es,andexplainthatt
hreechil
drenpresenttoanSFP.Thepartici
pantsare
todeci
dewhatact i
onisr equir
edandcompl etearef
erral
sli
pwher eappropri
ate.Askonepairtoreporton
Chil
dAandt henaskot herpairstoaddaddi ti
onali
nfor
mat i
on.RepeatforChil
dBandChi l
dC.Usi ngthe
answersheetbelow,coachpar ti
ci
pantstofilli
ngaps.

Exer
cise6.
1Ref
err
alsi
nCMAM (
answersheet
)
Chi
ldA
Questi
on:Chi
ldA, agir
lage18mont hs,wasadmittedtotheSFPwi
thaMUACof117mm, wei
ghtof10
kgandnomedi calcompli
cati
ons.Atthesecondvisit
,thechi
l
dhaddev
elopedbi
l
ater
alpi
tt
ingoedemaon
thef
eet(bi
lat
eraloedema+).Whatact i
onisneeded?
Answer
:Chi
l
dAshoul
dber
efer
redt
oout
pat
ientcar
e.
Iti
simport
anttoexpl
aint
othemother/
car
egi
verwhythechil
disbeingsenttoout
pati
entcar
eandwhat
s/hecanexpect
.Themother
/car
egiv
ershoul
dunder
standthatoncethechil
dhasrecover
edinout
pat
ient
care,
thechi
ldwil
lret
urnt
otheSFP.

Chi
ldB
Quest
ion:Chi
l
dB,
aboyage36months,
wasr efer
redt
otheSFPbytheoutr
eachwor
kerwi
thaMUACof
118mm.Onadmissi
on,
thenur
sef
indsthechil
dhasnoappeti
teandanext
remel
yhi
ghfev
er.Whatact
ion
i
sneeded?
Answer:Chi
ldBshouldberefer
redtothehospitalformedical
treatmentaccordi
ngtotheactionpr
otocol
andtr
eatedaccor
dingtotheWor l
dHealthOrganisati
on(WHO)andi nt
egrat
edmanagementofchi l
dhood
i
ll
ness(IMCI
)prot
ocols,andnat
ionalpr
otocols.Thechil
disgivenar efer
ralsl
i
p.Transpor
tat
ionshouldbe
arr
angedwherepossibl
e.Oncethechil
drecovers,thechi
ldwill
returntotheSFP.
Iti
simport
antt
oexpl
aint
othemot
her
/car
egi
verwhyt
hechi
l
disbei
ngsentt
othehospi
tal
andwhats/
he
canexpect
.

Chi
ldC
Questi
on:ChildC,aboyage8mont hs,
wasadmi tt
edtotheSFPwit
haMUACof116mm.Af t
erf
our
weeks( thi
rdwei
ghing),t
hechil
dhaslostweightandMUACi snow114.Thechil
dhasdiar
rhoeaandsome
appeti
te.Youwantt osendthechi
l
dt ooutpati
entcar
e,butt
hemother
/caregi
verref
usest
ogo.How
wouldy oudealwi
tht hi
s?
Answer:Themother/car
egiv ermightpr
efertheSFPt ooutpati
entcarebecausethefoodt heSFPprovi
ded
canbeusedf ort
hewholef ami l
yorbecauset heSFPrequir
esat t
endanceonlyever
yt woweeksorev er
y
month.Expl
aincaref
ull
ytot hemot her
/caregi
v ert
heneedf orandadvantagesofout
pat i
entcare
tr
eat
ment .I
nmostcases, oncet hemother/caregi
verseesthatthechil
drapidl
yimprovesinoutpat
ient

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,2018Ver
sion

care,thei
ssuewillr
esol
veitsel
f.I
fdist
anceistheissue,i
tmightbepossi
bletoprovi
deready
-to-
use
therapeut
icfood(RUTF)everyt
woweeksi nsteadofweekly.Themother/
caregi
vercoul
dalsorecei
vea
familyrat
ionwhil
ethechil
disinoutpati
entcare,
ifavai
labl
e.

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orCommuni
ty-
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eMal
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,2018Ver
sion

Modul
e6Wr
ap-
UpandModul
eEv
aluat
ion

Rev
iewl
ear
ningobj
ect
ivesandcompl
eteev
aluat
ionf
orm.

 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.I
nthi
smodul
eyouhav
e:
1. Descr
ibedpr
ogr
ammesf
ort
hemanagementofMAM andhowt
heyar
erel
evantt
oCMAM
2. I
dent
if
iedadmi
ssi
onanddi
schar
gecr
it
eri
afort
hemanagementofMAM
3. Di
scussedmedi
cal
treat
mentandnut
ri
ti
onr
ehabi
l
itat
ionf
ort
hemanagementofMAM
4. Pr
act
icedmaki
ngr
efer
ral
sfr
om suppl
ement
aryf
eedi
ngt
oout
pat
ientori
npat
ientcar
e

 Askf
oranyquest
ionsandf
eedbackont
hemodul
e.Letpar
ti
cipant
sknowt
hatt
heywi
l
lhav
ean
oppor
tuni
tyt
oobser
vepr
ocedur
esanddi
scusswi
thst
affdur
ingt
hesuppl
ement
aryf
eedi
ngf
iel
dvi
sit
.

 Fi
nal
l
y,askpar
ti
cipant
stocompl
etet
hemodul
eev
aluat
ionf
orm.

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,2018Ver
sion

Modul
e6Suppl
ement
aryFeedi
ngFi
eldVi
sit

Ov
erv
iew
 Amaxi
mum off
ivepar
ti
ci
pant
sshoul
dbeateachsuppl
ement
aryf
eedi
ngsi
teonagi
venday
.
Coor
dinat
ewi
thasmanysi
tesasnecessar
ytokeept
henumberofpar
ti
cipant
satf
iveorf
ewer
.
 Pai
rpar
ti
cipant
swi
thsomeonewhospeakst
hel
ocal
languageaswel
last
hei
rlanguage.
 I
ntr
oducepar
ti
cipant
stot
heper
soni
nchar
ge.

Lear
ningObj
ect
ives Handout
stoTaket
otheSuppl
ement
aryFeedi
ngFi
eldVi
sit
ReviewAdmissi
on,Treatmentand Handout6.
2Pri
nci
plesofSuppl
ement
aryFeedi
ngf
ort
he
Dischar
geProcedur
esf or ManagementofMAM
Supplement
aryFeedi
ng
Handout6.
4Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
or
ObserveandDi scussAdmissi
on, CMAM
Treatment,Dischar
geandReferal Handout6.
r 5DischargeCr
iteri
aandExi
tCategor
iesforCMAM
ProceduresforSupplementar
y Handout6.
13SupplementaryFeedi
ngFi
eldVisi
tCheckl
ist
Feeding

Module6FI
ELDVI
SITLEARNI
NGOBJECTIVE1:REVI
EW ADMI
SSI
ON,
TREATMENTANDDISCHARGEPROCEDURESFORSUPPLEMENTARY
FEEDI
NG
READTHENI
GHTBEFORE:ADMI
SSI
ONANDDI
SCHARGEPROCEDURESFORSUPPLEMENTARY
FEEDI
NG
I
npr eparat
ionf ort
hesuppl
ementar
yfeedi
ngf i
eldvi
si
t,askpar
ti
cipant
storevi
ewHandout6.2Pr
inci
ples
ofSupplement aryFeedi
ngf
ortheManagementofMAM, Handout6.4Admissi
onCrit
eri
aandEnt
ry
Categori
esf orCMAM andHandout6.5DischargeCri
ter
iaandExi
tCategor
iesforCMAM.

BRAI
NSTORM, PARTI
CIPATORYLECTURE:ADMI
SSI
ONANDDI
SCHARGEPROCEDURESFOR
SUPPLEMENTARYFEEDING
 Atsomepoi
ntbef
oreobser
vingpr
ocedur
esatt
hesi
te(
e.g.
,dur
ingabr
iefmeet
ingonar
ri
vi
ngatt
he
si
te)
,askpar
ti
cipant
stonameadmi
ssi
onanddi
schar
gepr
ocedur
es.
 Fi
l
lingapsbybr
ief
lyr
evi
ewi
ngt
headmi
ssi
onanddi
schar
gepr
ocedur
est
hroughapar
ti
cipat
ory
l
ect
ure.

Module6FI
ELDVISI
TLEARNINGOBJECTI
VE2:OBSERVEANDDISCUSS
ADMISSI
ON,TREATMENT,DI
SCHARGEANDREFERRALPROCEDURES
FORSUPPLEMENTARYFEEDING
TRAI
NER:
Becomef
ami
l
iarwi
thHandout6.
13Suppl
ement
aryFeedi
ngFi
eldVi
sitCheckl
ist
.

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,2018Ver
sion

Dur
ingt
hef
iel
dvi
sit
,obser
vet
hef
oll
owi
ng:
 Thepat
ientadmi
ssi
oncr
it
eri
aandpr
ocedur
e
 Di
schar
gecr
it
eri
aandpr
ocedur
e
 Recor
dingont
hei
ndi
vi
dual
chi
l
d’ssuppl
ement
aryf
eedi
ngt
reat
mentcar
d(e.
g.,
thei
nfor
mat
ion
col
l
ect
ed,
thechi
l
d’spr
ogr
ess)
 Thef
lowofact
ivi
ti
es
 Ther
efer
ral
process
 Suppl
ement
aryf
oodr
ati
onspr
ovi
dedt
othepat
ient
s

Dur
ingt
hef
iel
dvi
sit
,askt
hest
aff
:
 Howt
heyensur
eli
nkagebet
weent
hesuppl
ement
aryf
eedi
ngpr
ogr
amme(
SFP)
,out
pat
ientcar
eand
ot
hernut
ri
ti
oni
nter
vent
ions
 Howt
heyensur
ecar
egi
ver
sknowhowt
ouseorpr
epar
eandgi
vet
hesuppl
ement
aryf
oodi
fa
f
ort
if
iedbl
endedf
ood(
FBF)i
sused
 Whatki
ndofheal
th/
nut
ri
ti
oneducat
ionandcounsel
l
ingt
heyof
fer
 Wher
ethei
rsuppl
ement
aryf
oodcommodi
ti
escomef
rom andhowt
heyor
derandst
oret
hem

ACTI
VITY:FEEDBACKONSUPPLEMENTARYFEEDI
NGFI
ELDVI
SITSESSI
ONS

METHOD:
Feedback/
Discussi
on
Af
tert
hef
iel
dvi
sitt
othesuppl
ement
aryf
eedi
ngsi
te,
conductaf
eedbacksessi
oni
nwhi
chpar
ti
cipant
s
wi
ll
:
 Pr
ovi
def
eedbackonst
rengt
hsobser
vedateachsuppl
ement
aryf
eedi
ngsi
tev
isi
ted
 Rai
sei
ssuesf
orcl
ari
fi
cat
ionbyf
aci
l
itat
ors
 I
dent
if
ykeygapst
hatneedmor
eobser
vat
iont
ime

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,2018Ver
sion

MODULESEVEN:PLANNI
NGCMAM SERVI
CESATTHE
DI
STRI
CTLEVEL

Modul
eOv
erv
iew
Thismodul ei ntr
oducespar ti
cipant stothei ssuesandconsi derati
onsi nthedesi gnandpl anningofa
communi ty
-basedmanagementofacut emal nut r
iti
on(CMAM)ser viceorpr ogr amme.Thi smodul e
focusesont hedifferentstepsusedt opl anaCMAM ser vi
ceorpr ogr amme.I tai mstopr ovide
part i
cipantswi ththet ool
sandconcept ual framewor ksf orthi
nkingt hought hepl anni
ngst agesaccor ding
tot hecont ext.Thisincludest hinkingthroughwhoshoul dbeinv ol
v edi nplanning;conductingasi tuat
ion
anal ysistodef i
net heneeds; expl ori
ngt heoper ationalandpol i
cy -
level opportuniti
esandconst r
aints;
assessi ngcapaci tytoi mplementt heprogr amme; determiningaser viceorprogr ammedesi gnwi th
over allgoals,specifi
cobj ecti
ves, andsui tablei ndicatorstomeasur epr ogrammei mpactand
effect i
veness; andt r
anslatingthesei ntoanact ionplan.Themodul etakesi nt
oconsi derationtheWor ld
Heal thOr ganisati
on( WHO)“ buildingblocks”f orheal t
hsy stem strengt heni
ng, andasy stem
strengt heningappr oacht ointegr ati
ngCMAM i nt oexisti
nghealthcar esy st
em
AlthoughbudgetingisanimportantcomponentofplanningforCMAM servi
ces,thi
smoduledoesnot
providespecif
icguidanceonbudgetingforCMAM services.AMicr
osoftExcel
-basedCMAM costi
ngtool
designedtohelpplannersandmanager satdi
str
ictl
evel pl
anandcostforCMAM ser v
icescanbefound
at:https:
//www.fantapr
oject
.or
g/tools/
cmam-costi
ng-t
ool .
Part
ici
pantswill
wor kingr
oupsoffi
veorsixforthemajori
tyofthi
smodule,groupedbycountr
y,pr
ovince,
ordi
stri
ct,
wi t
hthoseofsimil
aror
igi
nsplacedtogether
.Ideal
ly
,eachgroupshouldworkondesigni
ngand
pl
anningCMAM ser vicesf
orit
sownarea.Ift
hisisnotpossibl
eornotappropr
iate,gr
oupsshoul
dselect
anappropri
atecontextandgeogr
aphi
caloradministr
ati
vecoveragear
eaforwhi chtodesi
gnandplan
CMAM services.
Par
ti
cipant
swi
llst
ayi
nthesameworki
nggroupforal
lthemodul
e’
sexer
cises.Attheendofthesessi
on,
par
ti
cipant
swi
l
lhavedevel
opedanout
li
neofadesignandpl
anforCMAM inthei
rrespect
ivear
eas.
Part
ici
pantswi
ll
practi
ceusi
ngtheconcept
sandframeworksi
nthi
smodul
eusi
ngacasest
udybasedon
arealexampl
eorusingthei
rowndi
stri
ctoradi
str
icti
nthei
rcount
ry.
Part
ici
pantsshouldbeaskedinadvancet
obr i
ngrelev
anti
nformati
onforCMAM pl
anningintheircount
ry,
prov
ince,ordi
str
ict,
andtoreadCaseStudy:Si
tuat
ionAnal
ysis,Ghanabefor
ethet
rai
ningsession.

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises
1.Descr
ibeKeyElementsof 30 Handout7.
1KeyEl
ementsofCMAM FrameworkAl
igned
CMAM andPr epar
eforthe mi
nut
es wit
htheWHOHealthSy
stemsStr
engtheni
ng(HSS)
Pl
anningProcess Bui
ldi
ngBlocks
2.I
denti
fyKeyComponents 2hour
s Handout7.
2CaseSt
udy
:Si
tuat
ionAnal
ysi
s,Ghana
ofaSit
uati
onAnal
ysi
sand
Handout7.
3Assessi
ngt
heNut
ri
ti
onSi
tuat
ion
ConductaBasi
cSi
tuati
on
Anal
ysis Handout7.
4Mappi
ngMat
ri
ces
Handout7.
5Capaci
tyGr
idf
orCMAM att
heDi
str
ictLev
el
Handout7.
6SWOTAnal
ysi
sforCMAM
Handout7.
7ExampleCapaci
tyGr
idsf
orOut
pat
ientCareat
theHeal
thFaci
l
ityLev
elandf
orCMAM att
heNational
Level

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,2018Ver
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3.Devel
opaLogical 1½hour
s Handout7.
1KeyEl
ement
sofCMAM Fr
amewor
k
Fr
ameworkforCMAM Handout7.
8Usi
ngaLogi
cal
Framewor
kforCMAM
Handout7.
9Exampl
eLogi
cal
Framewor
kforCMAM
4.Dev
elopanAct
ionPl
anf
or 2½hour
s Handout7.
1KeyEl
ement
sofCMAM Fr
amewor
k
CMAM
Handout7.
10Cal
cul
ati
ngEst
imat
edSAM andMAM Cases
Handout7.
11St
affNeeds,
Rol
esandResponsi
bil
i
ties
Handout7.
12Cal
cul
ati
ngEst
imat
edRUTFNeeds
Handout7.
13Ov
erv
iewofResour
cesf
orCMAM
Handout7.
14Mat
ri
xforAct
ionPl
anni
ng
5.Pl
anf orSpecial
Cases: 1¼hour
s Handout7.
15Mat
ri
xforTr
ansi
ti
onPl
anni
ngofCMAM
Transit
ioni
ngand
Handout7.
16Gui
dancef
orCont
ingencyPl
anni
ngf
or
Contingenci
es
CMAM

Wrap-
UpandModul
e 15
Ev
aluat
ion minut
es

Modul
eDur
ati
on:8hour
s
Not
e:Dependi
ngont heneedsoft hei
raudi
ence(s),t
rai
ner
smaychooset
oski
porspendmor
eorl
ess
t
imeoncertai
nlear
ningobject
ivesandacti
vit
ies.Themoduledur
ati
oni
sanest
imat
eofthet
imei
ttakes
t
ocompleteal
lthelear
ningobject
ivesandactiv
iti
es.

Mat
eri
als
 Handout
s
 Casest
udy
 Copi
esofHandout7.
4Mappi
ngMat
ri
ces,
Mat
ri
x2andHandout7.
6SWOTAnal
ysi
sforCMAM t
o
di
str
ibut
e
 Nut
ri
ti
onCl
ust
erSAM andMAM casel
oadcal
cul
ati
ont
ool
 Fl
i
pchar t
s
 Marker
s
 Maski
ngt
ape

Adv
ancePr
epar
ati
on
 Room set
up,
mat
eri
als
 Remi
ndpar
ti
cipant
sthatt
heymustbr
ingi
nfor
mat
ionont
heheal
th,
nut
ri
ti
onandunder
nut
ri
ti
on
prev
ent i
veandcurati
veser
vicesinthei
rdi
str
ict
,aswellasnutr
it
ionsurv
eysandinfor
mationont
he
contextoft
heirhealt
hsyst
em, howitworksandwhetheriti
scentr
ali
sed.Br
ingi
nformat
ionsour
ces
i
ncasepar ti
cipant
sdonotbr i
ngtheir
s.
 Askpar
ti
cipant
stor
eadHandout7.
2CaseSt
udy
:Si
tuat
ionAnal
ysi
s,Ghana.
 Downl
oadt
heNut
ri
ti
onCl
ust
erSAM andMAM casel
oadcal
cul
ati
ont
ool
(seel
i
nki
nref
erence
r
esour
cesbel
ow)
 Revi
ewr
elev
antr
efer
encer
esour
cesandf
urt
herr
eadi
ngr
esour
cesbel
ow.

119
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ngGui
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Ref
erenceResour
ces
1. ActionCont
rel
aFaim( ACF).2017.Healt
hSystem Str
engtheni
ng:From Diagnosi
stoPl
anni
ngGuide.
Availabl
eat
:ht
tp:
//nut
rit
ioncl
uster
.net
/wp-cont
ent/upl
oads/si
tes/4/2017/02/ACF-
HSS-
GUIDE-
2017-
LD.pdf.
2. Concer
nWorl
dwide.2016.CMAM SurgeApproach:Oper
ati
onalGui
de.Avail
ableat:
ht
tps:
//www.
concern.
net/
sit
es/
default
/fi
l
es/
medi a/r
esour
ce/cmam_surge_operat
ional
_gui
de_
0.pdf
.
3. GlobalNutri
tionClust .2015.CMAM Casel
er oadCalculat
ions(SAM andMAM Tr eat
ment).Av
ail
abl
eat:
http:
//www. google.
com/ url
?sa=t
&rct
=j&q=&esrc=s&source=web&cd=3&ved=0ahUKEwjw8eW41YXbA
hXRm- AKHcSVDJQQFgg3MAI &url
=ht
tp%3A%2F%2Fnut r
it
ioncl
ust
er.
net%2Fwp-
content%2Fuploads%2Fsi t
es%2F4%2F2016%2F12%2FNC- Casel
oad-t
arget
-and-
suppli
es-
calcul
ator.
xlsx&usg=AOv Vaw0hOL5uVgL7fxU6FW8Y2Y7j .
4. WorldFoodPr ogr
amme( WFP)andUni tedNati
onsHi ghCommi ssi
onerforRefugees( UNHCR) .2011.
Gui
delinesforSel
ecti
veFeedi ng:TheManagementofMal nutr
it
ioninEmer gencies.Avail
ableat:
ht
tps:/
/ cms.emer
gency .
unhcr.org/
documents/11982/32558/Guideli
nes+for+select
ive+feedi
ng.+The
+management +of+malnutr
it
ion+in+emergenci
es/117faa46-7f
a4-446b-8104-10f5a4c763e1.
5. Worl
dHeal t
hOrgani
sati
on( WHO).2010.Moni t
ori
ngtheBui l
dingBlocksofHealt
hSystems:A
HandbookofIndi
cat
orsandTheirMeasur ementStrategi
es.Avail
ableat:
ht
tp:
//apps.
who.i
nt/
iri
s/bi
tstr
eam/handle/10665/258734/9789241564052-eng.
pdf
?sequence=1.
6. WHO.2007.Ever
ybody’
sBusiness—Strengtheni
ngHeal
thSyst
emstoImpr
oveHeal
thOut
comes:
WHO’sFrameworkforActi
on.Avai
labl
eat :
ht
tp:
//www.who.
int
/healt
hsyst
ems/ st
rategy/ev
ery
body
s_busi
ness.
pdf
.
7. Vali
dInter
nat i
onal.2006.Communi t
y-basedTherapeut
icCare(CTC):
AFieldManual
.Oxfor
d:Vali
d
I
nternat
ional.Avail
ableat:ht
tps:
//www. f
antapr
oject
.or
g/si
tes/
defaul
t/f
il
es/r
esour
ces/
CTC-Fi
eld-
Manual-
Oct 2006-508.pdf
.

Fur
therReadi
ngResour
ces
1. Bult
i,A.etal
.2017.“I
mprovingEsti
matesoft heBurdenofSev ereAcuteMal
nutr
iti
onandPredi
cti
ons
ofCaseloadforProgr
amsTr eati
ngSev er
eAcut eMalnutr
it
ion:Experi
encesf
rom Niger
i ”Ar
a. chi
vesof
Publi
cHeal t
h.75:
66.DOI10.1186/s13690-017-
0234-4.Avail
ableat:
htt
ps://www.ncbi
.nl
m.ni
h.gov/pmc/art
icl
es/PMC5679511/ .
2. Deconinck,H.etal
.2016.“Chal
lengesofEst
imati
ngt heAnnualCaseloadofSever
eAcute
Malnutri
ti
on:TheCaseofNi ger
.”PLoSONE.11(9):e0162534.doi
:10.1371/
jour
nal
.Avai
l
ableat
:
ht
tp:/
/journal
s.pl
os.
org/pl
osone/arti
cl
e?i
d=10.
1371/jour
nal.
pone.0162534.
3. Your
chuck,
A.;
Tumwi
ne,
K.;
Namugumy
a,B.
;Mor
la,
J.;
Dol
edec,
D.;
andMuper
e,E.2014.Heal
th
Syst
emsPer
for
mancef
orI
MAM/
NACSi
nUganda:Consi
der
ati
onsf
orDel
i
ver
yofNut
ri
ti
onSer
vices.
Washi
ngton,
DC:FHI360/
FoodandNutri
ti
onTechnical
AssistanceII
IProj
ect(
FANTA) .Avail
abl
eat
:
ht
tps:
//www.f
ant
aproj
ect
.or
g/si
tes/
def
ault
/fi
l
es/r
esources/Uganda-HSS-
Report
-Sep2014.pdf.
4. FANTA.2012.CMAM CostingTool
.Washingt
on,DC:FHI360/
FANTA.Av
ail
abl
eat
:
htt
ps:
//www.fant
apr
oject
.org/
tool
s/cmam-cost
ing-
tool
.
5. St
andar
disedMoni
tor
ingandAssessment
sforRel
i
efandTr
ansi
ti
on( .Measur
SMART) ingMor
tal
i
ty,
Nut
ri
ti
onalSt
atusandFoodSecur
it
yinCr
isi
sSi
tuat
ions(
int
erpr
etat
ion)
.
ht
tps:
//smar
tmet
hodol
ogy
.or
g/.

120
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orCommuni
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eMal
nut
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ti
on(
CMAM)
,2018Ver
sion

Modul
e7Learni
ngObject
ive1:Descr
ibeKeyEl
ement
sofCMAM and
Pr
epar
efort
hePlanni
ngProcess

TRAI
NER:Becomef
ami
l
iarwi
thHandout7.
1KeyEl
ement
sofCMAM Fr
amewor
kAl
ignedwi
tht
he
Heal
thSy
stemsSt
rengt
heni
ng(
HSS)Bui
ldi
ngBl
ocks.

PARTI
CIPATORYLECTURE:WORLDHEALTHORGANI SATION( WHO)HSSBUI LDING
BLOCKS.Expl
aint
hesi
x“bui
l
dingbl
ocks”bywhi
chheal
thsy
stem f
unct
ionsar
eor
gani
sed.Expl
aint
hati
f
al
lthebuil
dingblocksareperformi
ngthei
rfuncti
onsef f
ecti
vel
y,t
hiswouldl
eadtoimprovedaccess,
coverage,
quali
ty,andsafet
yofhealthser
v i
ces.Notethatwhenplanni
ngCMAM activi
ti
es,managersand
healt
hcareprovi
der sshoul
dal way
saimt ostr
engthenthehealt
hsy st
em’sf
unct
ions.Revi
eweach
buil
dingbl
ock,hi
ghl i
ghti
ngthecoredesi
rableatt
ri
butesasdescribedbel
ow:
1. Leadershi
pandgover
nanceshoul
densuret hatst
rategi
cpolicyf
rameworksexi
standar
e
combinedwit
heff
ecti
veover
sight
,regul
ati
ons,system desi
gn,andaccount
abil
i
ty.
2. Wor kf
orceshoul
dberesponsiv
e,f
air
,andef
fici
ent
,gi
venavai
lableresourcesandcircumst
ances.
Thereshouldbesuf
fi
cientnumber
sofstaf
fthatar
efair
lydi
str
ibuted,competent
,responsi
ve,and
producti
ve.
3. Financi
ngshouldbesuff
ici
enttoensur
ethathealt
hservi
cesar
eaccessi
bleandt
hatpeopl
ecan
useorpayforthem wi
thoutri
skoffi
nanci
alcatast
ropheori
mpover
ishment.
4. Inf
ormat
ionsystemsshoul
densur
etheproducti
on,anal
ysi
s,di
ssemi
nat
ion,anduseofr
eli
abl
e
andti
melyi
nformati
ononheal
thsyst
em per
formance,heal
thdet
ermi
nants,
andhealt
hstat
us.
5. Medicalpr
oducts,
v accines,andt
echnologi
esshoul
dbeaccessi
blet
otar
getcommuni
ti
es;
shoul
dbesafe,eff
icacious,andcost
-ef
fecti
ve;
andshoul
dbeusedproper
lyandi
nacost
-
eff
ecti
veway
6. Servi
cedel
iv
eryshoul
dbeeffect
iveandsaf
eandshoul
dprov
idequal
it
yhealt
hint
ervent
ionst
o
thosewhoneedthem,whenandwhereneeded,
wit
hminimum wast
eofresour
ces.

BUZZGROUP:KEYELEMENTSOFCMAM ALI
GNEDWI
THTHEHSSBUI
LDI
NGBLOCKS.Ref
er
par
ti
cipantstoHandout7. 1KeyEl ementsofCMAM Fr ameworkAli
gnedwi tht
heHSSBuildi
ngBlocks.
Askthem tolookoverthelistwi
thapar tnerandtoqui
ckl
yident
if
ywhi chkeyel
ementsst
andoutas
par
ti
cularl
yrelev
antfortheirdi
str
icts.Askaf ewpai
rstocomment.Discussbri
efl
y.

READI
NGANDGROUPDISCUSSI
ON:USI NGTHEKEYELEMENTSOFCMAM ALI GNEDWI
TH
THEHSSBUI
LDI
NGBLOCKS.Ref
erpar
ti
ci
pant
stot
hekeyel
ement
sofCMAM.Di
scussthe
fr
amewor k’
smanyuses,suchascapaci
tyassessment,desi
gn,pl
anni
ng,ev
aluat
ion,
andr
evi
ewof
i
ntegr
ation.Expl
aint
hatt
hismodul
elooksattheplanni
ngprocessthr
oughthisf
ramewor
kwher
ever
possi
ble.

PARTI
CIPATORYLECTURE:OVERVI
EW OFCMAM PLANNI
NGPROCESS.Expl
aint
hekeyst
eps
t
hismodul
eaddr
essesi
ntheCMAM pl
anni
ngpr
ocessandwr
it
eonaf
li
pchar
t:
1. Si
tuat
ionanal
ysis(t
odeterminetheneeds),whichconsist
sof:
a. Assessingt
henutri
ti
onsituat
ion
b. Mappinghealt
handnut r
iti
onsystems
c. Assessingt
hecapacityf
orCMAM atadi str
ictorheal
thfaci
li
tyl
evel
d. Analy
singstr
engths,
weaknesses, opport
uniti
esandthreats

2. Logi
calf
ramewor
k
3. Acti
onpl
an(i
mplement
ati
onpl
an)

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orCommuni
ty-
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ti
on(
CMAM)
,2018Ver
sion

4. Pl
anni
ngf
orspeci
alcases

BRAI
NSTORM:I
DENTI
FYI
NGWHOM TOI
NVOLVEI
NCMAM PLANNI
NG.Remi
ndpar
ti
cipant
sof
theworktheydi dinModule3:Communi tyOutreachtot
hinkthroughwhom t
heyneedtoinv
olvein
planni
ng.Giventhemai nareasofact
ivi
tyident
if
iedabov
e, askpart
ici
pant
swhotheythi
nkshouldbe
i
nv ol
ved.Possibleanswerscoul
dincl
ude:
 Thet
eam coor
dinat
ingandsuper
visi
ngt
hei
nter
vent
ion
 Di
str
ictheal
thof
fi
cial
s
 Heal
thcar
epr
ovi
der
s
 Communi
tymember
s;soci
al,
pol
i
tical
andr
eli
giousl
eader
s;t
radi
ti
onal
heal
ers;
tradi
ti
onal
bir
th
at
tendant
s;t
eacher
s;mot
her
s,f
ather
sandcar
egi
ver
s(suchasgr
andmot
her
s)
 Communi
tygr
oups,
women’
sgr
oups,
far
mer
sassoci
ati
ons
 Nongover
nment
alor
gani
sat
ions(
NGOs)andcommuni
ty-
basedor
gani
sat
ions(
CBOs)wor
kingi
n
heal
thandnut
ri
ti
oni
nter
vent
ionsi
nthedi
str
ict

Note:Communityl
eadersandmembers,andmother
s/caregi
versmustbei
nvolvedi
nthecommuni t
y
outr
eachpl
anningprocesst
ohelppl
annersgai
nabetterunderst
andi
ngofcausesofunder
nutri
ti
on,how
thecommunit
yv i
ewsandt r
eat
sundernut
ri
ti
on,andbarr
ierst
oaccessandhealt
hservi
ceuptake

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orCommuni
ty-
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eMal
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ti
on(
CMAM)
,2018Ver
sion

Module7Learni
ngObjecti
ve2:I
dent
ifyKeyComponent
sofaSi
tuat
ion
Anal
ysisandConductaBasi
cSit
uati
onAnalysi
s

TRAI
NER:
Rev
iewHandout7.
2CaseSt
udy
:Si
tuat
ionAnal
ysi
s,Ghanaandbecomef
ami
l
iarwi
thHandout7.
3
Assessi
ngtheNutri
ti
onSituat
ion,Handout7.
4Mappi
ngMat ri
ces,Handout7.
5Capacit
yGri
dforCMAM atthe
Di
stri
ctLevel
,Handout7.6SWOTAnal ysi
sforCMAM andHandout7.7ExampleCapaci
tyGr
idsforOut
pat
ient
CareattheHeal
thFacil
i
tyLevelandforCMAM att
heNationalLev
el.

BRAI
NSTORM:COMPONENTSOFTHESI
TUATI
ONANALYSI
S.Dr
awagr
idwi
thf
ivecol
umns.The
col
umnheadi
ngswil
lref
lectt
hef
ivecomponent
sofasi
tuat
ionanal
ysi
s(bel
ow)
,butdonoti
dent
if
ythe
col
umnheadi
ngsatt
hispoint
:
1.Assessi
ngt
henut
ri
ti
onsi
tuat
ion(
incl
udi
ngcausal
framewor
kofunder
nut
ri
ti
on[
UNI
CEF]
)
2.Mappi
ngheal
thandnut
ri
ti
onsy
stems,
ini
ti
ati
vesandpar
tner
satt
hedi
str
ictandf
aci
l
ityl
evel
s
3.Assessi
ngt
hecapaci
tyf
orCMAM
4.Conduct
ingast
rengths,weaknesses,
oppor
tuni
ti
esandt
hreat
s(SWOT)anal
ysi
sforCMAM
5.Concl
usi
on:Det
erminingneeds

Askparti
cipant swhatinformationisneededtopr eparet oplanCMAM ser vi
ces.Provi
deaf ewexampl esto
gettheconv ersati
onst ar
ted,i
fnecessary.Exampl escouldincludepr evalenceofwast ingi nthei
rdistr
ict,
how
manyout patientcarefacil
it
iesareinthedistr
ict
, whethertheyprovideser vicesforsever eacutemal nutr
iti
on
(SAM),etc.Wr it
etheirresponsesintheappropriatecolumn.Di scussandaski fparti
cipant scanthinkofwhat
theit
emsi neachcol umnhav eincommon.Wr it
et heintendednamef oreachcolumnandpoi ntoutthatthese
arethefi
v ekeycomponent sofasi t
uati
onanal y
si s.Putthefli
pchar tupont hewalltor efert
oast heLear ni
ng
Object
iveprogr esses.

READI
NGANDREVI
EW:UNDERSTANDI
NGNUTRI
TIONSI
TUATI
ONASSESSMENTS.Ref
er
parti
cipantst
oHandout7. 3AssessingtheNut rit
ionSi
tuat
ionandaskthem toreaditqui
etly
.Askgr oupsif
theyhav eanyaddit
ionsforColumn1ont hesituati
onanal
y si
sgri
dproducedearl
ieri
nthisLearni
ngObj ect
ive.
Discusswhyt heywouldneedt hati
nformationandwher etheycanfi
ndit.Wri
tethefol
lowingsourcesof
i
nformat i
onont hehealt
handnut ri
ti
onalstatusofpopulat
ionsonthefl
ipchart
,andaskpar t
ici
pantsifthey
haveanysour cestoaddt otheli
st:
 Demogr
aphi
candHeal
thSur
vey
s(DHS)
,seeht
tps:
//dhspr
ogr
am.
com/
 Mul
ti
pleI
ndi
cat
orCl
ust
erSur
vey
s(MI
CS)
,seeht
tp:
//mi
cs.
uni
cef
.or
g/
 UNSt
andi
ngCommi
tt
eeonNut
ri
ti
on,
Nut
ri
ti
onI
nfor
mat
ioni
nCr
isi
sSi
tuat
ions(
NICS)
,Nut
ri
ti
onSur
vey
Resul
tsDat
abase.
 Compl
exEmer
gencydat
abaseont
hei
mpactofcompl
exemer
gences(
CE-
DAT)
.

WORKI
NGGROUPS:PRACTI
CEASSESSI
NGANUTRI
TIONSI
TUATI
ON.Di
vi
depar
ti
cipant
sint
o
workinggroupsoffi
veorsi xpeopl ebydistr
ictorr
egionandexplainthattheywil
lremaininthesegroupsfor
muchoft hemodule’sduration.Askgroupst orevi
ewt henutri
ti
onsurveyinformati
onthattheyhavebrought
forthei
rcountry
/pr
ovince/distr
ictandcreateachar tofkeyinf
ormati
onont hefl
i
pchart.Thechartshould
fol
lowthef or
matoftheexampl echartbelow( t
rai
nermaypostabl ankexampl echart
),butpart
ici
pants
shouldfeelfr
eetoaddanyaddi ti
onali
nformat i
ontheythinkwouldbehelpful.
Askonegroupt
opr esenti
tsr
esul
tsi
nplenar
y,summarisi
ngt
henut
ri
ti
onsi
tuat
ioni
nit
scount
ry,
prov
inceor
di
str
ict
,andpoi
nti
ngoutanyareasofconcer
norfocus.

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orCommuni
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eMal
nut
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ti
on(
CMAM)
,2018Ver
sion

Exampl
eNut
ri
ti
onSi
tuat
ionChar
t

Crude Pr
eval
ence(
%) Casel
oad(
%) Pr
eval
ence(
%)
0t o5Deat h
DeathRate
Rate( 5DR) Wast
0- i
ng
Severe Stunt
ing
Age Geographi
c (CRD) Bil
ater
al Under-
Sour
ce Dat
e deaths wast i
ng MUAC MUAC HFA
Group Ar
ea deaths/
underfive/ WFH WFH<- 3
Pi
tti
ng
<125 <110 <-2z-
weight
10,000/
10,000day <- 2z-
z-score
Oedema
score
WFA<-2
day score
0-
59 Sept Eastern
DHS NA NA 8.
4 1.
2 NA NA NA 35.
3 22
mos 2006 Region
0-
59 Aug Eastern
MI
CS NA NA 6.
2 0.
9 NA NA NA 36 25
mos 2007 Region
Dist
rictB,
Di
stri
ct Sub-
0-
36 Dec
healt
h RegionA, NA NA 6.
0 0.
8 NA 6.
7 NA 37 23
mos 2007
offi
ce Eastern
Region
Dist
rictC,
MOH/
Sub-
NGO 6-
59 Dec
RegionB, NA NA 5.
8 0.
6 NA 6 NA 30 20
nutr
it
ion mos 2007
Eastern
surv
eyX
Region
Dist
rictC,
MOH/ N
Sub-
GO 6-
59 Mar
RegionB, 0.
21 0.
54 7.
1 1.
0 0.
3 6.
5 NA 34 24
nut
ri
ti
on mos 2008
Eastern
sur
veyY
Region

PARTI
CIPATORYLECTURE:MAPPI
NGHEALTHANDNUTRI
TIONSERVI
CES.Expl
aint
opar
ti
cipant
s
thatiti
simpor t
antt
oknowandmaphowt hedi
str
ictheal
thsy
stem isst
ruct
ured,
whatot
herserv
icesand
i
nitiat
ivesexi
standwhoi sdoi
ngwhat
,wher
eandhow.CMAM servicesshoul
dcomplementandli
nkwith
existi
ngprograms.Prov
ideexampl
es:

 Whatar
etheheal
thf
aci
l
iti
es’
str
uct
ures,
cat
chmentar
eas,
staf
fi
ngandheal
thout
reachsy
stems?
 Whatheal
thandnut
ri
ti
onser
vicesandi
nit
iat
ivesar
epr
ovi
dedorongoi
ng?
 Whatf
ormal
andi
nfor
mal
communi
ty-
basedsy
stemsexi
st?(
Ref
ert
oModul
eThr
ee:Communi
ty
Out
reach.
)
 I
sther
apeut
icf
eedi
ngf
ort
hemanagementofSAM i
nchi
l
drenav
ail
abl
e,andwhoi
sresponsi
blef
ort
hese
pr
ogr
ammes?
 Ar
eNGOs,
thegov
ernmentorot
heror
gani
sat
ions(
e.g.
,Wor
ldFoodPr
ogr
amme[
WFP]
)runni
ng
suppl
ementar
yf eedi
ngser
vicesorpr
ogr
ammesf
ort
hemanagementofmoder
ateacut
emal
nut
ri
ti
on
(MAM)inchil
dren?
 Ar
eser
vicesorpr
ogr
ammesf
ort
hepr
event
ionofunder
nut
ri
ti
oni
npl
ace?
 Ar
ether
eanygener
alr
ati
onorsaf
etynetpr
ogr
ammes,
andwhoi
srunni
ngt
hesepr
ogr
ammes?

WORKI
NGGROUPS:PRACTI
CEMAPPI
NGHEALTHANDNUTRI
TIONSERVI
CES.Ref
erpar
ti
cipant
s,
stil
li
nwor ki
nggr oups,toHandout7. 4Mappi ngMat ri
ces.Explai
nthatanimpor tantfi
rststepistodev el
opa
spatial mapoft hedistri
ct.Thenaskparti
cipantstolookov ert
hemappi ngmat ri
ces.Discusst heinformati
on
i
neachandwhyt hemat r
ixwouldbeuseful.ProvidecopiesofMat r
ix2foreachwor ki
nggr oupt ofi
llout
,
cl
ar i
fyingthatthemat rixislooki
ngfori
nformat i
ononheal thandnutri
ti
onserv i
ces,programmesand
communi tyini
ti
atives,andnotnecessari
lyCMAM.Foreachoft heothermat r
ices,askthegr oupst odevel
opa
planf orhowt heinformationwoul dbegathered.Askonegr ouptopresenttheirmat r
ixtotheot hergroups.
Discussi nplenary.

PARTI
CIPATORYLECTURE:CAPACI
TYASSESSMENTS.Expl
aint
opar
ti
cipant
sthatanessent
ial
par
t
124
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orCommuni
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eMal
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,2018Ver
sion

ofplanni
ngCMAM servi
ces,
inbot
hemergencyandnon-
emergencycontext
s,i
st oassesst
hecapaci
tyof
exi
stingheal
thsy
stemstosuppor
tCMAM.Thishelpspl
anner
stoident
if
ywhatt heycanbui
ldon.Thi
s
i
ncludes:
 At
hor
oughanal
ysi
sofl
eader
shi
pandgov
ernance:
Assessi
ngt
hecapaci
tyoft
heMi
nist
ryofHeal
th
(MOH)andcoll
aborati
ngNGOs;identi
fyi
ng,creat
ingoradapti
ngnati
onalpol
i
ciesandgui
deli
nesthat
supportCMAM ser
vices;r
evi
ewi
ngt hehealt
hsurv ei
l
lanceandrepor
ti
ngsyst
emsi nt
hedist
ri
ct,
regionor
countr
yinwhi
chapr ogrammeisbeingplanned.
 Anal
ysi
ngt
heheal
thf
inanci
nganddet
ermi
ningf
inanci
alr
esour
cest
osuppor
tthepr
ogr
ammeorser
vice
del
i
ver
yinasust
ainabl
emanner
 Heal
thwor
kfor
cef
orCMAM
 Knowl
edgeandi
nfor
mat
ionsy
stemsf
orCMAM
 Accesst
oCMAM equi
pmentandsuppl
ies:
Ther
apeut
icf
oodsuppl
i
es(
e.g.
,ready
-to-
uset
her
apeut
icf
ood
[RUTF]
,F75,F100,
ReSoMal,combi
nedminer
alandvi
tami
nmi
x[CMV])
,medici
nes,
equipment(
e.g.
,
scal
es,hei
ghtboards,
mid-
upperar
m ci
rcumfer
ence[
MUAC]t
apes)
,moni
tor
ingandrepor
ti
ngtools
 CMAM ser
vicedel
iv
ery
:Communi
tyout
reach(
e.g.
,communi
tyassessment
,communi
tymobi
l
isat
ionand
trai
ning,communityscr
eeni
ngandref
erralsy
stems),
inpat
ientcare,
outpat
ientcare,suppl
ementary
feeding,heal
thsyst
em,staf
fi
ng,
int
egrat
ioninheal
thservi
ces,l
inkswit
hotherrelevantser
vices,
and
continuousquali
tyi
mprovement

WORKI
NGGROUPS:PRACTI
CECAPACI
TYASSESSMENTFORCMAM.Ref
erpar
ti
cipant
sto
Handout7. 5Capacit
yGridforCMAM attheDist
ri
ctLevelandt
ot hegri
dsi
nHandout7. 7Exampl eCapacit
y
Gri
dsforOut pati
entCareattheHeal
thFacil
it
yLevelandforCMAM attheNationalLevel
.Discussthegrids
andinwhatsi t
uati
onstheywouldbemostuseful
.Askgroupstorefl
ectontheElementstoAddr esscol
umn
andfi
llintheothercol
umns: WhoCur
rentl
y,HowCurrent
ly,MOHCapacityt
oDoThi s,Gaps,Soluti
onsand
Pri
ori
ty.Askonegr ouptosharer
esul
ts.
Note:Faci
li
tat
orsandot
herr
esour
cepeopl
eshoul
dsuppor
tthewor
kinggr
oupsast
heyassesst
hei
rMOH
capacit
yforCMAM.

GROUPDI
SCUSSI
ON:GHANACASESTUDYSWOTANALYSI
S.Remi
ndpar
ti
cipant
sofCaseSt
udy
:
Situati
onAnal ysi
s,Ghana,whichtheywer etohav ereadbefor
ebeginningthismodul e.Askifthereareany
quest i
ons.Ifso,di
scuss.Askifanyparti
cipantsarefami l
i
arwit
hSWOTanal y
ses.Explainthattheanaly
sisis
i
mpor t
antinprogrammepl anningtoexplorestrengt
hs,weaknesses,opportuniti
esandt hr
eatsinareassuch
aspr ogrammequal it
y,capacit
y,humanresourcesdev elopmentandany t
hingel sepert
inenttothe
i
ntroduct i
onofCMAM ser vices.Notet
hatt hi
sisbestdonei nasessionwithst akehol
dersinvolvedi
nnut r
it
ion
programmi ng.

WORKI
NGGROUPS:PRACTI
CEASWOTANALYSI
S.Askpar
ti
cipant
stor
etur
ntot
hei
rwor
kinggr
oups.
Distri
butecopiesofHandout7.6SWOTAnal ysisforCMAM.Askpar t
ici
pantstofil
li
nt heSWOTt abl
eandto
thinkofstrengths,
weaknesses,opportuni
ti
esandt hr
eatsi
ntermsofintr
oducing,i
mpl ementi
ng,
strengtheni
ngandexpandingCMAM i nthei
rarea.I
nplenar
y,askonegrouptosharet hestr
engthsi
nthei
r
distr
ict
, whil
eothergr
oupswi l
lpresentweaknesses,oppor
tuni
ti
esandthreat
s, r
espectiv
ely
.

WORKI
NGGROUPS:PRACTI
CEDETERMI
NINGNEEDSBASEDONTHESI
TUATI
ONANALYSI
S.
Sti
ll
inwor ki
nggroups,
askpar
tici
pant
stodi
scussthei
rover
allf
indi
ngsanddeter
minet
heneedsf oran
i
ntervent
ionbasedontheanal
ysisoft
hesi
tuat
ion.Worki
nggroupsshoul
dspecif
ythet
argetpopul
ati
on,
geographiccov
erageandti
meframe.

125
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orCommuni
ty-
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eMal
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ti
on(
CMAM)
,2018Ver
sion

Modul
e7Lear
ningObj
ect
ive3:Dev
elopaLogi
cal
Framewor
kforCMAM

TRAI
NER:
Rev
iewHandout7.
1KeyEl
ement
sofCMAM Fr
amewor
kAl
i
gnedwi
tht
heHeal
thSy
stems
St
rengt
heni
ng(HSS)Bui
ldi
ngBl
ocksandbecomefami
li
arwi
thHandout7.
8Usi
ngaLogi
cal
Framewor
kfor
CMAM andHandout7.
9ExampleLogi
calFr
ameworkf
orCMAM.

WORKI
NGGROUPS:TRANSLATENEEDSI NTOAGOALANDOBJECTI VESOFTHEPROPOSED
I
NTERVENTI
ON.Askpar
ti
cipant
stodr
aftt
hegoal
andobj
ect
ivesoft
hepr
oposedi
nter
vent
ionbasedont
he
i
dentif
iedneeds, incl
udingtargetpopulation,geographi
calareaandt i
mefr
ame.Askgr oupstodiscussthe
typeandst rat
egyofCMAM neededi nthei rar
ea.Groupsshoul ddeter
minewhethertheser vi
cesshouldbe
short
-t
er m emergency ,emergencywithav iewtolonger-
ter
m servicedel
iv
eryornon-emer gencyservi
ce
deli
ver
y .I
naddi t
ion,groupsshoulddiscusswhet hertheserv
iceswi l
lbeoper
atedbyanNGOorbyt heMOH
andwhet hertheser v
iceshouldbei ntegratedintohealt
hservicesorshoul
dbest and-alone.Groupsshoul
d
reachaconsensusandr epor
tbacki nplenar y
.

PARTI
CIPATORYLECTURE:LOGI
CALFRAMEWORKFORCMAM.Dr
awagr
idonaf
li
pchar
tandf
il
li
n
thecolumnheadi ngsastheyappearinHandout7.9Exampl eLogicalFr
amewor kforCMAM.Expl ai
nthata
l
ogical f
rameworkisasimplif
ieddesignandplanni
ngtoolthatwil
lhelptoidentif
ygoals,
object
ives,
outcomes,
outputs/act
ivi
ti
esandinputsforplannedCMAM servi
ces.Fil
lint
her owheadi ngsastheyappearinHandout
7.9whi l
eexplai
ninghoweachmai ncomponent( goal
,ser
viceobjecti
ve,outcome, out
put
/acti
vi
ty)di
ffer
sfrom
theothers.UseHandout7.8Usi ngaLogicalFr
amewor kforCMAM, Secti
onsAandBasagui de.

Ref
erpar
ti
cipant
stoHandout7.
9andaskt
hem t
oreadi
tqui
etl
y.I
npl
enar
y:
 Aski
fany
onecanexpl
aint
hedi
ff
erencebet
weena“
goal
”andan“
obj
ect
ive,
”thenbet
weenan“
obj
ect
ive”
andan“outcome,”and,
final
l
y,bet
weenan“out
come”andan“ output/
acti
vi
ty”andan“
input
.”Suggest
thatt
heyrefert
oHandout7.8tohelpar
ti
cul
atethei
ranswer
s,ifnecessar
y.
 Ref
err
ingt
otheOut
put
s/Act
ivi
ti
essect
ion,
askpar
ti
ci
pant
sift
heyr
ecogni
set
hef
iveheadi
ngs(
desi
red
out
comes)underwhi
chout
puts/act
ivi
ti
esappear.Thesear
ethesixdomai
nsinthekeyel
ement
sof
CMAM f
ramewor kal
i
gnedwi
ththeHSSbui l
dingblocks,
asli
stedi
nHandout7.
1.
 Askwhy“
assumpt
ions”i
sani
mpor
tantcat
egor
yofi
nfor
mat
ion.Whati
fnoassumpt
ionswer
emade?
Whati
mpactcoul
dthi
shav
eonmeasur
ingr
esul
tsoncet
heser
viceorpr
ogr
ammei
soper
ati
ng?
Ref
err
ingpart
ici
pantstoHandout7.
8,Secti
onC,
discusst
hedi
ff
erencebet
weenper
for
mancei
ndi
cat
orsand
out
putindi
cat
ors.Answeranyquest
ions.

WORKI
NGGROUPS:PRACTI
CEDEVELOPI
NGALOGI
CALFRAMEWORK.I
nthesamewor
king
groups,askpart
icipantstocompl eteal ogisti
calfr
ameworkforCMAM ser vi
cesi
nt heirdi
str
ictbasedont he
needstheydetermi nedearli
er.Expl ai
nt hatHandout7.1KeyElement sofCMAM Fr amewor kAlignedwi t
ht he
HSSBui ldi
ngBlockscanpr ovideausef ulframeworkindet
erminingoutput
s/act
ivi
ties,asi
nt heexamplein
Handout7. 9,
abov e.Inplenar
y ,askwor ki
nggr oupstocomparethegoalsandobjectivesandprovideexampl e
outcomes,outputs/ act
ivi
ti
esandi nputs.Discusstheassumpti
onseachgr oupmadeaswel lastheindicators.

126
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orCommuni
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on(
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,2018Ver
sion

Modul
e7Lear
ningObj
ect
ive4:Dev
elopanAct
ionPl
anf
orCMAM

TRAI
NER:Revi
ewHandout7.
1KeyEl
ement
sofCMAM Fr
amewor
kAl
i
gnedwi
tht
heHeal
thSy
stems
Str
engt
hening(HSS)Bui
l
dingBlocksandbecomefamil
iarwit
hHandout7. 10Cal
cul
ati
ngEsti
matedSAM
andMAM Cases,Handout7.11Staf
fNeeds,Rol
esandResponsibil
i
ties,
Handout7.
12Calcul
ati
ng
Esti
matedRUTFNeeds,Handout7.13Overvi
ewofResourcesforCMAM andHandout7.14Matri
xfor
Acti
onPlanni
ng.

BRAI
NSTORM:I
NFORMATI
ONTOASSESSBEFOREACTI
ONPLANNI
NG.Askpar
ti
cipant
sto
quicklyrevi
ewsomeoft heplanningstepstheyhav ecompl etedinthismodul esofar
,theconclusi
ons
theyhav ereachedanddeci si
onsmade.Thepoi ntstheyraisedonothav et
obeexhaust iv
e.Explai
nthat
,
buil
dingont hesit
uationanalysi
s( needs)andlogicalfr
amewor k( desi
gnandst rat
egy),
thenextstepisan
actionplan.Befor
ecreatingtheact i
onplan,additi
onalinf
ormat i
oni srequi
red.Askpart
ici
pantstoname
whatt heythinkmightbekeyi nf
ormat i
onfordev el
opinganact ionplan.Writeanswersont hef
li
pchart,
askingleadingquesti
onsasnecessar ytoeli
ci
tthef ol
lowinganswer s:
1.Defi
ningt
argetpopul
ati
onandgeogr
aphi
cal
cov
erage,
incl
udi
ngest
imat
ingt
henumberofSAM
cases
2.I
dent
if
yingsi
tes,
incl
udi
ngl
ear
ningsi
tes
3.Det
ermi
ningst
aff
ingneedsandst
affr
olesandr
esponsi
bil
i
ty
4.Det
ermi
ningRUTFneeds

DEMONSTRATI
ON:ESTI
MATI
NGSAM CASES.Expl
aint
opar
ti
cipant
sthatt
hepar
amet
ersoft
he
serv
icedel i
veryareimportanttoquant
if
y.Thr
ought hei
rworkonasi tuati
onanalysi
sandlogical
fr
amewor k,t
het ar
getpopulati
oncanbedetermined.CMAM pri
orit
izeschildr
enunder5,butthetarget
populati
oncoul dbelargerornarr
owerincert
aincontext
s.Oncethepar ametershavebeenident
ifi
ed,i
tis
i
mpor tanttocalculat
etheest i
matednumberofchildr
enwhoneedt reatmentforSAM.Referparti
cipant
s
toHandout7. 10Cal cul
ati
ngEst i
matedSAM andMAM Casesanddemonst r
atethecal
culat
ion.

WORKI
NGGROUPS:PRACTI
CEESTI
MATI
NGSAM ANDMAM CASES.Askpar
ti
cipant
stot
hink
backtot hei
rsituati
onanal ysi
s.Usingt
heinformati
ontheygeneratedther
e,askt hem toesti
matethe
numberofSAM casesi nthegeographi
ccov er
ageareaoftheirproposedprogramme.( Ift
heyhavenot
donesoal ready,theyshouldbeaskedt ospecifyt
hegeographicaloradmini
strati
v ear
eawher eCMAM
servi
ceswi l
lbepr ov i
ded.ThisassumesthatCMAM i snotincl
udedinthenat i
onal pol
i
cyandhenceisnot
partofthenational essenti
alheal
thcarepackageorrouti
nehealthservi
ces).Reviewthecalcul
ati
onsin
plenar
y.
Explainthatest
imati
onofthecaseloadusi
ngpreval
enceofacutemal nut
rit
ionshoul
dbei nt
erpr
etedand
usedwi t
hcaut i
onasrecentstudi
eshaveshownitcoul
dresulttogrossunderesti
mati
onoft heactual
caseload6.Tobett
erpredi
cttheesti
matedSAM andMAM casel oad,emergi
ngev i
dencesuggests
applyi
ngasi mplemathematicalmodelt
oprogr
am datathatarereadil
yavail
abletoprogr
am managers7.
Showt heglobalnutri
ti
oncl usterSAM andMAM casel oadcalculatorandallowpar t
ici
pant
ssomet imeto
practi
ceusingtheMi crosoftExcel -
basedtool.Thetool canbedownl oadedf r
om thisl
ink:
http:
//www.google.com/ url
? sa=t&rct
=j&q=&esrc=s&sour ce=web&cd=2&v ed=0ahUKEwi C_oKt
yIXbAhVQdt
8KHeR6DWoQFggv MAE&ur l=http%3A%2F%2Fnut rit
ioncluster
.net%2Fwp-
content%2Fuploads%2Fsites%2F4%2F2016%2F12%2FNC- Casel
oad- t
arget
-and-suppli
es-

6
Deconi
nck,
H.etal
.2016.“
Chal
l
engesofEst
imat
ingt
heAnnual
Casel
oadofSev
ereAcut
eMal
nut
ri
ti
on:
TheCaseofNi
ger
.”
PLoSONE.11(
9):
e0162534.doi
:
10.
1371/
jour
nal
.
7
BultiA.etal.2017.“
Improvi
ngEst
imatesoft
heBurdenofSev
ereAcuteMalnutri
ti
onandPredi
cti
onsofCasel
oadf
or
ProgramsTr eati
ngSev er
eAcuteMalnut
ri
ti
on:
Exper
iencesf
rom Ni
ger
i ”Ar
a. chivesofPubl
i
cHealth.75:
66DOI
10.1186/s13690-017-
0234-4.

127
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def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

cal
cul
ator
.xl
sx&usg=AOv
Vaw0hOL5uVgL7f
xU6FW8Y2Y7j
.
Expl
aintopar
ti
cipant
sthati
tisimport
antt
oconsi
derpot
ent
ial
forseasonal
peaksi
nSAM andMAM r
ates;
thi
swill
becoveredinmoredetai
ll
ateri
nthemodul
e.

PARTI
CIPATORYLECTURE:I
DENTI
FYI
NGLEARNI
NGSI
TES.Expl
aint
hatal
ear
ning,
orpi
l
ot,
sit
e
i
sonewher ehealt hcareprovi
dersfrom othersitescancomet olearnskil
lsduringin-serv
icet r
aini
ngor
onalearni
ngv i
sit.Learni
ngsit
esar ei mport
antinnon- emer gencysi t
uati
onsbutmaybedi ff
icultto
est
abli
shinanemer gencysetti
ng.Askpar ti
cipantstoqui cklynamewhatt heythinkkeychar acteri
sti
csof
agoodlearni
ngorpi lotsit
eare(e.g.,str
ongcapaci t
y,easyaccess) .Notethatestabli
shingal earni
ngsite
i
sanef f
ecti
vebaseonwhi cht
or oll
outadditionalservices.Next,itisimportanttodef i
nehowser vi
ces
wil
lberoll
edoutt ocov ert
heout pat
ientandinpat i
entsitesaspl annedandt oensur ecommuni tyoutreach
ski
ll
sinallt
argetedcommuni t
ies.

ELI
CITATI
ON:CONSI
DERATI
ONSI
NSELECTI
NGHEALTHFACI
LITI
ES.Askpar
ti
cipant
swhat
shoul
dbet akeni
ntoaccountwhensel
ecti
ngpotent
ial
heal
thf
aci
l
iti
esforCMAM servi
ces.Possi
ble
answersinclude:
 Suf fi
cientnumberofquali
fi
edstaf
f(accor
dingt
onati
onal
pol
ici
es)forexpect
edcasel
oad
 Expect
ednumberofpat
ient
s
 Suf
fi
cientspaceatheal
thf
aci
l
ity
 Ensur
ingt
hatout
pat
ientcar
eact
ivi
ti
eswi
l
lnoti
nter
fer
ewi
thot
herongoi
ngact
ivi
ti
es
 St
orageav
ail
abl
e
 Sour
ceofcl
eandr
inki
ngwat
er
 Ar
easofpopul
ati
oni
nfl
uxand/
orhotspot
swher
ecasel
oadi
sal
way
shi
gh
 Communi
tydemand

WORKI
NGGROUPDI
SCUSSI
ON:I
DENTI
FYI
NGLEARNI
NGANDI
MPLEMENTATI
ONSI
TES.
Askpar
ticipant
s, st
il
linworkinggroups,t
odiscusspot
enti
all
ocati
onsf
orl
ear
ningandi
mpl
ement
ati
on
si
tesi
nt heirdi
stri
ct.Askthem todiscussthefol
l
owingquest
ions:
 Whi chgeogr aphiclocat
ionsarebest?
 Whatki
ndofsuppor
twi
l
lthesesi
tesneed?
 Whi
chsi
tesseem t
obegoodcandi
dat
esandwhy
?

Haveeachgr
oupsharetwoort hr
eekeypointsoft
hei
rdi
scussion.Di
scussandansweranyquest
ions.
Next
,askpar
ti
cipant
stodiscusshowt heywoul
dgoaboutexpandingCMAM servi
cesfr
om thel
earni
ng
si
te:
 Atwhatpacewoul dt
heyr ol
loutnewservi
ces?
 Howwoul
dtheybui
l
dcapaci
tyatnewout
pat
ientcar
esi
tes?
 Howwoul
dtheydeci
dewher
etoexpand?
Hav
eeachgr
oupshar
etwoort
hreekeypoi
ntsoft
hei
rdi
scussi
on.

READI
NG:UNDERSTANDI
NGSTAFFI
NGNEEDS.Ref
erpar
ti
cipant
stoHandout7.
11St
affNeeds,
Rol
esandResponsi
bil
it
iesandaskt
hem t
oreadqui
etl
y.Answeranyquest
ions.

PRACTI
CE:CALCULATI
NGRUTFNEEDS.Remi
ndpar
ti
cipant
sthatRUTFi
sanessent
ial
component
ofCMAM, therefor
e, cal
culat
ingesti
matedRUTFneedsisessent
ial
.Ref
erparti
cipant
stoHandout7. 12
Cal
culati
ngEst i
mat edRUTFNeeds.Di scusstheexamplegi
venandansweranyquestions.Thenask
par
tici
pantstocalculatetheesti
matedRUTFneedsf ort
heCMAM servi
cesplannedintheirdi
str
ictbased
onthenumberofSAM casesest i
matedabove.

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orCommuni
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nut
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ti
on(
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,2018Ver
sion

GROUPDI
SCUSSI
ON:ACCESSTOCMAM EQUI
PMENTANDSUPPLI
ES.Ref
erpar
ti
cipant
sto
Handout7. 13Overvi
ewofResourcesforCMAM.Discusseachcategory:
st af
f,equipmentandsuppli
es,
tr
ansport,physi
cal
struct
uresandequi
pmentpersi
te.(
NotethatwhileRUTFi sment ioned,
act
ualsuppl
y
shoul
dbebasedonRUTFneedsascal culat
edabove.
)Askparti
cipantswhichoft hesuppli
esontheli
st
arechall
engingtoobtai
nandwhattheywouldneedtodotoobtainthem.Discussandanswerany
questi
ons.

WORKI
NGGROUPS:PRACTI
CEPRODUCI
NGANACTI
ONPLANNI
NGMATRI
X.Ref
er
part
ici
pantstoHandout7.14Mat ri
xforActi
onPlanning.Di
scusstheoveral
lcat
egor
iesandhowt othi
nk
thr
ought heti
mingoftheacti
vit
ies.Havepart
ici
pant
sr et
urnt
ot hei
rworki
nggroupsand,bui
l
dingonwor k
completedinthepastact
ivi
ti
es,askthem t
o:
 Li stallpl
annedact
ivi
ti
esusingthekeyelementsofCMAM, aslist
edinHandout7.1,
toclassi
fyt
he
activi
ti
es
 Devel
opat
imel
i
ne
 I
ndi
cat
eresponsi
bleper
sonsandr
esour
cesf
oreachact
ivi
ty(
uset
hekeyel
ement
sofCMAM al
i
gned
wi
tht
heHSSbui
l
dingbl
ockst
ocl
assi
fyt
heact
ivi
ti
es)
Hav
epar
ti
cipant
spr
esentt
hei
ract
ionpl
ansi
npl
enar
y,r
ecei
vi
ngf
eedbackandsuggest
ionsf
rom ot
her
s.
Note:Logist
icalpl
anni
ngcanbedevel
opedsepar
atel
yandincl
udesspeci
fi
cacti
onsonorgani
sing
t
ransportati
on,shel
ter
,equi
pment
,mater
ial
sandsuppli
es,
incl
udi
ngmonitori
ngandrepor
ti
ngforms.

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orCommuni
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,2018Ver
sion

Modul
e7Lear ni
ngObj
ect
ive5:Pl
anni
ngf
orSpeci
alCases:Tr
ansi
ti
oni
ng
andCont
ingenci
es

TRAI
NER:
Becomef
ami
l
iarwi
thHandout7.
15Mat
ri
xforTr
ansi
ti
onPl
anni
ngofCMAM andHandout
7.16Gui
danceforCont
ingencyPlanni
ngf
orCMAM.Ref
erbackt
oHandout7.
5Capaci
tyGr
idf
orCMAM
attheDi
str
ictLev
eli
fnecessary
.

BRAI
NSTORM:TRANSI
TIONPLANNI
NG.Expl
aint
opar
ti
cipant
sthatt
ransi
ti
onr
efer
stot
hepr
ocess
l
eadingupt ohand-ov er,i
ncl
udingpl
anningandpreparati
onf ort
hegr adualtr
ansferofrolesand
responsi
bil
iti
esforCMAM ser v
icestotheMOHunt i
lhand-
ov eri
scompl ete.Notethati
nmanyl ocati
ons,
CMAM hasbeeni ni
tiatedbyNGOsorout si
dedonorsincollabor
ati
onwi ththeMOHorl ocal/
distr
ictheal
th
offi
ce.Fr
om t heoutset,aplanshoul
dbei nplacefortheMOHt oeventuall
yassumecont r
oloftheCMAM
servi
ces,part
icul
arl
yi ftheserv
iceswil
lbeintegr
atedintorouti
nehealthservices.Pl
anningalsois
requi
rediftheint
erventionisshortt
erm andmustbephasedout .
Ont hefli
pchart,createachartwi t
htwocol umns,labelled“ EmergencyCMAM Pr ogr
amme”and“ Non-
Emer gencyCMAM Pr ogramme. ”Askpar t
ici
pantstobr ainstorm onthedif
ferencesbetweenan
emer gencyCMAM pr ogr
ammeandanon- emergencyCMAM pr ogramme( e.
g.,management ,goals,
objecti
ves,r
esour ces,i
ntensi
ty,pri
ori
tywithint
heheal thsy stem, st
aff
ing,
component s).Writ
eideason
thefli
pchart.Basedont hesedi ff
erences,askparti
cipant swhatt heywouldneedt oconsiderdur
ing
CMAM pl anningiftheyaretransit
ioningfr
om anemer gencyt oanon- emergencycontext.

WORKI
NGGROUPS:PRACTI
CETRANSI
TIONPLANNI
NG.Ref
erpar
ti
cipant
stoHandout7.
15
Matr i
xf orTransi
ti
onPl anningofCMAM andt el
lthem t oref
erbackt ot hei
rcapaci
tyassessmentatt he
di
strictlevel
.Askeachwor kinggrouptof il
loutthemat ri
x.Hav egroupscompar ePotentialAdaptations:
Thisisav er
ycontext-
speci f
icacti
vit
y.Trainersshoul dadapti ttoaudienceneedsandadj usttheamount
ofti
mespentont hi
stopi c.Thisshouldhav ebeendi scussedi nmuchgr eat
erdetai
linLearningObj ecti
ve
4:Dev elopanAct i
onPl anf orCMAM.I tcanal sobepar toftheCMAM Capaci tyGri
d( seeHandout7. 5
Capaci tyGridforCMAM att heDistri
ctLev elforreference),
ratherthanasepar at
eact i
vi
ty.Parti
cipants’
professionalrol
eswillalsoaf f
ectthi
sact i
vity.Forexampl e,healthcaremanager smightneedt othink
aboutl ong-t
erm supportfortheprogramme, whi l
eheal thcareprovidersmightbemor econcer nedwi th
howt ohandl etheserviceswi t
hcur r
entstaf f
inglevels.

PARTI
CIPATORYLECTURE:CONTI
NGENCYPLANNI
NG.Expl
aint
opar
ti
cipant
sthatunexpect
ed
eventsorci
rcumstances,suchasciv
ilunr
estornaturaldi
sast
ers,mightrapidl
yincr
easethenumberof
SAM casesamongal readyvul
nerabl
epopulat
ions.Iti
scri
ti
caltoplanfortheseconti
ngenci
essothatt
he
system i
sprepar
edtohandl eani
ncreasedcaseload.
Forcont
ingencyplanning,t
hethresholdlev
el—thepointwherethecasel
oadexceedst
hecapaci
tyt
o
manageit—mustbedet er
mined.Factorstoconsideri
nclude:
 Numberofst affperhealt
hfacil
it
yav ai
labl
eforoutpati
entcar
e
 Expect
edcasel
oad
 Havi
ngast
rat
egi
cpl
ani
npl
acet
odeal
wit
hanout
pat
ientcar
ecasel
oadt
hatexceedscapaci
tyt
o
manageit
Inemergenci
es,i
tisimport
anttoconsi
derwhi
chheal
thfaci
l
iti
escanoff
erCMAM, aswellaswhet
her
moreoutpati
entcaresi
teswil
lbeneededandwher
etolocatethem.Humanresour
cerequir
ement
s
shoul
dalsobeestimated.

GROUPDI
SCUSSI
ON:CONTI
NGENCYPLANNI
NG.Askpar
ti
cipant
stoshar
eexampl
esofany
advanceconti
ngencyplanni
ngtheyhav
edoneint
hei
rheal
thcent
resf
oranysi
tuat
ion(
notnecessar
il
y
undernut
ri
ti
on).Askthefoll
owi
ngquesti
ons:
 Whatki
ndoff
luct
uat
ionsi
ntheheal
thandnut
ri
ti
onsi
tuat
ionar
ecommoni
nthei
rcommuni
ty?

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,2018Ver
sion

 Whatar
esomekeyel
ement
sthatt
heyconsi
der
?

Referparti
cipantstoHandout7. 16GuidanceforConti
ngencyPl anni
ngf orCMAM.Showt he
Cont i
ngencyPl anningProcessflowchartandaskpart
icipantstodescr
ibethebasi
celementsofal
lof
themaj orst
eps.Al sohighl
ightontheCMAM sur geapproachasanExampl eofanApproachfor
Strengtheni
ngt heHealthSy st
em toPlanandManageI ncr easedDemandf orSAM andMAM Servi
ces.

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orCommuni
ty-
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eMal
nut
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ti
on(
CMAM)
,2018Ver
sion

Modul
e7Wr
ap-
UpandModul
eEv
aluat
ion

Suggest
edMet
hod:Rev
iewl
ear
ningobj
ect
ivesandcompl
eteev
aluat
ionf
orm.
 Revi
ewt
hel
ear
ningobj
ect
ivesoft
hemodul
e.I
nthi
smodul
e,y
ouhav
e:
1. Descr
ibedkeyelement
sofCMAM al
i
gnedwiththeWHOheal
thsy
stemsst
rengt
heni
ng(
HSS)
bui
ldi
ngblocksandarepr
epar
edf
orthepl
anningpr
ocess
2. Ident
if
iedkeycomponent
sofasi
tuat
ionanal
ysi
s,andanal
ysedandconduct
edabasi
csi
tuat
ion
analy
sis
3. Dev
elopedal
ogi
cal
framewor
kforCMAM
4. Dev
elopedanact
ionpl
anf
orCMAM
5. Plannedfort
ransi
ti
onandcont
ingenci
es,
andhav
eabasi
cunder
standi
ngoft
heCMAM sur
ge
approach

 Askf
oranyquest
ionsandf
eedbackont
hemodul
e.

 Askpar
ti
cipant
stocompl
etet
heev
aluat
ionf
orm.

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orCommuni
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eMal
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ti
on(
CMAM)
,2018Ver
sion

MODULEEI
GHT:MONI
TORI
NGANDREPORTI
NGON
CMAM

Modul
eOv
erv
iew
Thi
smodulei
ntroducespar
ti
cipant
stot
hebasicprinci
plesofmoni
tori
ng,r
epor
tingonandsupervi
sing
communi
ty-
basedmanagementofacutemalnutr
it
ion(CMAM)ser v
ices,wi
thafocusonoutpat
ientcar
e.
Themoduledescr
ibeshowindi
viduali
nfant
sandchil
drenaretr
ackedandmoni t
oredi
nCMAM andhow
monit
ori
nginf
ormationanddat
aar ecol
lect
edandreport
edfortheser
vice/
programmeasawhole.The
pur
poseandfunct
ionofsuppor
tandsuper vi
sor
yvi
sitsaredi
scussed.
Theimportanceoftr
ackinginf
antsandchil
drenbetweenoutpati
entcar
eandinpat
ientcare,
usi
ngref
err
al
sl
ips,f
il
li
ngintheoutpati
entcaretr
eatmentcardsandusingasimplenumberi
ngsystem hasbeen
previ
ousl
ycov er
ed.Thismodulefocusesonbri
ngingitt
ogetherthr
oughasimplemonitor
ingsyst
em.
Thismoduleincl
udespract
icalexercisesthatwillpr
ovi
departi
cipant
swi t
htheopport
unityt
opr
act
ice
compil
ingdataandinfor
mat i
on.Italsoincludesahalf-
dayfi
eldpract
iceatanoutpat
ientcar
esi
tet
o
obser
veregistr
ati
on,t
racki
ng,moni t
or i
ng,report
ingandsupervi
sionprocedur
es.
Moni t
or i
ngandreport
ingonCMAM combinesout
pati
entcareandinpat
ientcar
einf
or mat
ion,
and
perfor
mancei ndi
catorsar
ebasedonthesecombi
nedstati
sti
cs.Themoni t
ori
ngsystem f
rom each
outpatientcar
eandinpati
entcar
esi
temustbewellst
andardizedandcoordi
natedt
oav oi
ddouble
counting.
Note:Thi
smoduledoesnotcovermonit
ori
ngandrepor
ti
ngont hesuppl
ysy
stem (e.
g.,managementand
t
ransport
ati
onofequi
pment,mater
ial
s,dr
ugs,
ther
apeuti
cfood)oronhumanresources.

Lear
ningObj
ect
ives Dur
ati
on Handout
sandExer
cises
1.Describet hePr i
ncipl
es 15mi nutes
ofaMoni tori
ngand
Repor t
ingSy stem for
CMAM
2.DescribeHowt he 45mi
nutes Handout8.1:Monitori
ngt heI
ndiv
idualInfantorChil
din
I
ndividual I
nfantorChi l
d Outpat
ientCare
I
sTr ackedand Handout8.2:Regi
strationNumberingSy stem Pr
oposedfor
Monitor edinCMAM CMAM
Handout8.3Moni t
oringandRepor t
ingonCMAM
Handout8.4Fil
ingOut pati
entCar
eTr eatmentCar ds

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,2018Ver
sion

3.Compl eteSit
eTally 1hour Handout8.
3Moni
tor
ingandRepor
ti
ngonCMAM
SheetsandSi t
eand Handout8.5Si
teTal
lySheetfortheManagementofSAM
Dist
rictReports; andNutri
ti
onal
lyVul
nerabl
eInfantsUnder6Months
I
nterprettheFindi
ngs
Handout8.
6SiteReportSheetf
ortheManagementof
SAM andNutr
it
ional
lyVulner
abl
eInfant
sUnder6Months
Handout8.
7Dist
ri
ctorNat
ionalReport
ingSheetfort
he
ManagementofSAM andNutri
ti
onal
lyVulner
ableInf
ant
s
Under6Months
Exer
cise8.
1( a)Out
pat
ientCar
eSi
teTal
l
ySheetandSi
te
Report
ingSheet
Exer
cise8.
2Compl
eti
ngSi
teTal
l
ySheet

4.Cal
culateandDiscuss 45mi
nut
es Handout1.
2Ter
minol
ogyf
orCMAM
Ser
vice/Pr
ogramme
Handout8.
8CMAM I
ndi
cat
ors
Per
formanceand
Coverage Handout8.
9Pr
inci
plesofCov
erage
Exer
cise8.
1(b)Out
pat
ientCar
eSi
teRepor
ti
ngSheet
5.Monit
orandRespondt
o 30mi
nut
es Handout8.
10Moni
tor
ingBar
ri
erst
oAccess
Bar
ri
erstoAccess
Exer
cise8.
3Communi
tyMeet
ingRol
e-Pl
ay

6.Expl
ainthePurposeof 1hour Handout8.
11Suppor
tandSuper
visi
onf
orCMAM
SupportandSupervi
sion
Handout8.12Suppor
tandSuper
visi
onCheckl
i
stf
or
Visi
tsandtheRoleofa
Outpat
ientCar
e
Supervi
sor/
Mentor
Handout8.
13SupportandSuper
visi
onCheckl
i
stf
or
CommunityOut
reach
Exerci
se8.4Anal
ysisoft
heSit
eRepor t
sofThr
ee
Outpati
entCar
eSitesandOneInpat
ientCar
eSi
te
OPTI
ONAL:Supplemental
Refer
ence8.1Sett
ingUpa
CMAM Moni
tori
ngSystem Usi
nganElect
roni
cDat abase
i
nExcel
andUsingaCMAM mHeal thAppli
cation
7.Pr
epar
eanOut l
i
nef
or 30mi
nut
es Handout8.
14Gui
danceonCMAM Repor
ti
ng
CMAM Repor
ti
ng

Wrap-UpandModule 15mi
nut
es
Eval
uati
on
Fi
eldVisi
tforMoni
tor
ing ½day Handout8.
3Moni
tor
ingandRepor
ti
ngonCMAM
andReporti
ng
Handout8.
8CMAM I
ndi
cat
ors
Handout8.12Suppor
tandSuper
visi
onCheckl
i
stf
or
Outpat
ientCar
e

Modul
eDur
ati
on:Fi
vehour
sincl
assr
oom,
hal
f-
dayf
iel
dpr
act
ice

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eMal
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ti
on(
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,2018Ver
sion

Note:
Dependingont heneedsoftheiraudi
ence(
s),
trai
nersmayski
porspendmoreorl
essti
meon
cer
tai
nlear
ningobjectiv
esandactiv
iti
es.Themoduledurati
oni
sanesti
mateoft
hetimeitt
akest
o
complet
eallt
helearningobj
ecti
vesandact i
vi
ti
es.

Mat
eri
als
 Handout
s
 Cal
cul
ator
s
 Fl
i
pchar
ts
 Mar
ker
s,maski
ngt
ape
 Copi
esofout
pat
ientcar
etr
eat
mentcar
ds
 Copi
esofHandout1.
2Ter
minol
ogyf
orCMAM,
Handout4.
1Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
ies
f
orCMAM,
andHandout4.
20Di
schar
geCr
it
eri
aandExi
tCat
egor
iesf
orCMAM.

Adv
ancePr
epar
ati
on
 Room set
up
 Createi
ndi
vidual
role-pl
aycardsforGr
oupExerci
se8.1(b):CommunityMeet
ingRol
e-Pl
ay.
 Reviewrel
evantr
eferenceresour
cesandfur
therreadi
ngresourcesl
i
stedbel
ow.

ReferenceResour ces
1.Frank,T.2017.AMobileHeal
thAppl
i
cat
iontoManageAcuteMalnut
ri
tion.Lessonsfr
om
Devel
opingandPil
oti
ngtheAppinFi
veCountr
ies.Wor
ldVi
sion/
SavetheChildren.
Av
ail
abl
eat
:ht
tp:
//www.
tr
ansf
ormnut
ri
ti
on.
org/
wp-
cont
ent
/upl
oads/
sit
es/
3/2017/
04/
TN_
Wor
kingPaper
1_Mobi
l
eApp_
Onl
i
ne.
pdf
.
2. My
att
, .2012.Semi
M.etal -Quant
it
ati
veEval
uat
ionofAccessandCover
age(
SQUEAC)
/Si
mpl
i
fied
LotQual
i
tyAssur
anceSampl
i
ngEval
uat
ionofAccessandCover
age(
SLEAC)Techni
calRef
erence.
Washington,DC: FHI360/
FoodandNutri
ti
onTechnical
AssistancePr
oject(
FANTA) .Av
ail
ableat:
ht
tps://
www. f
antaproj
ect
.or
g/si
tes/
def
ault
/fi
l
es/r
esources/SQUEAC-SLEAC-Techni
cal
-Ref
erence-
Oct2012_0.pdf.
3. Val
idInt
ernat
ional.2006.Communi ty-
basedTherapeuti
cCare:AFieldManual.(Chapt
ers9and10.
)
Oxfor
d:Vali
dInternati
onal.Avail
ableat:
ht
tps:
//www. f
antaproject
.org/si
tes/defaul
t/f
il
es/
resources/
CTC-Fiel
d-Manual-
Oct2006-
508.
pdf
.

Fur
therReadi
ngMat
eri
als
1. Roschni
k,N.
;Chui
,J.
;andKeane.
,E.June2017.Pr
eli
minar
yFi
ndi
ngsf
rom aMal
nut
ri
ti
on
Mobi
l
eAppRandomi
sedTr
iali
nWaj
i
r,Kenya.Avai
l
abl
eat
:
htt
p://www.
transf
ormnutr
it
ion.
org/wp-
content/
upl
oads/si
tes/
3/2017/06/
TN_Resear
chBr
ief
14_
Onl
i
ne.
pdf
.
2. TheSpher
ePr
oj .TheSpher
ect eHandbook:Humani
tar
ianChar
terandMi
nimum St
andar
ds
i
nHumani
tar
ianResponse(
2018Revi
sion)
.Av
ail
abl
eat
:
htt
p:/
/www. spher
epr
oject
.or
g/handbook/
rev
isi
on-
spher
e-handbook/
draf
t-
ready
-for
-f
eedback/
food-
secur
ity
-nut
rit
ion/
.
3. FANTA.2008.ReportontheI nternat
ionalWorkshopontheIntegrati
onofCommuni ty-
Based
ManagementofAcut eMalnut r
iti
on(Washington,D.
C.,
Apr i
l28-30,2008)
.Avail
ableat:
htt
p:/
/fi
l
es.
ennonli
ne.net
/attachment s/1200/
integr
ati
on-of-
cmam- washingt
on-enn-
2008.pdf
.

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ngGui
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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module8 Lear
ningObj
ect
ive1:Descr
ibet
hePr
inci
plesofaMoni
tor
ing
andRepor
ti
ngSy st
em f
orCMAM

TRAI
NER:Revi
ewHandout4.
1Admi
ssi
onCr
it
eri
aandEnt
ryCat
egor
iesf
orAt
-Ri
skMot
her
sandI
nfant
s
Under6MonthsandChil
dren6-
59MonthsandHandout4. 20Dischar
geCri
ter
iaandExitCat
egori
esfor
CMAM.Not et
hesehandoutsar
etobeusedforr
eferencethr
oughoutthemodule.Ref
erModules4-6for
addi
ti
onal
revi
ewofadmissionanddi
schar
gecri
ter
iaifnecessary.

GROUPDISCUSSI
ON:RATI
ONALEANDPRI NCIPLESFORCMAM MONI TORI
NGAND
REPORTI
NGSYSTEMS.Askpar
ti
ci
pant
stobr
ainst
ormt
hefol
l
owi
ngquest
ions:

1. Whatar
ethekeyaspect
sofmoni
tor
ingandr
epor
ti
ngonCMAM?
Fi
lli
nthegapsi
nthediscussi
onwi
tht
hef
oll
owi
ngi
nfor
mat
ion:
Tomoni
toraCMAM ser
vice
ef
fecti
vel
y,y
ouwil
lneedto:
 Moni
tort
hei
ndi
vi
dual
inf
antorchi
l
d
 Moni
torandr
epor
tont
heef
fect
ivenessoft
heser
viceasawhol
e
 Super
viseandsuppor
ttheheal
thcar
epr
ovi
der
s

2. Whydowemoni t
orCMAM ser vi
ces?
Fi
ll
inthegapsinthedi scussi
onwiththef
oll
owi
nginf
ormation:Moni
tori
nghel
pstoidenti
fywhat
i
sworkingwell(
strengths),whati
snotworki
ngandwheretheremightbegaps(weaknesses)
.
Wit
hthisinf
ormati
on, weaknessesandgapscanbeaddressed.
 InCMAM,theindi
vi
dual
infantorchi
ldi
smoni
tor
edtoensur
ethatshe/
heistr
eated
appr
opr
iat
elyandeff
ect
ivel
y,whichhel
pst
ocont
inual
l
yimprov
etheservi
cestheyr
ecei
ve.
 Healt
hcareprovider
saresuper
visedandsuppor
tedtomai
ntai
nthei
rski
ll
sandensur
ea
successf
ulser
vicethatt
reat
salli
nfant
sandchil
drenwhomeetthecr
it
eri
a.

3. Whatar
esomechar
act
eri
sti
csofanef
fect
iveheal
thmanagementi
nfor
mat
ionsy
stem (
HMI
S)?
Fi
llinthegapsi nthediscussi
onwiththefollowinginfor
mat i
on:AnHMI Smustbesi mpleto
minimisethedemandsonheal thcareprovidersbutprovidesuff
ici
entusefuli
nfor
mationto
ensureservice/pr
ogrammeef f
ecti
venessandt oal
lowhealthmanager stomakedecisionsand
adjustments.AnHMI Sshoul dcomplement--notdupli
cate--
exi
sti
ngsystems.AnHMI St hat
i
ncludesrepor t
ingoncasesofSAM mi ghtalreadyexi
st,and/ort
heMi nist
ryofHealt
h(MOH)or
UNI CEFmighthav ereporti
ngrequi
rementsf orreport
ingonacutemal nutr
it
ion.

4. Whoshoul
dber esponsi
blef
ormonit
ori
ngandr
epor
ti
ngonCMAM?Whoshoul
dsuper
viset
he
CMAM ser
vice/
programmeinyourdi
str
ict
s?
Fil
linthegapsinthediscussionwi
ththefol
l
owi nginfor
mati
on:
Thiswil
ldi
ff
erforeachdist
ri
ct.
Butforeachaspectofmoni tori
ng,
iti
simportanttodetermi
nei
nadvancewhospecifi
cal
l
yis
responsibl
eforcol
lect
inganddocument i
ngthedat aandwhospeci
fi
cal
lyi
sresponsi
blefor
report
ing.

Modul
e8Learni
ngObj
ect
ive2:Descr
ibeHowt
heI
ndi
vi
dual
Inf
antor
Chi
ldI
sTr
ackedandMoni
toredi
nCMAM

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orCommuni
ty-
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

TRAI
NER:
Becomef
ami
l
iarwi
thHandout8.
1Moni
tor
ingt
heI
ndi
vi
dual
Inf
antorChi
l
dinOut
pat
ientCar
e,
Handout8.
2Regi
str
ati
onNumber
ingSystem ProposedforCMAM,Handout8.3Moni
tor
ingandRepor
ti
ng
onCMAM andHandout8.
4Fil
i
ngSystem forOutpat
ientCar
eTreat
mentCards.

ELI
CITATI
ON:I
NFORMATI
ONANDTOOLSFORI
NDI
VIDUALMONI
TORI
NG.Askpar
ti
cipant
s
whatt
ool
stheyhaveencount
eredinthei
rtr
aini
ngt
hatcoul
dhelpt
rackinf
ant
sandchi
l
dreni
nCMAM.
Howdoeachofthesetool
shelp?Fi
ll
inthegapswit
hthetool
sdescri
bedbel
ow:
 Thei
nfant
’sorchi
l
d’suni
quer
egi
str
ati
onnumber
 Out
pat
ientcar
etr
eat
mentcar
d:Eachi
nfantorchi
l
d’smedi
cal
hist
ory
,feedi
ngi
nfor
mat
ion,
phy
sical
exami
nati
on,ant
hropometr
y,appet i
te,medi
calt
reatmentandnut
rit
ionrehabi
li
tat
ionaremonitoredon
anout
pati
entcaretr
eatmentcard.Pr ogr
essofi
ndivi
dualt
reat
mentisrecordedthroughcl
ini
calsigns,
themot
her/car
egiv
er’
sreportofil
lnessandanthropometr
y(mid-
upperarm cir
cumf er
ence[MUAC]
andwei
ght).
 Ready-
to-
uset
her
apeut
icf
ood(
RUTF)r
ati
oncar
d:Thepr
ovi
sionofRUTFpersessi
oni
scal
cul
ated
basedont
hechi
l
d’swei
ghtandi
srecor
dedonanRUTFr
ati
oncar
d,al
ongwi
tht
hesessi
onf
requency
 Ref
err
alsl
ips:Thesef
orms,
whi
chuset
hei
nfantorchi
ld’
suni
quer
egi
str
ati
onnumber
,ar
eused
t
oref
erchi
ldr
enf
rom out
pat
ientcar
etoi
npat
ientcar
eandvi
cever
sa.

Ref
erparti
cipantstoHandout8.1Monit
oringtheIndiv
idualI
nfantorChil
dinOutpat
ientCar
e.Ask
par
ti
cipant
swhatot herinf
ormati
onisnecessarytomonitort
heinfantorchi
l
dadmi t
tedtoCMAM.Ask
whoisresponsibleformoni
tor
ing.Askt
hem tof i
ndtheanswersinHandout8.1.

PARTI
CIPATORYLECTURE:REGI
STRATI
ONNUMBERS.Not
etopar
ti
cipant
sthati
ndi
vi
dual
i
nfantsandchil
drenenrol
ledinCMAM aretrackedwit
hinoutpat
ientcareandwhenr ef
err
edtoother
serv
ices.Thi
sensuresthatadmissi
on,
dischargeandtreat
mentpr ocedur
esar
efollowedand
documentedcorrect
ly,
whichall
owshealthcareprov
iderstofol
l
owcasesofchi l
drenasnecessary.
Inf
antsandchildr
enareregist
ereduponadmissi
ontoCMAM att hesi
tewheretheyfi
rstpr
esentandare
assignedauniqueregi
strat
ionnumber.Thi
snumberisnotedonthei
rtreat
mentcardorhealt
hcard(ori
n
theregist
rat
ionbookifoneisused)andisusedt
otracktheinf
antorchil
dwhil
eshe/heisenrol
ledi
n
CMAM.

GROUPDI
SCUSSI
ON:REGI
STRATI
ONNUMBERS.Dr
awt
henumber
ingsy
stem i
nHandout8.
2
Regi str
at i
onNumber i
ngSy st
em Proposedf orCMAM, Table1onaf li
pchar t.Explaint hatast andard
number ingsystem forCMAM ( Exampl e1)hast hreepar t
s:thehealt
hfacili
ty’snameorcode, theinfantor
child’sindivi
dualnumberandacoder epresentingt heservicewheretheinfantorchi ldfir
streceived
treatment .Compar ethiswiththeHMI Snumber ingsy stem forMalawi(Exampl e2).Askpar t
icipantsif
theircount ryusesanHMI Snumber i
ngsy stem oranot hernumberingsystem f orotheri nterv
ent i
ons.
Discusshowt hesemi ghtdif
ferf
rom thest andar dnumber ingsystem f
orCMAM.Di scusst hebul l
etpoi nts
onHandout8. 2andansweranyquest ions.Emphasi sethatnumber i
ngsy stemscanv arypercount r
y ,
thereforeconsul tat
ionwiththenati
onal guideli
nei sessent i
al.Al
sonotet hatwhenest abli
shingCMAM, i
ts
number ingsystem shouldbecompat iblewi thther egi
strati
onnumber i
ngsy stem alreadyi nplace.

PARTI
CIPATORYLECTURE:CLASSI
FYI
NGCHI
LDRENI
NTOENTRYANDEXI
TCATEGORI
ES.
Explai
ntopar ti
cipant
sthatchi
ldr
eninCMAM ar etrackedamongservi
cesandarenotdouble-
counted.
Referparti
cipantstoHandout8.3Monitori
ngandRepor ti
ngonCMAM, Par
tAformoreinformati
on.This
i
nformationandt heremainderofHandout8.3wil
lbecov er
edfur
theri
nLearni
ngObjecti
ve3:Compl et
e
Sit
eTallySheet sandSiteandDistr
ictReport
s;I
nterprett
heFi
ndings.
 Classify
ingEnt
ri
es:
Atentry,t
heinfantorchil
disclassif
iedasanewadmissionageunder6
mont hs,6to59months(opti
onal
:admi ssi
oncrit
eriarecorded)
,asanew“ot
her”admissi
on
(chi
ldren≥5y ,
adol
escents,
adult
s)orasanol dcase( whenr ef
err
edfr
om i
npati
entoroutpat
ient

137
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orCommuni
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eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

car
eorwhenret
urni
ngafterdefault
ing)
.Arelapsei
scl
assi
fi
edasanewadmi
ssi
on,
whi
chwi
l
lbe
i
ndicat
edont
heoutpat
ientcaretreatmentcard.
Askpar t
icipantswhatt oolstheyhav eencounteredint
heirt
rainingthatcanhelpdeterminewhi ch
categoryeachchi ldfall
sintoandhowt otrackhim/her(e.
g.,CMAM admi ssi
oncri
teri
a,CMAM
entrycategories,outpati
entcaretreatmentcards).Tel
lpart
icipantsthattheywi
ll
shortlylearn
aboutothert oolstohelpthem wi t
hcl assi
fi
cati
onandt r
acking:fil
i
ngt reat
mentcardsinbi nder
s
andcompl et i
ngsi t
et al
l
ysheet sandsi t
ereporti
ngsheets.
 Classifyi
ngExits: Onexitfrom out patientcare,eachinf
antorchi ldiscategor i
sedasdi scharged
ascur ed,died,default
edornon- r
ecov er ed;
thisisalsoindicatedont heout pati
entcaretreatment
cardandt alli
ed.Theexi t
sar ealsocat egori
sedbyage( <6mont hs,6-59mont hsandot hers
[chil
dren≥5y ,adolescents,adults]).Askpar ti
cipant
sagai nwhatt oolstheyhav eencounter
edin
theirt
raini
ngt hatcanhel pdet ermi newhi chcategoryeachi nfantorchildfall
si ntoandhowt o
trackhim/ her(e.g.,
CMAM di schargecr i
ter
ia,CMAM exi tcategori
es, outpati
entcaretreatment
cards,binders,sitetal
lysheet s)
.Ref erralstoinpati
entcareorout patientcarear easeparateexit
category.
Not e:Infantsandchi l
dr enwhoar ereferredbet weenout pat i
entcar eandi npatientcareareconsidered
dischar gedfrom thesitebutNOTf r
om t heser vice/programme.Theyar er egister
edatt henewsi t
e
usingt heiruniqueregist r
ationnumberandmayr et
urntot heiroriginalsit
e; t
heirstatusis“ref
err
ed.”
Childrenwhoar enotr ecov eri
ngarerefer r
edf orf ur
thermedi cali
nv esti
gationassoonast he
conditioni sdiagnosedandexi tfr
om CMAM asnon- r
ecov eredonl yiftheydonotr eachthedischarge
crit
eriaaf t
erfourmont hsoft reat
ment.Chi ldrenr ef
erredt oout patientcarefrom suppl ementary
feedingbecauset heircondi ti
onhasdet erioratedar econsi derednewadmi ssions.

REVI
EW:OUTPATI
ENTCARETREATMENTCARDS.Di
str
ibut
ecopi
esofout
pat
ientcar
etr
eat
ment
cardst oparti
cipants.Rev iewwher eanthropomet ry,medical hi
stor
y ,
feedi
nginformat ion,physi
cal
exami nat
ion,appetitetest, medicalt
reatmentandnut ri
ti
onr ehabil
i
tationi
nformationf oreachchildare
entered.Rev i
ewt hebackoft hecardwher ei nfor
mat i
ononr efer
ral
sanddi scharges( i
nfantsandchildr
en
whower ecured,died,def ault
edordi dnotr ecover)shouldbeent ered.Remindpar t
icipantsthatheal
th
carepr ov
idersandsuper visorsshouldreviewt heoutpatientcaretreatmentcardsr egular
lytoensurethat
currentprotocolsarefollowed.

PARTI
CIPATORYLECTURE:FI
LINGOUTPATI
ENTCARETREATMENTCARDS.Expl
aint
o
parti
cipant stheimportanceofhav i
ngacl earandaccessiblefil
i
ngsy stem foroutpati
entcaretreatment
cardst hatmakest r
ackingact i
veandexitedcasessimpleandal lowsf orquickrefer
ence.Outpati
entcar
e
tr
eatmentcar dsshouldbeor gani
sedinbindersorfi
lesthatremai ninthehealthfacil
it
yandshoul dbe
accessi bleatallti
mes.Act i
veandexi t
edcasesshoul dbesepar atedintotwobi nder
sorset soffil
eswit
h
div
iders.Theact i
vecasesbi nderorfil
esincl
udecardsforallinfantsandchi l
drencurrent
lyenroll
edin
CMAM ser vi
cesatthatsite.Cardsintheexit
edcasesbi nderorf i
lesareorganisedaccordingtoexit
categor y.Staffshoul
dreviewt hebindersorfi
lesweekly.

PRACTI
CE:FI
LINGOUTPATI
ENTCARETREATMENTCARDS.Dr
awat
abl
ewi
tht
wocol
umnson
thefli
pchart
.Markt hefi
rstcolumnheadingas“Act
iveCases”andthesecondcolumnas“
Exi
ts.
”In
plenary
,askpar
ti
cipantswhi chcolumneachofthefoll
owingcl
assif
icat
ionsbel
ongsi
n:
 I nfant
sandchildrencurrentl
yinout
pati
entcar
e( Act
iveCases)
 Cur
ed(
Exi
ts)
 Di
ed(
Exi
ts)
 Non-
recov
ered–t
hosewhohav
enotr
eacheddi
schar
gecr
it
eri
aaf
terf
ourmont
hsoft
reat
ment(
aft
er
medi
cal
inv
est
igat
ion)(
Exi
ts)
 Absent
ees–t
hosewhohav
emi
ssedoneort
woout
pat
ientcar
efol
l
ow-
onv
isi
ts(
Act
iveCases)
 Def
aul
ted–t
hosewhohav
emi
ssedt
hreeout
pat
ientcar
efol
l
ow-
onv
isi
ts(
Exi
ted)

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,2018Ver
sion

 Ref
err
alsawai
ti
ngr
etur
n–t
hosewhohav
ebeenr
efer
redf
rom out
pat
ientcar
etoi
npat
ientcar
e
(Exi
tedtemporaril
ythesite,
nottheser
vice/pr
ogramme)orformedical
inv
esti
gati
on(Act
iveCases)
(Notetoparti
cipantsthatwhenthei
nfant/chi
l
dretur
nsaf
terdefaul
ti
ngorref
err
al,
thesame
outpat
ientcaretreatmentcardi
sused.)
Di
stri
but
ecopiesofHandout4.
1Admi
ssi
onCrit
eri
aandEnt
ryCat
egor
iesforAt
-Ri
skMother
sandInf
ant
s
Under6MonthsandChil
dren6-
59Mont
hs,Handout4.
20Di
schar
geCri
ter
iaandExi
tCat
egori
esf
orCMAM
andref
erpart
ici
pantstoHandout8.
4Fil
ingOutpat
ientCar
eTr
eat
mentCar
dsf
orr
efer
ence.Di
scusst
he
act
ivecasesorexi
tscategor
iesi
fquest
ionsar
ise.

139
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aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module8Learni
ngObject
ive3:Complet
eSi
teTal
lySheet
sandSi
teand
Di
str
ictRepor
ts;
Int
erpr
ettheFi
ndings

TRAI
NER:
Rev
iewHandout8.
3Moni
tor
ingandRepor
ti
ngonCMAM andbecomef
ami
l
iarwi
thHandout
8.5SiteTal l
ySheetf
ortheManagementofSAM andNut rit
ional
lyVulner
ableI
nfantsUnder6Mont hs,
Handout8. 6Sit
eRepor
tSheetf ortheManagementofSAM andNut ri
ti
onal
lyVulner
abl
eInfant
sUnder6
Mont hs,Handout8.7Dist
rictorNational Repor
ti
ngSheetfortheManagementofSAM andNut r
it
ional
ly
VulnerableInfant
sUnder6Mont hs, Exercise8.
1Outpati
entCareSiteTall
ySheetandSiteReport
ingSheet
andExer cise8.2Complet
ingOut patientCareSit
eTall
ySheet.

PARTI
CIPATORYLECTURE:ROUTI
NEDATACOLLECTI
ON.Rout
ineser
vicedat
aar
erecor
dedon
sit
etallysheetsateachsi t
e,basedonquant i
tat
ivedat ar ecordedaf tereachsession.Thesi
tetal
lysheets
arecompi l
edinsiteanddi str
ictreporti
ngsheets.Di str
ictr eportscombi netheinformati
onfr
om the
dif
ferentheal
thfacili
ti
esinthedistrictt
hatprovi
dedCMAM ser vices.Distr
ictr
eportsinf
ormthenat i
onal
reporti
ngsheetsandr epor
tsy st
em.TheCMAM r epor t
ingsy stemscanbeacompi l
ati
onofreport
ing
sheets(hardcopies)orenteredinanel ectr
onicdat abase( Excel spreadsheet)
.Emphasisetoparti
cipant
s
theimportanceofinpat i
entandout pati
entcaresitesusi ngst andardizedreport
ingsheetssothatthe
servi
ce’soveral
leffecti
venesscanbepr eci
sel
ymoni tor
ed.

Note: Attheendofeveryout
patientcar
esessi onoutpati
entcaretreatmentcar dsfornew
admissionsandnewexi tsar
eusedt ofil
l t
hesitetal
lysheetforthatsession.Newadmi ssi
ons
aretalli
edbasedontheirent
rycategory(peradmissioncrit
erionandagegr ouporperagegr oup
only
).Newexi tsaretal
l
iedbasedont heirexi
tcategory(cured,di
ed,defaulted,non-r
ecover
ed).
Dependi ngonthesit
etall
ysheetused,referr
alsfr
om inpati
entcaret ooutpatientcarecoul
dbe
tal
li
edasanadmi ssi
on(underrefer
ralf
rom inpati
entcare)orseparatelyfrom newadmi ssi
onsas
“mov edin.”

GROUPDI
SCUSSI
ON:QUANTI
TATI
VEDATAFROM SI
TETALLYSHEETS.Askpar
ti
cipant
sif
theyhaveev erusedt all
ysheetsint hei
rwor kand,i
fso,whatt heywereusi
ngthetall
ysheetstot r
ack.
Referparti
cipant stoHandout8. 5SiteTallySheetfort
heManagementofSAM andNut r
it
ionall
y
VulnerableInfantsUnder6Mont hsandaskt hem t
oexami nehowt heoutpat
ientcaresit
etall
ysheet
considersthequant it
ati
vedat atheyrecord.Whiler
efer
encingt hesheet
,askpart
ici
pantswher ethe
foll
owingcat egoriesofchi
ldrenwoul dbelong:
 Chi l
drenunder5whoar ereferr
edf r
om supplementar
yf eedingandsentt
oout pati
entcarebecause
t
heirconditionhasdeteriorated
(
Answer :classifi
edas“newcase’ admission6-
59mont hs)
 Def
aul
ter
swhoexi
tedf
rom t
heser
vicebutr
etur
nedt
oout
pat
ientcar
eandhadnoty
etmett
he
dischar
gecrit
eri
a
(Answer:cl
assif
iedas‘
oldcase’
admi
ssi
on:
from out
pat
ient
/inpat
ientcar
eorr
etur
neddef
aul
ter
s)
 Chi
l
drenwhor
etur
ntoout
pat
ientcar
efr
om i
npat
ientcar
eorv
icev
ersa
(
Answer
:cl
assi
fi
edas‘
oldcase’
admi
ssi
on;
from out
pat
ient
/inpat
ientcar
eorr
etur
neddef
aul
ter
s)
 Chi
l
drenwhoar
emov
edf
rom oneout
pat
ientcar
esi
tet
oanot
hert
ocont
inuet
hei
rtr
eat
ment(
Answer
:
cl
assi
fi
edas‘Oldcase’admissi
onfrom outpat
ient/i
npati
entcar
eorret
urneddef
ault
ersont
he
out
pati
entcar
esitetal
l
ysheetofnewsi te,
andcl assi
fi
edasexitas‘
ref
erral
toout
pati
ent
car
e/i
npati
entcar
e’onthetall
ysheetoftheoldsi t
e)

 Al
lchi
l
drenwhoar
eadmi
tt
edt
oinpat
ientcar
eaf
terspendi
ngsomet
imei
nout
pat
ientcar
e
(
Answer:cl
assi
fi
edas“
oldcase”admi
ssi
on,
“toout
pat
ient
/inpat
ientcar
e”ont
hei
npat
ientcar
esi
te
t
all
ysheet)

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 Chi
l
drenwi
thSAM andmedi
cal
compl
i
cat
ionswhopr
esentdi
rect
lyati
npat
ientcar
e
(
Answer
:cl
assi
fi
edas“
newadmi
ssi
on6-
59mont
hs”ont
hei
npat
ientcar
esi
tet
all
ysheet
)
 Chi
l
drenwi
thSAM andmedi
cal
compl
i
cat
ionswhof
ir
stpr
esentatt
heout
pat
ientcar
esi
te,
are
admi t
tedandcl assi
fiedaft
erregi
strat
ionandst artoftr
eatmentandt henref
erredtoinpatientcare
(Answer :classif
iedas‘oldcase’admissionfrom outpati
ent
/inpati
entcareorretur
neddef ault
ers”on
theinpatientcar esit
etall
ysheetsincetheywereadmi t
tedandexitedattheoutpati
entcar esit
e,thus
classi
fiedtwi ce,onceas‘Newcase’ admi ssi
onandonceas‘ Ref er
ral
’exi
tontheout pati
entcar esit
e
tall
ysheet )
, whichavoidsdouble-
counting)
Askparti
cipantsi
ftheycanthi
nkofaddi ti
onalquant
it
ati
vedatat
hatthatmightbehel
pful
tocaptur
eon
thesesheets.Askwheretheycouldfindt heinf
ormati
on(e.
g.,
outpat
ientcar
etreat
mentcards)
.Answer
s
couldi
nclude:
Genderofnewadmi ssi
onsanddischar ges
 Admi ssi
oncrit
eriaofnewadmi ssions
 Feedi
ngst
atusandpr
ogr
ess
 Aver
agedai
l
ywei
ghtgai
nofcur
edexi
ts
 Aver
agel
engt
hofst
ayofcur
edexi
ts
 Readmi
ssi
onaf
terdi
schar
georr
elapse

PRACTI
CE:COMPLETI
NGSI
TETALLYSHEET.Ref
erpar
ti
cipant
stoExer
cise8.
1(a)Out
pat
ient
CareSiteTall
ySheet .Askthem t
of i
ll
inthetot
al numberofadmissionsandexit
sperweek,aswellasthe
numberr egi
ster
edint heservi
ce/pr
ogrammeatt heendofeachweekandbegi nni
ngofeachsubsequent
week.Ast heywork,checktheirr
esponsesagainsttheanswerkey.Attheendcheckanswersbyasking
par
tici
pantstocalloutsomeoft hetotal
s.Answeranyquestions.

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on(
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,2018Ver
sion

Exer
cise8.
1(a)Out
pat
ientCar
eSi
teTal
lySheet(
wit
hanswer
s)

SI
TE Kawal
e

Wk6 wk7 wk8 wk9 TOTAL

11/
02/1 18/
02/1 25/
02/1
Dat
e
4/
02/
18 8 8 8  
(
A)Tot
alst
artofweek 50 56 62 57  
NewCases<6m ( B1) 2 1 3 0 6
NewCases6- 59m bil
ateralpi
tt
ingoedema( B2a) 5 3 2 3 13
NewCases6- 59m MUAC/ WFH( B2b) 7 15 1 6 29
OtherNewCases( chi
ldr
en≥5y ,adol
escents,
0 0 0 1 1
adult
s)(B3)
Oldcases:Refer
redfr
om inpati
entcare;ot
her
2 1 0 1 4
outpat
ientcar
e;orRetur
neddef aul
ter
s(C)
(
D)TOTALADMI
SSI
ONS(
D=B+C) 16 20 6 11 53
Cured<6mont hs(E1a) 1 2 2 2 7
Cured6-59months( E1b) 3 4 6 5 18
CuredOther(
chil
dren≥5y ,adol
escent
s,adul
ts) 7
1 2 2 2
(E1c)
Di
ed<6mont hs(E2a) 0 1 0 0 1
Di
ed6-59months( E2b) 1 0 0 0 1
Di
edOther(
chil
dren≥5y ,adol
escent
s,adul
ts)(
E2c) 0 0 0 0 0
Def
aul
ted<6mont
hs(
E3a) 1 1 0 1 3
Def
aul
ted6-59mont
hs(
E3b) 1 0 0 0 1
Defaul
tedOt
her(
chi
l
dren≥5y
,adol
escent
s,adul
ts) 0
0 0 0 0
(E3c)
Non-r
ecov ered<6mont hs(E4a) 1 0 0 0 1
Non-r
ecov ered6-59mont hs(E4b) 0 1 0 1 2
Non-
recov eredOther(
chi
ldren≥5y ,adolescent
s, 0
0 0 0 0
adul
ts)(E3c)
Refer
ralstoinpati
entoroutpati
entcare(F) 1 3 1 2 7
(
E)TOTALDI
SCHARGES 9 11 10 11 41
(
G)TOTALEXI
TS(
G=E+F) 10 14 11 13 48
(
H)Tot
alendofweek(
H=A+D-
G) 56 62 57 55  

PARTI
CIPATORYLECTURE:MONTHLYSI
TEREPORTSPERHEALTHFACI
LITY.Expl
aint
o
parti
cipant
sthatthesi
terepor
ti
ngsheeti
scompl etedmont hlyusi
ngthesitetal
l
ysheets.Itpr
ovi
des
performanceindi
cator
sforthepr
oport
ionofchi
ldrendischargedascured,died,
def
ault
edornon-
recovered,
inaddi
tiontot
hecompilednumbersoft ot
aladmi ssi
ons,t
otalexi
tsandtot
al numberunder
treatment.

Note:
Explaintoparti
cipant
sthatt
hemont hl
yrepor
ti
ngsystem isbasedonepi
demiologi
calweeksthat
ar
eagreedonatt henati
onall
evel
.Ever
ymont hhasapre-defi
nednumberofweeks(e.g.
,Januar
yhas
weeks1-5,Februaryhasweeks6-9,Marchhasweeks10-13).Thisi
simport
antbecausethenumberof

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,2018Ver
sion

weeksv
arypermont
horcanbei
nter
pret
eddi
ff
erent
ly,
whi
chcancr
eat
erepor
ti
nger
ror
s.
Referpar
ti
cipant
stoHandout8.
3Monit
ori
ngandRepor ti
ngonCMAM andaskt hem t
oreadt
he
i
nformati
oninprepar
ati
onfort
hefol
l
owingexer
cise.Br
ief
lyansweranyquest
ions.

PRACTI
CE:COMPLETI
NGSI
TEREPORTI
NGSHEET.Expl
aint
opar
ti
cipant
sthatt
heywi
l
lnowent
er
theinf
ormationfr
om thesi
tetall
ysheetont
ot hesit
erepor
ti
ngsheetExer
cise8.1(b)Outpat
ientCare
Sit
eRepor t
ingSheet.Askt
hem tof or
m pai
rs.Answeranyquest
ions.Whi
l
et heyar
ewor ki
ng,ci
rcul
ate
amongt hem andcheckontheirprogr
essusingtheanswer
sbelow.

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,2018Ver
sion

Exer
cise8.
1(b)Out
pat
ientCar
eSi
teRepor
ti
ngSheet(
wit
hanswer
s)

MONTHLYREPORTFORMANAGEMENTOFSAM -SI
TE

 
SI
TE  
Kawal
e I
MPLEMENTEDBY
 
 
 
REGI
ON   MONTH/YEAR Febr
uar
y 2018  
 
TYPEOFMANAGEMENT
        I
npat
ient Out
pat
ient
(
CIRCLE)
  ESTIMATED
 
DI
STRI
CT   MAXI MUM
 
  CAPACI TY
ESTIMATEDTARGETmalnouri
shed<5' s
 
(
basedonl
atestsur
veydat
aandadmissi
oncrit
eria)
kg
packet
s/sachet
s equi
val
ent
RUTFConsumpt
ion
   

Tot
al NewCases Ol
dCases TOTALADMI
SSI
ONS Di
schar
ges REFERRAL TOTAL TOTALEND
begi
nni
ngof (
B) (C) (
D) (
E) (F) EXI
TS(G) OFTHE
t
hemonth(A) t
oinpati
ent MONTH(H)
AgeCat
egor
y NON-
B+C=D CURED DIED DEFAULTE or (
E+F=G)
RECOVERED
(E1) (E2) D(E3) outpati
ent (
A+D-
G=H)
(E4)
care
<6Mont hs 6
(accordi
ngt o 7 1 3 1
admi ssi
oncriteri
a)
6-59Mont hs 42
(accordi
ngt o 18 1 1 2
admi ssi
oncriteri
a)
Other 1
(chi
ldren≥5y ,
7 0 0 0
adolescents,adult
s
)
TOTAL 50 49 4 53 32 2 4 3 7 48 55
78.
0% 4.
9% 9.
8% 7.
3%
TARGET
>75% <10% <15%
(
Spher
eSt
andards)
E1:Cur
ed=r eacheddi
schargecri
teri
a
E2:Def
ault
ed=absentf or3consecuti
vesessi
ons
E3:Non-
recovered=doesnotreadthedischar
gecri
ter
iaaf
ter4mont
hsi
ntr
eat
ment(
aft
ermedi
cali
nvest
igat
ions)

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,2018Ver
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PRACTI
CE:COMPLETI
NGSI TETALLYSHEETSTARTI NGFROM OUTPATI ENTCARE
TREATMENTCARDS.Expl
aintopar
ti
ci
pant
sthatt
heyar
egoi
ngtopr
act
icecompil
i
ngi
nfor
mat
ionf
or
si
tetallysheetsfr
om outpat
ientcaretr
eatmentcards,andforasit
ereportf
rom thesi
tetal
l
ysheet.Ref
er
part
icipantstoExerci
se8.2Compl eti
ngSiteTall
ySheet.Askthem tofor
m pair
sandreadthe
i
nstructions.Answeranyquesti
onsand, whi
letheyarecompleti
ngthesit
etall
ysheetandsit
ereport
,
ci
rculateamongt hegroupstocheckont heirpr
ogress.

Checkanswersagainstt
heanswerkeybelow,andansweranyquest
ions.Emphasi
zetopart
ici
pant
sthat
theserepor
tscantakemanyfor
msandt hatiti
sessenti
altodet
ermi
neandcoor di
nat
ewithrepor
ti
ng
systemsusedinthecountr
yanddist
ri
cttheyareworki
ngin.

Exer
cise8.
2Compl
eti
ngOut
pat
ientCar
eSi
teTal
lySheet(
answerkey
)
Week1
Ensurethatthe“tot
alst
artofweek”sect
ioni
s0f orWeek1.Theparti
cipant
sshouldaddthethr
eecases
tothetotaladmissi
onsinYir
baHealthFaci
li
ty.I
ntheadmi
ssionsecti
on,outpat
ientcar
ecase1shoul
dbe
addedtot he“Newcases<6Mont hsSAM”and2shouldbeaddedt othe“New6- 59monthsMUAC/WFH”
box.
Thet
all
ysheetf
orWeek1shoul
dread:
One<6mont
hsadmi
ssi
on,
twoMUACadmi
ssi
ons,
thr
eet
otal
admi
ssi
ons.Ther
ear
enoexit
sforWeek1.
Week2
I
nWeek2, the“totali
nout pat
ientcareatt hestar toftheweek”boxi supdatedwi t
hthei
nfor
mat i
onfrom
Week1( threecases) .I
ntheadmi ssionssect i
on, outpatientcarecase4shoul dbeaddedtothebilat
eral
pit
ti
ngoedemaboxandt othe“ r
eferredtoinpatientcar e”sectionunderexi t
sbecausethechil
dhas
bil
ater
al pit
tingoedema+++andr equir
esinpatientcar e.Thechi l
dhasbeenent eredandexi
tedfr
om the
Yir
baHeal t
hFaci l
i
t yandisnowbei ngtreatedininpat i
entcar e.Out pat
ientcarecase5shoul
dbeaddedt o
the“weight-for-
height/weight
-for-
length[WFH/ WHL] ”newadmi ssi
onbox .
Thet
all
yf orWeek2shouldread: t
hreeinoutpati
entcar
eatstar
tofweek,onebi
later
alpi
tti
ngoedema
admi
ssion,oneWFH/WFLadmi ssion,oneexitasref
err
alt
oinpat
ientcar
e,t
wototaladmissi
ons,
oneexi
t
asaref
erralandf
ourtot
alinout pati
entcar
eatendofweek.
Week3
IntheWeek3t all
ysheet,
thetotali
noutpati
entcareatt
hest ar
toftheweekshoul
dbef our
.Inthe
admissionsection,out
pati
entcarecase6shoul dbeaddedtot hebi
lat
eral
pit
ti
ngoedemabox .Thi
scase
doesnotr equi
reinpati
entcarebecausethechil
dhasbilat
eralpit
ti
ngoedema++,whichcanbet r
eat
edin
outpat
ientcare.ThereisalsooneMUACadmi ssion.
Thetal
lyf
orWeek3shoul dread:
Fourtotal
inoutpati
entcareatst
artofweek,onebil
ateralpi
tti
ng
oedemaadmission,oneMUACadmi ssi
on,t
wotot
aladmissi
ons,nodischar
ges,
not ot
aldischarges,
six
tot
ali
noutpat
ientcareatendofweek.
Week4
IntheWeek4t al
l
ysheet
,thetot
ali
noutpat
ientcar
eatthestar
toft heweekshoul dbesix.Thebi
l
ater
al
pit
tingoedema+++casethatwasref
err
edtoinpat
ientcar
ereturnstooutpat
ientcaret
hisweekand
shouldbeaddedtot
headmi ssi
onasanoldcase“fr
om outpat
ient/i
npat
ientcare”box.
Thetal
lyf
orWeek4shouldread:
Fournewadmi
ssi
ons:
thr
eeMUACcasesandoneWFH/
WFLcase.The
tot
ali
noutpat
ientcar
eshoul
dbe11.

Exer
cise8.
2Yi
rbaOut
pat
ientCar
eSi
teTal
lySheet(
wit
hanswer
s)

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,2018Ver
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Heal
thf
aci
li
tyname Yi
rbaHeal
thCent
re
Di
str
ict Boricha
Inpati
ent Outpat
ient
Si
te care car
e    

wk1 wk2 wk3 wk4 TOTAL

Dat
e  
Tot
alst
artofweek(
A) 0 3 4 6 0
NewCases<6m (
B1) 1 0 0
NewCases6-
59m Bi
l
ater
alPi
tt
ingoedema(
B2a) 1 1
NewCases6-
59m MUAC(
B2b) 2 1 3
NewCases6-
59m WFH/
WFL(
B2c) 1 1
Ot
herNewCases(
chi
l
dren≥5y
,adol
escent
s,adul
ts)(
B3)
Ol
dCases:
Ref
err
edf
rom i
npat
ientcar
e,orRet
urneddef
aul
ter
s 1 1
(
C)
TOTALADMI
SSI
ONS(
D=B+C) 3 2 2 5 12
Cur
ed<6months(E1a)
Cur
ed6-59mont
hs( E1b)
Cur
edOt
her(
chi
l
dren≥5y
,adol
escent
s,adul
ts)(
E1c)

Di
ed<6months(E2a)
Di
ed6-59mont
hs( E2b)
Di
edOt
her(
chi
l
dren≥5y
,adol
escent
s,adul
ts)(
E2c)

Def
aul
ted<6mont
hs(
E3a)
Def
aul
ted6-59mont
hs(
E3b)
Def
aul
tedOt
her(
chi
l
dren≥5y
,adol
escent
s,adul
ts)(
E3c)
Non-
recov
ered<6mont
hs(
E4a)
Non-
recov
ered6-59mont
hs(
E4b)
Non-
recov
eredOt
her(
chi
l
dren≥5y
,adol
escent
s,adul
ts)
(
E3c)
Ref
err
edt
oinpat
ientcar
e(F) 1 1
TOTALDI
SCHARGES(
E) 0 0 0 0 0
TOTALEXI
TS(
G=E+F) 0 1 0 0 1
Tot
alendofweek(
H=A+D-
G) 3 4 6 11 11

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,2018Ver
sion

Module8Learni
ngObj
ecti
ve4:Cal
cul
ateandDiscuss
Ser
vice/
Progr
ammePerfor
manceandCoverage

TRAI
NER:Ref
erbackt
oHandout1.
2Ter
minol
ogyf
orCMAM andt
oExer
cise8.
1(b)Out
pat
ientCar
e
Si
teRepor
ti
ngSheet
.Becomef
ami
l
iarwi
thHandout8.
8CMAM I
ndi
cat
orsandHandout8.
9Pr
inci
plesof
Cover
age.

PAI
RWORKANDGROUPDI
SCUSSI
ON:MONI
TORI
NGSERVI
CEPERFORMANCEOFCMAM.
Expl
aint
opart
ici
pantsthatsi
tet
all
ysheetsandsi t
erepor t
swi t
hsummar i
sedper
for
mancei
ndicat
orsper
si
tearei
mport
anttoolstomonit
ortrendsi
nt hatpart
icularsi
te.Theypr
ovi
dealookatadmi
ssi
onsand
perf
ormancet
oseeifparti
cul
arareasneedinvesti
gationorsupport.

Divi
depar t
icipantsint
opairsandaskt hem t or ef
erbackt oExercise8.1( b)Out pati
entCareSite
Report
ingSheet .Havethepairscalculat
et heper centagesthateachexi tcategor y(Di
scharges[ E]
)
comprisesoft hetotalexi
ts(TotalExits[G]).Explainthatanal
ysisofthesi terepor t
sprovidesinformati
on
abouttheper formanceoftheCMAM ser vi
cef ortheindivi
dualhealt
hfaci li
tyandt hedist
rictasawhol e.
Theadmi ssionandsummar isedper f
ormancei ndicat
orscanpoi ntt
oar east hatneedi nvesti
gationand
support.Forexampl e,t
heymi ghtfi
ndt hattheser vicehasv er
yhighdef aultrates.Onceknown, wayscan
befoundt oaddr esstheproblemsandst r
engt hent heservi
ce.

Askt
hepai
rst
odr
awanyconcl
usi
onst
heycanf
rom t
hedat
a.Di
scussi
npl
enar
y.

NotetoparticipantsthatSpher
eminimum standar
dsmightnotapplyto(orbereali
sti
cfor)CMAM
ser
vicesoper atedbyt heMOHaspar tofrout
ineheal
thser
vices.However,
intheabsenceofot her
comparisons, Spheremi ni
mum st
andardscanbeusedasbenchmar kstodetermineperformanceand
ser
vicequality.

BRAI
NSTORM:I
NDI
CATORSFOROUTPATI
ENTCARE.Askpar
ti
cipant
s,st
il
lwor
kingi
npai
rs,
to
takef
iveminut
estoli
stperf
ormanceandoutputindi
catorsforoutpat
ientcar
e.Remindpar
ti
cipantsoft
he
worktheydi
dindevel
opingl
ogicalf
rameworksinModul eSeven.Askonepairtosharesomeindicat
ors
andaskothergr
oupstoshareonlyaddi
ti
onali
nformati
on.Wr i
teresponsesonthefl
ipchar
t.

READI
NGANDREVI
EW:CMAM I
NDI
CATORS.Ref
erpar
ti
cipant
stoHandout8.
8CMAM I
ndi
cat
ors
andaskthem toreadqui
etl
y.Whentheyhavef
ini
shed,
askt
hem i
ftheyhav
eanymodi
fi
cat
ionsf
ort
he
i
ndicat
orsident
if
iedint
heexerci
seabove.

GROUPDI
SCUSSI
ON:PROGRAMMEEFFECTI
VENESS.Askpar
ti
cipant
showt
heCMAM
ser
vice/
programmeisef f
ect
ive.Fol
l
owupbyaski ngparti
cipantswhethert
heCMAM servi
ce/progr
amme
canbeconsideredef
fecti
veifonl
yhalft
hechil
drenwhor equir
et r
eat
mentactual
l
yaccessit
.(Servi
ce
per
formancepluscoveragedeter
minesprogr
ammeef fecti
veness).

PARTI
CIPATORYLECTURE:COVERAGE.Expl
aint
opar
ti
cipant
sthati
tisi
mpor
tantt
odet
ermi
ne
cover
agelev
elstoseewhet hertheservi
ce/ pr
ogrammei sreachi
ngchil
drenwhoneedt r
eatment.
Cover
ageisoneofthemosti mpor t
antindicator
sofhowwel l
aservi
ceismeet i
ngneeds.Aservi
cemi ght
beofver
ygoodqual i
ty,
withv eryf
ewdeat hs,lowdef
aultratesandhi
ghr ecover
yrat
es.But,
ift
heser v
ice
i
sreachi
ngonly30percentoft hechi
ldrenwhoneedt reatment,t
henitcannotbeconsi
deredsuccessful
.
Theaimistoachiev
ebot hgoodqualityandgoodcov erage.

Askpar ti
cipantstoreadHandout8. 9Princi
plesofCov er
age.Paypar ti
cul
aratt
enti
ontot
hegraphin
Fi
gur e1,not i
ngthedirectcor
relat
ionbetweencov erager at
e,recoveryrat
eandmetneed.Remind
part
icipantsthattheycanuseHandout8. 9asar eferenceintheirownwor k.
Coverageisexpr essedasaper centage.Ift
hereare100chi ldr
enwi thacutemalnut
ri
ti
onl
ivi
nginaserv
ice
areaand70oft hem areintheservice,t
hencov er
agei s70per cent.

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Askpart
ici
pantst
orefert
oHandout1.2Ter
minol
ogyf
orCMAM andr
eadt
hedef
ini
ti
onof“
cov
erage
rat
io.
”Askift
herear
eanyquest
ions.

PARTI
CIPATORYLECTURE:COVERAGESURVEYS.Expl
aint
hatcov
eragei
susual
l
ydet
ermi
nedby
conductingacov eragesur vey .Thecov eragesur v eymet hodscal l
edSemi -
Quant i
tati
veEv aluati
onof
AccessandCov erage( SQUEAC) /Simpl i
fiedLotQual it
yAssur anceSampl i
ngEv aluati
onofAccessand
Coverage( SLEAC)ar ecommonl yusedi nCMAM.SQUEACcombi nesr out i
nepr ogram moni tori
ngdata,an
arr
ayofqual it
ativei nformation, andsmal l-sampl equant i
tat
ivesur v ey
s.Thi scombi nationofdat apermits
i
denti
ficationofkeyi ssues.SLEACi sasmal l-
sampl equantitati
vemet hodf ormappi ngandest imati
ng
cover
ageov erlargear eas; i
tisal ow-resour cemet hodforclassifyingandest imat i
ngt hecov erageof
sel
ectivefeedingpr ogr ammes.Thet womet hodsar enormal lyusedt oget her.Formor einformat i
onon
SQUEAC/ SLEAC, referparticipantstot hi
st echnical ref
erenceont hemet hods:
htt
ps://www. fantapr oject
.org/ monit
or i
ng-and- evaluati
on/squeac- sleac.Al so,letparti
cipant sknowthat
newtechni quesf orassessi ngaccessandcov er
aget hatarelessr esour ce-intensiveareunder
devel
opment .
Coveragesurvey
scanpr ovi
deal otofinfor
mat i
onaboutwhychi ldr
endonotat t
endt heser
vice,why
somemi ghtbeexcludedandwhatt hepossi bl
ebarri
erstoaccessar e.However
, cov
eragesurveysar
e
costl
yandrequirespeciall
ytrainedst af
f.Theneedt ofi
ndsi mpl
emechani smst ogaugecoveragelev
els
i
nsituati
onswher ecoveragesur vey
sar enotpracti
calorfeasi
bleisrecogni
sed.Simpli
fi
edcov er
age
surv
eymet hodsarebeingdev elopedandt ested.
I
ntheabsenceofcov eragesurvey
s,someser vi
ceshaveusedsimpl
e,somewhatcr ude,methodst o
monitorcover
agebasedont arget
scalculat
edforthetot
alnumberofchi
ldrenexpect edtoenrol.Other
s
hav
eusedt henumberofchi l
drenscreened,r
efer
redoradmitt
edasproxies.Thesear enotideal
i
ndicator
s,buttheymightpr
ovidesomeusef uli
nformati
onwhenacov er
agesur veyisnotfeasible.
Askparti
cipant
stor
efert
oHandout1.
2andt
oreadt
hedef
ini
ti
onf
or“
cov
erage,
”Aski
fther
ear
eany
quest
ions.

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Module8Lear
ningObj
ect
ive5:Moni
torandRespondt
oBar
ri
erst
o
Access

TRAI
NER:Becomef
ami
l
iarwi
thHandout8.
10Moni
tor
ingBar
ri
erst
oAccessandExer
cise8.
3
Communi
tyMeet
ingRol
e-Pl
ay.

GROUPDI
SCUSSI
ON:BARRI
ERSTOACCESS.Askpar
ti
cipant
stospecul
ateonpossi
bler
easons
forpoorcover
age.Discusshowv i
ewsandpercepti
onsoftheser
vicecanplayapar
tinpoorser
vice
uptake.Di
scussbarr
ierstoaccessandremi
ndparti
cipant
softheworktheydidi
nthecommunity
assessmentinModuleThr ee.Rev
iewi
fnecessar
y.
Askpar
ti
cipant
stor
eadHandout8.
10Moni
tor
ingBar
ri
erst
oAccess;
answeranyquest
ions.

ROLE-
PLAY.I
NVOLVI
NGTHECOMMUNI
TY.I
ntr
oducet
heexer
ciset
othepar
ti
cipant
sbyr
eadi
ng
al
oudt
hef
oll
owi
ngi
ntr
oduct
ion:

Thesi t
ereportfrom t
heoutpati
entcar eatHeal thFaci li
ty22(Wambal adistr
ict)showsahi ghdefaul
t
rate(20percent)andahighdeathr at
e( 12per cent).Theheal thcarepr ovi
dersatt heoutpati
entcare
sit
ear econcernedaboutthi
s.Theyal soknowt hatt hemot hers/caregiver
sofmanyoft hechildr
enthat
theyrefer
redtoinpati
entcareatthedi st
ricthospital r
efusetogo; theheal t
hcar eprovi
derssuspectthat
thehighdefaultandmortali
tyr
atesar elinkedtot his.Thenur seaskst hecommuni t
yhealthworker
(CHW)t oorganiseacommuni tydiscussiont ogett ot hebottom oft heseissuesandt r
yt ofi
ndway sto
addressthem.

Askforninev ol
unteer
sandassi gnt heseroles:anoutpati
entcarenurse,aCHW andacommuni ty
vol
unteerinvolv
edincommuni tyoutreachforCMAM, twomot hers,afat
her, agr
andmot herofchi
ldr
en
undertr
eatmenti nCMAM, acommuni tyel
derandat radit
ionalheal
er.Exercise8.3Communi tyMeeting
Role-
Play(below)descri
best heroles.Giveeachv ol
unteeracar ddescri
bingher/hisr
ole(prepar
edin
advance)andaskt hem t
ost artthe“communi t
ymeeting.”Tell
them thatrolescanbeadapt edandthey
shouldfeelf
reet oi
mprovise.
Aft
er20minutes,askpart
icipant
showt heywoul
dusewhattheyl
earnedf
rom t
hecommunitymeeti
ngto
makechangest otheser
vices.Refert
oExerci
se8.3AnswerKeyatt
heendofthisl
ear
ningobj
ect
iveto
gui
dethediscussi
on.

Exer
cise8.
3Communi
tyMeet
ingRol
e-Pl
ay
Outpat
ientCareNur se:Youareanurseatthehealt
hfaci
li
tyinchargeofoutpat
ientcar
eandaskthe
CHWst oexplor
et heissuesthatl
eadtohighdefaul
tanddeathrates.Youalsot
akeanactiver
olei
n
rev
iewi
ngoutpatientcaretreat
mentcardsandmoni t
ori
ngreport
st oident
if
ypossibl
ecausesf
orpoor
perf
ormance.

CHW:Younot ethatthepeopl
einy ourcommuni tyrefusetogotothehospit
alf
ori
npatientcar
ef or
sever
alr
easons:Theydonotlikethehospi tal
;theyar eafr
aidt
heywill
havetopayfortheservi
ces;they
havenotranspor
tati
onorcannotcov erthecost s;ortheydonotwanttoleavet
hei
rotherchil
dren.Refusal
togotothehospital
iswhyseveralchildrenhavedi ed.

Communi t
yVolunt
eer:Youareav eryacti
vevolunteer.Therearemanydef ault
ersinyourareabecausei t
i
sinapartofthedi
stri
ctthati
sfarthestfr
om theout pati
entcaresit
e.Yout hi
nkthateit
heranout pat
ient
car
esitecl
osertoyourcommunityisneededort hatpeopl efr
om yourareashouldbeabl etocomet ot he
exi
sti
ngsit
eeveryt
woweeksi nsteadofev er
yweek.Becauset hereisnootherhealthfaci
li
tyi
ny ourarea,
youwonderifanur
secanuset heheal t
hfaci
li
tymot orbikeandbringtheRUTFdi rect
lytoyourarea.There

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al
soar esomei ssueswi threfer
ral
susingbil
ateralpi
tti
ngoedemaandt heMUACt ape.Somet i
mesyou
sendachildbecauseshe/ hehasbilat
eral
pitt
ingoedemaort heMUACr eadingi
sred,butthenurse
makesadi ff
erentdeci si
onandsendst hechil
dhome.Yout hinkt
hatvol
unteersneedmor etrai
ningt
o
preventt
hesedi screpanciesandfeelt
hatifav ol
unteerref
ersamother/caregi
verandchil
dtoCMAM
serv
ices,t
hechi ldshouldbeadmi tt
ed.

Mot her1:Youl iket heCMAM ser vi

cesandknowt hatot herpeopl e’schildr
engotbetterintheservice.
Yoursonhadswel li
ngonhi sf
eetandl egs.Yout ookhimt ot heclinicandgott hepeanutpast eand
medi cine.Youshar edt hepeanutpast ewithyoursixot herchi l
drenbecausei ti
sthehungr yseasonand
thereisnotmuchf oodi nthehouse.Yoursi cksonat emai zeaswel lassomeoft hepeanutpast e,butthe
maizewasnotsogoodbecausei thadbeenst oredforal ongt i
me.Af t
erthreeweeks,yoursonbecame
veryswol l
enall
ov erhisbody ,andwheny ouwentf ortheout pati
entcar efoll
ow-onsession,thenurse
want edt osendy out othehospi t
al.Iti
sveryfaraway ,andev eryoney ouknowwhogoest heredies.The
hospi t
al cost
sal otofmoney ,andy ouhav enotranspor t
at i
on.Youwanty oursontogetbet t
erin
outpatientcare,noti nthehospital,andyoudonotunder standwhyt henur sesai
dyoursonneedst ogo
there.Lastweek, youdi dnottakey oursont otheout patientcar esitebecausey oudidn’
twantt obet ol
d
togot ot hehospital again.

Mot her2:Youwereref
er r
edtoCMAM ser vi
cesbycommuni t
yv olunteer
s.Theytookameasur ementof
yourdaughterusi
ngat apeandt henputtheirthumbsonherf eet.Theysaidthatshehadswellingonher
feetandthatyoushoul
dt akehert otheoutpatientcar
esit
e.Wheny ougotthere,
thenursemeasur edyour
daughterandlookedatherfeetagain.Thenur sesaidshewasf i
neanddi dnotneedtobei ntheser vi
ce.
Youwer eangryandtol
dev eryonenottobot herwi t
hthi
sserv
ice.Youknownear l
yeverymotheriny our
vil
lage.

Father :Your-8-month-oldt wi
nsar ei noutpatientcare.Onetwinwassi ckandt heotherwasnot ,butthey
bothr eceivedthespeci alfood.Thesi ckonet ookthemedi ci
negivent oheri noutpati
entcareand
recover edwell.Youli
v efarf r
om theout pati
entcaresite,andyourwi fehast ocarrybot hchi
ldr
enonher
backt ogett hem tothesi te.Shehadt omisst hr
eeweeksatt heout pat i
entcaresitebecauseoft he
distance.Acommuni tyv olunteervisitedyouandy ourwifeandtoldy ouhowi mportantitwastot akethe
chil
drenbackt otheclinic.So,yourwi fewentbackt henextweek, andt hechil
drencont i
nuedtorecover.
Youknowot herpeoplef rom yourar eawhoar eattendingtheserv
icebutdonotgoev eryweekbecausei t
i
st oof araway .Onechi ldfrom yourar eadi
edbecausehegotsuddenl yv erysickandt hefamil
ycouldnot
gethimt otheclini
cint ime.Youwonderi fiti
spossi bl
et ogotothecl iniceverytwoweeksi nsteadof
everyweek.Youar ev eryhappywi tht heser vi
cesandhav etol
dthemeni ny ourvi
ll
aget osendtheirwives
andchi l
drentotheout patientcaresi t
e.

Grandmot her :Yourdaughterdiedandyouwer el

eftwithfourofherchi
ldren,
incl
udingtheyoungest—a
four
-mont h- oldbaby .Thebabygotv er
ysickandthin.Youtri
edfeedi
ngt hebabycow’ smil
kmi xedwit
h
water,butt hebabygotwor se.Youtookthebabyt othehealt
hfacil
it
yandt henursetoldyouthatthebaby
wasdehy drat edandv erymalnouri
shed(thi
n)andneededat t
enti
onatthehospital.Youcannotgettothe
hospit
al orst ayt her
ebecauseoft heotherchi
ldr
enathomeandbecausey ouareoldandcannotwal kfar
.
Twoday sl at er,t
hebabydi ed.

Communi tyEl
der:YouliketheCMAM ser vices.Your emembert hebadt i
met hreey earsagowhenpeopl e
cameandsetupt ents,andalltheswol lenandt hinchi l
drenwer esupposedt ogot here.Manyoft hem did
notgo, andmanyoft hem died.Nowmot her s/caregi
v erscant aketheirchil
drentot heout pati
entcaresit
e
atthenear byheal
thfacil
it
yandgett het r
eat ment ;everythingisgood.Youhav eli
stenedt owhatt he
othershavesaidaboutt heproblemswi thget ti
ngt othehospi tal.Yousuggestt hatthev il
l
ageheal t
h
commi tteesetupaf undtohel pprovidet r
anspor t
ati
ont othehospi t
alformot hers/caregiver
sand
chil
drenwhoneedi t.
Tradit
ionalHealer:Atfi
rst,
youwer ev eryr esistanttot heideaoft heCMAM ser vi
cesandwonder edwhat
thi
sst r
angepeanutpast ewas.Usual l
ymot hersandf atherswoul dbri
ngt hei
rchildrentoy oufir
standgo
totheheal t
hfacil
i
tyasal astresort.Youhav ey ourownt radit
ionaltr
eatmentf orthinandswol lenchil
dren.
Howev er,youhaveseent hechildr
enget t
ingbet t
erwhent heygot otheheal t
hf acil
ity
.TheCHW hast aken

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ti
met oexpl aintoyouhowCMAM ser v
iceswor k,
andthecommuni tyvolunteershaveshowny oualotof
respect.Theyaskedf oryourhel pinsendingthinorswoll
enchil
drentoCMAM ser v i
ces.Youagr eewith
thecommuni tyelder
.Yout hinkthevill
agehealthcommi t
tee(i
nwhi chyouhav eakeyr ol
e)shouldmeett o
discusssettingupat ransportat
ionfund.Youal sothi
nkthatpeopl
ecomi ngfrom farawayareasshould
onlyhav etogot ooutpatientcaresit
esev erytwoweeksandt hatthevolunteersshouldsendt hem t
othe
healthfaci
li
tyi ft
hereisanypr oblem betweensessions.

Exer
cise8.
3AnswerKey
Possi
bleser
viceadj
ust
ment
sbasedongr
oupdi
scussi
onwi
thcommuni
tymember
s:
Communications
 Makeabet tereff
ortt
oexplai
nthatadmissioninoutpat
ientcaredoesnotalwaysinv
olveref
err
ingthe
mother/
caregiverandchi
l
dt othehospi
tal(becausethefearofoutcomesthereandofthecostis
appar
entl
yv erystr
onginthecommuni t
y).Besuretoexplai
nthatoutpat
ientcarei
sfree.
 Fur
therexpl
aint
hatt
hemot
herandheri
nfantunder6mont
hsofagewi
l
lrecei
veski
l
ledf
eedi
ng
suppor
twhil
einoutpat
ientcare.Breast
feedi
ngisextr
emelybenefi
cial
toaninfantunder6mont
hsof
agebecausebr
eastmil
kcont ainsallt
henutr
ient
s(food)andwatertheinf
antneedstogrowwel
l.
 Makesur
ethatv
olunt
eercase-
fi
nder
sar
etaki
ngcar
etoexpl
aint
hataf
tert
hechi
l
d’smedi
cal
condit
ioni
seval
uatedattheout
pati
entcar
esit
e,t
hechil
dmi
ghtneedr
efer
ral
toi
npat
ientcar
eif
her/
hiscondi
ti
onisser
ious.Mostchi
ldr
enwil
lbetr
eat
edasout
pati
ent
s.
 Rei
ter
atet
hatRUTFi
snott
obeshar
ed.Achi
l
dwhoeat
sal
ltheRUTFgai
nswei
ghtandi
slessl
i
kel
y
t
ogetsi
ckandber
efer
redt
othehospi
tal
.

Pr
ocedures
 Tor educebouncedr
efer
ral
s,al
i
gnbot
href
err
alandadmi
ssi
onar
oundt
heMUACent
rycr
it
eri
on,
ift
his
i
snotalreadyt
hecase.
 I
ntheshor
tter
m,al
l
owpeopl
efr
om di
stantv
il
lagest
oret
urnf
orout
pat
ientcar
efol
l
ow-
onsessi
ons
t
wiceamont
handgi
vet
hem t
woweeks’
wor
thofRUTF.
 I
nthei
nter
medi
atet
erm,
consi
deropeni
ngmor
esi
test
opr
ovi
deweekl
yout
pat
ientcar
efol
l
ow-
on
sessi
onswi
thi
nev
ery
one’
sreach.
 Gi
vev
olunt
eer
sref
reshert
rai
ningi
nbi
l
ater
alpi
tt
ingoedemaandMUACcheckst
oimpr
ovet
he
accuracyofr
efer
ral
s.Consideri
ntr
oducingaref
err
alsl
i
pthati
dent
if
iest
her
efer
ri
ngv
olunt
eert
o
pinpoi
ntthesour
ceofinaccurat
erefer
rals.
 I
nst
it
utepr
ocedur
esf
orcasef
oll
ow-
upt
oensur
ethatchi
l
drenwhomi
ssanout
pat
ientcar
efol
l
ow-
on
sessi
onar evi
sit
edatt
hei
rhomes(
fol
l
ow-
uphomev
isi
t)andt
hatt
hef
ami
l
iesar
eur
gedt
oret
urnt
o
theser
vice.
 Gi
vet
heout
pat
ientcar
enur
set
hedi
scr
eti
ont
okeepchi
l
drenwi
thmedi
cal
compl
i
cat
ionsi
n
out
pati
entcarei
f,af
termaki
ngt
her
iskscl
eart
othemot
her
/car
egi
ver
,she/
hest
il
lref
usesr
efer
ral
to
i
npati
entcar
e.
 Uset
hev
il
lageheal
thcommi
tt
eest
oest
abl
i
shwi
dercont
actwi
tht
radi
ti
onal
heal
erst
odi
scusst
he
CMAM servicewi
ththem,
li
stent
oanyconcer
nst
heyhav
eandencour
aget
hem t
obet
rai
nedi
n
ref
err
ingcasesofSAM.
 Encour
aget
hev
il
lageheal
thcommi
tt
eest
ofol
l
owupont
hesuggest
ionofest
abl
i
shi
ngaf
undt
o
covercost
srel
atedt
oref
err
albetweeninpat
ientcar
eandoutpati
entcare(
e.g.
,tr
anspor
tat
ion).Use
Exerci
se8.3asanexampl
eoflocalpr
oblem-solv
ingindi
scussi
onswithot
hersit
esandv i
l
lages.

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Module8Learni
ngObj
ect
ive6:Expl
aint
hePurposeofSuppor
tand
Super
visi
onVi
sit
sandt
heRoleofaSupervi
sor
/ Ment
or

TRAI
NER:
Becomef
ami
l
iarwi
thHandout8.
11Suppor
tandSuper
visi
onf
orCMAM,
Handout8.
12
SupportandSuperv
isionCheckl
i
stforOutpat
ientCar
e,Handout8.
13Suppor
tandSupervi
sionCheckl
i
st
forCommunityOutreachandExerci
se8.4Analysi
softheSit
eReport
sofThr
eeOutpat
ientCareSit
esand
OneInpati
entCareSite.

WORKI
NGGROUPS:DEFI
NINGSUPERVI
SIONANDSUPERVI
SORRESPONSI
BILI
TIES.For
m
wor
kinggr
oupsoff
ivepar
ti
ci
pant
s.Askt
hegr
oupst
o:
1. Todef
inet
het
erm“
super
visi
on”
2. Li
stt
her
esponsi
bil
i
tiesofasuper
visor(
orsuper
visor
yteam)
3. Det
ermi
newhoshoul
dber
esponsi
blef
orsuper
visi
onofCMAM i
nthei
rdi
str
ict
s
4. Descr
ibehowsuper
visor
yvi
sitsar
eusuall
yconduct
edi
nthei
rdi
str
ict
sandhowsuper
visi
on
forCMAM fi
tsi
ntot
heexist
ingsuper
visi
onsyst
em
Askonegr oupt osharetheiranswersinplenaryandot hergroupstoshar
eonlyaddit
ionalinfor
mation.
Referparti
cipantstoHandout8. 11Suppor tandSuperv i
sionforCMAM andaskthem t oreaditquiet
ly
andt odi
scussi nthei
rgroupsanyaddi ti
onal i
nfor
mat i
ont heywouldaddtot
hepreviousdiscussion.
Discussthisinformati
oninplenary.Notethatsupervi
sioni snotl
imit
edtoev
aluati
ngper f
or mancebutisa
greatopportunitytomentorandpr ovi
detechnicalsupporttothestaf
f.

GROUPDI
SCUSSI
ON:SUPPORTANDSUPERVI
SIONCHECKLI
STS.I
npl
enar
y,askpar
ti
cipant
s
whatki ndofi nformationt heywouldexpecttoseeonasuppor tandsuper vi
sioncheckli
stforoutpati
ent
care.Remi ndt hem, onet opicatatime,tothi
nkthroughstaff
ing, admissionpr ocedur
es,medicaland
nutri
tiont herapeut i
ccar e,fol
low-upforabsent
eesanddef aul
t ers,i
nventorycont r
olanddischarge
procedur es.Ref erparticipantstoHandout8.12Suppor tandSuper v
isi
onCheckl i
stforOutpati
entCare
andr eview.Ref erthem toHandout8. 13Suppor tandSupervisionCheckl istf
orCommuni tyOutreachfor
futur
er efer ence.

WORKI
NGGROUPS:ANALYSI
SOFCONSOLI
DATEDSI
TEREPORTS.Wi
thpar
ti
cipant
sint
he
samewor ki
nggr oups,distri
buteExer cise8. 4Anal ysisoft heSiteRepor t
sofThr eeOut pat i
entCar eSi tes
andOneI npat ientCar eSiteandhav epar ti
cipant sdiscusst hereportswi thint heirgroups.Usi ngt hesi te
andconsol i
dat edr eport
s, askpartici
pant stothinkt hroughanyconcl usionst hatcanbedr awnaboutt he
si
tes,performanceandcov er
agei ssues, andwhatki ndoff oll
ow-upi nformat iont heywoul dneedt omake
appropri
atedeci sionsinr esponse.Youcoul dsuggestt hattheycompar ecasel oads, commonadmi ssion
cri
teri
a,admi ssionandr ef err
alpatterns,andr easonsf orandr at
esofdi schar geamongsi tes.I f
appropri
ate, gi
v eanexampl eort wof rom Exer cise8.4Di scussionKey , below.Checki nwi theachwor king
groupand, iftheirconversat i
onislaggi ng,providethem wi thaddit
ional conclusi onst odeter mi net hekey
questi
onst oaddr ess.Whengr oupshav ehadt imet odi scuss,askonegr oupt or eportaconcl usionand
whataddit i
onal informati
oni sneeded, i
npl enary.Askanot hergroupt opr ovideanaddi t
ional concl usion,
etc.

Notetoparti
cipantsthatspecif
icdi
schar
ger atesf rom t
heinpati
entcaresitearenotcalcul
ated.I
nfants
andchil
drenwhoi mprovearerefer
redtooutpat i
entcaretocont i
nuetreatment.Thespecif
icdischarge
rat
eswoul dnotr efl
ectpoorqualit
yast heyincludeONLYt hosechildrenwithSAM whohadmedi cal
compli
cati
ons.Thisisoner easonwhytheser v
ice/ progr
ammemustbeev al
uatedasawhol e,combining
i
nformati
onfrom bothinpati
entcareandoutpatientcareaspresentedi
nt hecombinedreport
ingsheet.

Exer
cise8.
4Anal
ysi
soft
heSi
teRepor
tsofThr
eeOut
pat
ientCar
eSi
tesandOneI
npat
ientCar
e

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Si
te(
Discussi
onKey
)

Concl
usi
onsDr
awnFr
om Repor
ts Quest
ionsorPossi
bleExpl
anat
iont
oVer
if
y
1.Heal
thcent
reBhasmorepat
ient
s 1.Isthisnor mal ?Doesi tcov erahi ghlypopulatedar eaora
thant
heothercent
res. verywi dear ea?Whatar ethewal kingdi st
ancestot hecentr
e?
Isthiscent remanageabl e?Coul dasecondcent rebeopened
withexi sti
ngr esour ces?
2.AthealthcentreC,morethanhal ft
he 2.I sthisnor mal ?Ar etheot herheal thcentresneglecti
ngthi
s
admissionsarefrom bi
later
alpit
ting diagnosi s?Or, t
heopposi te—i sther eanov er-
diagnosisof
oedema. bil
ateral pi
tti
ngoedemaher e?I st hishealthcentreina
diff
erentf oodeconomyar ea?Wast hesameobser v at
ion
madei npr evi
ousmont hsandi nsur vey s?
3.Outoft heoveral
l246newadmi ssi
ons, 3.Thiscoul dbeani ndicatoroft heef f
icacyof“earl
y
227wer eadmitteddir
ectlyt
oout pati
ent det ection”andt hereforeoft hequal it
yofcommuni ty
care(92.3%)and19t oinpati
entcare mobi l
isat i
on.Italsocoul di ndicatet hatchildr
enwi t
hser i
ous
(7.
7%). conditionsar ehi ddenathousehol dsandar enotreached.

4.Heal
thcentr
eAi snotref
err
ingany 4.Thi
scoul
dmeanthatnopatient
srequi
redt
ransf
er,
buti
t
pati
ent
stoinpati
entcar
e. shoul
dbecheckedt
hroughsuperv
isi
on.

5.Thedeat handnon- recov er edr at esi n 5.Thisraisesquest i

onsaboutt hequal i
tyoftheassessment
heal t
hcent reAar equi tehi ghf or ofpatient
si nthiscentreandt heapplicati
onofand
out patientcar e. adherencet otreatmentandact ionprotocols.
6.Heal thcent reB’ sdef aultr atei squi te 6.Perhapsmot hers/car
egiversdecidenott oreturnbecause
highandwar rant sf ollow- upt odet ermi ne waiti
ngt i
mesorwal kingdi
st ancesaret oolong.Itwil
lbe
ther easons. necessarytov i
sitthecentret odeterminethereasons.
7.Heal thcent reC’ scur edr at ei sgood 7.Isthisrel
atedt othenumberofcaseswi thbilat
eralpi
tt
ing
althought her ear equest i
onsaboutt he oedema, notedabov e?Couldt hisbeinv est
igated?
non- recov eredr at e.
8.Ov er all
,211chi l
dr enl eftout pat ient 8.Whyistheconditionofchil
drendeter
ior
atingwhenunder
car edur ingt hemont h; 200oft hese tr
eatmentinoutpati
entcare?Isther
ecompl i
ancetomedici
ne
childrenwer edi schar ged.Howev er ,11 andRUTFpr otocol
s?Whatheal thandnutr
iti
onmessagesare
wer er eferredbackt oi npat ientcar e, mother
s/caregiver
sr ecei
vi
ng?Ar et
hereotherunder
lyi
ng
meani ngt hatt hecondi t i
onsof5. 5%of heal
thconditi
onsthatmustbeaddr essed?
thechi ldrenundert reat menti n
out patientcar edet er i
or ated.
9.Whi l
e17chi ldrenwer eref erredf rom 9.Thedi fferencebet weenr ef erralsf rom i npat ientcar eand
i
npat ientcar et oout pat ientcar e,the admi ssionst oout pati
entcar ecoul dbeduet oaweak
out patientcar esi t
esadmi ttedonl y14 regist r
at ionsy stem orbecausesomer eferredchi ldrendi dnot
childrenr efer r
edf rom i npat i
entcar e. got ot heout pati
entcar esites.Thi sobser v ati
onshoul d
Not et hat11pat ientswer er ef erredf rom tri
ggercl oserassessmentandsuper visi
onoft her egistrati
on
out patientcar et oinpat ientcar eand11 andr efer ralsystem (e.g.,
theuseofr efer r
al sli
ps, t
he
admi ssi onsar er egist eredi nt hei npat ient prov i
si onoft ransportati
on, themessagesandexpl anations
car esiter epor tasr ef erredf rom givent ot hemot her/caregiveratt het imeofr ef erral)
.Not e
out patientcar e. thatchi l
dr enwhower ereferredl ef tthesi tewher et heywer e
beingt reat edbutdi dnotl eav etheser v i
ce/ progr amme.The
compi lednumberofcasesundert reat menti nt hedi stri
ctis
209, whi chcount s9casesl esst hant hesum oft heindiv i
dual
repor t.Thi sdi ff
erencei sduet othe3mi ssedr eferrals.Other
missedcasesmayhav ebeeni nt ransi twhi l
er ef erredacr oss
mont hs
(Not e: thiscoul dbeashor t
comi ngi nt heexer ciseandi fthis
i
sr epeat edatt hedistri
ctlev elint hef i
eld, i
tshoul dbe
repor tedf orreviewoft hecompi lationsy stem) .

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Note:Thespecifi
cdischarger atesfrom theinpati
entcaresi
tear enotcalculated.Chil
drenthati
mpr ove
arerefer
redtooutpatientcaretocont i
nuet r
eatment.Thespecificdischargerateswoul dnotref
lectpoor
quali
tyastheyincl
udeONLYt hosechildrenwithSAM thathadmedi cal complicati
ons.Thisisoneofthe
reasonswhyt heprogrammeneedst obeev aluat
edasawhol e,combininginformationfrom bot
h
i
npat i
entandoutpati
entcar easpr esentedinthecombi nedreporti
ngsheet ,wheretheper f
ormance
i
ndicatorspr
ov i
deinformationoft heCMAM ser v
iceinthedi
st r
ictf
ort hemanagementofSAM.

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Modul
e8Lear
ningObj
ect
ive7:Pr
epar
eanOut
li
nef
orCMAM Repor
ti
ng

TRAI
NER:Becomef
ami
l
iarwi
thHandout8.
14Gui
danceonCMAM Repor
ti
ng.

WORKI
NGGROUPS:DI
SCUSSCMAM REPORTI
NGNEEDSANDDRAFTANOUTLI
NE.For
m
wor
kinggr
oupsoff
ivepar
ti
ci
pant
s.Askt
hegr
oupst
o:
1. Di
scussneedsanduseofCMAM r
epor
ts:
-
Whoneedsandwhousest
her
epor
tforwhatpur
poses
-
Whopr
epar
est
her
epor
t?
2. Draf
tanoutl
i
nef ormini
mum report
ingonCMAM anddi
scusst
heexi
sti
ngmoni
tor
ingt
ool
s
andhowtheyfeedinf
ormat
ionintotherepor
t
Askonegr oupt
oshareinplenar
yandot hergr
oupstoshareonlyaddi
ti
onali
nformat
ion.Ref
er
part
ici
pantstoHandout8.
14Gui danceonCMAM Repor t
ing,askthem t
oreaditqui
etl
yandtodi
scussi
n
thei
rgroupsanyi
nformati
ontheywouldaddt othei
rout
li
ne.

OPTI
ONALACTI
VITY

EXTERNALTRAI
NING:USI
NGANELECTRONI
CDATABASE.Att
hedi
str
ictl
evel
,coor
dinat
ea
special t
rai
ningsessiononhowt osetupaCMAM moni tori
ngsystem usinganel ectronicdatabasei n
Excel.Ifpossibl
e,ensurethattherearesuf f
ici
entcomputersavail
ableforpart
icipant stowor kinpairs.
Becomef amili
arwithSupplement alRef er
ence8.1Setti
ngUpaCMAM Moni t
or i
ngSy stem Usingan
Elect
roni cDatabaseinExcel andUsi ngaCMAM mHeal thAppl i
cati
onandhav epar ti
cipantsrevi
ewt his
refer
encebef oretheactivi
ty.Bri
ngcopi esofcompletedsitetal
l
ysheet s,si
terepor t
ingsheet sandlistsof
outpatientandinpati
entcaresites(wi t
hnamesandl ocationsofhealthfaci
li
ti
es); passt hem outto
parti
cipants.UsingSupplement alReference8.1,gothr
ought hesetupstepbyst ep, maki ngsurethat
parti
cipantsunderstandthecont entandmanagementoft hesoftware.

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Modul
e8Wr
ap-
UpandModul
eEv
aluat
ion

SUGGESTEDMETHOD:
Rev
iewl
ear
ningobj
ect
ivesandcompl
eteev
aluat
ionf
orm.Rev
iewt
hemodul
e’
s
l
ear
ningobj
ect
ives.
I
nthi
smodul
eyouhav
e:
 Descr
ibedt
hepr
inci
plesofmoni
tor
ingandr
epor
ti
ngonCMAM
 Descr
ibedhowt
hei
ndi
vi
dual
inf
antorchi
l
dist
rackedandmoni
tor
edi
nCMAM
 Compl
etedsi
tet
all
ysheet
sandsi
teanddi
str
ictr
epor
ts,
andi
nter
pret
edt
hef
indi
ngs
 Cal
cul
atedanddi
scussedser
vice/
progr
ammeper
for
manceandcov
erage
 Moni
tor
edandr
espondedt
obar
ri
erst
oaccess
 Expl
ainedt
hepur
poseofsuppor
tandsuper
visi
onv
isi
tsandt
her
oleofasuper
visor
/ment
or
 Pr
epar
edanout
li
nef
orCMAM r
epor
ti
ng

Askf
oranyquest
ionsandf
eedbackont
hemodul
e.
Askt
hef
oll
owi
ngr
evi
ewquest
ions:
 Howar
eindi
vi
dual
inf
ant
sandchi
l
drent
rackedi
naCMAM ser
vice?
 Whati
nfor
mat
ioni
scol
l
ect
edonsi
tet
all
ysheet
sandsi
teanddi
str
ictr
epor
ts?
 Whati
ndi
cat
orsar
eusedt
odet
ermi
neser
viceper
for
mance?
 Whatar
ether
olesandr
esponsi
bil
i
tiesofsuper
visor
sinout
pat
ientcar
e?
 Di
scussandcl
ari
fy.
 Letpar
ti
cipant
sknowt
hatt
heywi
l
lhav
eanoppor
tuni
tyt
oobser
vepr
ocedur
esanddi
scusst
hem wi
th
st
affdur
ingt
hef
iel
dvi
sit
.
 Askpar
ti
cipant
stocompl
etet
hemodul
eev
aluat
ionf
orm.

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MODULE8MONI
TORI
NGANDREPORTI
NGONCMAM:
OUTPATI
ENTCAREFI
ELDPRACTI
CEFORHEALTHCARE
PROVI
DERS

Ov
erv
iew
 Amaxi
mum off
ivepar
ti
ci
pant
sshoul
dbeateachout
pat
ientcar
esi
teonagi
venday
.Coor
dinat
ewi
th
asmanyout
pat
ientcar
esi
tesasnecessar
ytokeept
henumberofpar
ti
cipant
satf
iveorf
ewer
.
 Thi
ssi
tev
isi
tisbestconduct
edononeoft
hef
inal
day
soft
het
rai
ning,
aft
erobser
vingandpr
act
ici
ng
out
pat
ientcar
eact
ivi
ti
esataheal
thf
aci
l
ity
.Par
ti
ci
pant
smustbeknowl
edgeabl
einal
laspect
sof
out
pat
ientcar
e.
 Thesuper
visi
oncheckl
i
sti
slongsoi
tcanbebr
okeni
ntosev
eral
sect
ions,
all
owi
ngdi
ff
erent
par
ti
cipant
sto“
super
vise”di
ff
erentact
ivi
ti
esdur
ingout
pat
ientcar
e.
 Pai
rpar
ti
cipant
swi
thsomeonewhospeakst
hel
ocal
language.

Handout
stoBri
ngtot
heOut
pat
ient
Lear
ningObj
ect
ives
CareFi
eldPr
act
ice
ObserveandHelptheOutpati
entCareSit
eTeam Compl eteSi
te Handout8.3Monitor
ingandReporti
ng
Tal
lySheetsfr
om theIndi
vi
dualOutpat
ientCareTreatmentCar
ds onCMAM
ReviewaSiteTal
lySheetandthePrevi
ousMont h’sSi
teReport Handout8.8CMAM Indicat
ors
andDiscussWithStaf
fHowt oUseandI nter
pretData
Handout8.12SupportandSuper
visi
on
ReviewtheSyst
em forRecor
dingRUTFDi str
ibut
ionandStock Checkl
istf
orOutpati
entCare
Levels

Pr
epar
ati
onf
ort
heOut
pat
ientCar
eFi
eldPr
act
ice
 Di
scussandr
evi
ewt
hepr
ocedur
esandst
epst
hatpar
ti
cipant
swi
l
lunder
takeatt
heout
pat
ientcar
e
si
tes:
- Observeandhelpt
heout
pat
ientsi
tet
eam compl
etesi
tet
all
ysheet
sfr
om t
hei
ndi
vi
dual
out
pat
ient
caret
reatmentcar
ds
- Calcul
atet
henumberofcli
entsenr
oll
edi
nCMAM anddoubl
e-checkitagainstt
henumberofcar
ds
- Reviewacomplet
edsi
tetall
ysheetandt
hepr
evi
ousmonth’
ssitereportanddiscusswhatt
heyr
eveal
aboutt
heser
vice/
progr
amme(
e.g.
,recov
eri
es,
def
aul
ts,
deat
hs,
any
thi
ngsur
pri
sing)
 Br
ingcopi
esofHandout8.
12Suppor
tandSuper
visi
onCheckl
istf
orOut
pat
ientCar
eincaset
he
out
pat
ientcar
esi
tedoesnothav
eanyf
ort
hepar
ti
ci
pant
stocompl
ete.

Module8 FI
ELDPRACTI
CELEARNINGOBJECTI
VE1:OBSERVEAND
HELPTHEOUTPATIENTCARESITETEAM COMPLETESI
TETALLY
SHEETSFROM THEINDI
VIDUALOUTPATI
ENTCARETREATMENTCARDS

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HANDS-
ONACTI
VITYATSI
TE:Hel
pout
pat
ientcar
esi
test
affcompl
etesi
tet
all
ysheet
s.

OPTI
ONALACTI
VITY(
IFTI
MEPERMI
TS)
:Revi
ewaSampl
eofOut
pat
ientCar
eTr
eat
mentCar
ds
Revi
ewsamplesofoutpat
ientcar
et r
eatmentcar
dsandnotethegener
alpr
ofi
l
esoft
hechi
l
dreni
nthe
ser
vice:
 Ar emostcasesadmit
tedonbilater
alpi
tt
ingoedemaorlowMUAC?
 Whatar
ethemai
nagesofi
nfant
sandchi
l
dreni
ntheser
vice/
progr
amme?
 Ar
ether
emanyr
etur
neddef
aul
ter
sorr
elapsecases?
 Domanyi
nfant
sandchi
l
drencomef
rom i
npat
ientcar
e?
 Ar
emanyi
nfant
sandchi
l
drenr
efer
redt
oinpat
ientcar
e?
 Domanyi
nfant
sandchi
l
drenr
equi
ref
oll
ow-
uphomev
isi
ts?
 Howar
efol
l
ow-
uphomev
isi
tsnot
edont
heout
pat
ientcar
etr
eat
mentcar
d?

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Module8FI
ELDPRACTI
CELEARNINGOBJECTI
VE2:REVI
EW ASI
TE
TALLYSHEETANDPREVIOUSMONTH’SSI
TEREPORTANDDISCUSS
WITHSTAFFHOW TOUSEANDINTERPRETDATA
ACTI
VITY:REVI
EW SI
TETALLYSHEETANDDI
SCUSSRECOVERYANDDEFAULTWI
THSTAFF
Met
hod:Hands-
onr
evi
ewatsi
te
 Wi
tht
heout
pat
ientcar
esi
test
aff
,rev
iewsi
tet
all
ysheetandt
hepr
evi
ousmont
h’ssi
ter
epor
t.
 Di
scusst
oget
herr
ecov
eryanddef
aul
t.
 Di
scusswi
thheal
thf
aci
l
ityst
aff
:
-Whati
stheser
vice/
progr
amme’
sresponset
opoorr
ecov
ery
,deat
h,anddef
aul
trat
es?
-Whati
sthepr
ocessf
orr
epor
ti
ngonf
oll
ow-
uphomev
isi
tsi
npr
obl
em cases?
-Whati
sthesy
stem/
processf
orr
evi
ewi
ngt
hecaseswhodi
edt
hatmont
h?
-Whatar
ethechal
l
engeswi
thr
efer
ral
sandmoni
tor
ingofi
ndi
vi
dual
sbet
weensi
tesandser
vices?

159
 Tr
aini
ngGui
def
orCommuni
ty-
BasedManagementofAcut
eMal
nut
ri
ti
on(
CMAM)
,2018Ver
sion

Module8 FI
ELDPRACTICELEARNINGOBJECTI
VE3:REVI
EW THE
SYSTEM FORRECORDI
NGRUTFDI STRI
BUTIONANDSTOCKLEVELS
HANDS-
ONREVIEW ATSI
TE:REVI
EW WI
THSTAFFSYSTEM FORRECORDI
NGRUTFDI
STRI
BUTED,I
N
STOCKANDPROCUREMENT
 Wi
thst
aff
,rev
iewRUTF:
dist
ri
but
ion,
in-
stockandpr
ocur
ement
.
 Gooverasuper
visi
oncheckl
i
stwi
thi
nsmal
lgr
oups.
 Fi
l
lout(
par
tsof
)asuper
visi
oncheckl
i
stbasedonobser
vedact
ivi
ti
esl
i
nkedt
osuppl
i
esatout
pat
ient
car
e.

ACTI
VITY:FEEDBACKONFI
ELDPRACTI
CESESSI
ONS
Met
hod:Feedback/
Discussi
on
Af
tereachf
iel
dpr
act
ice,
conductaf
eedbacksessi
oni
nwhi
chpar
ti
cipant
swi
l
l:
 Pr
ovi
def
eedbackonst
rengt
hsobser
vedateachheal
thf
aci
l
ity
 Rai
sei
ssuesf
orcl
ari
fi
cat
ionbyf
aci
l
itat
ors
 I
dent
if
ykeygapst
hatneedmor
epr
act
ice/
obser
vat
iont
imeoraddi
ti
onal
classr
oom t
imef
orpr
act
ice
wi
thf
orms,
cal
cul
ati
ons,
etc.
 Di
scusshowy
ouwoul
dment
ort
hest
afft
oimpr
oveper
for
mance

160