guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Community 18 COMMUNITY ASPECTS OF IMAM 1. Community involvement The success of out-patient management of most children with severe malnutrition [8,9] depends to a large extent on identifying children before they develop complications and present at a health facility. This requires screening all children in the community. For this to be successful there needs to be support from the community to identify and treat these children. The key people are the community health workers and outreach workers who need the support and cooperation of the community. The quality of engagement with the community is an important determinant of the programme’s success. Many mothers only come to the health services after the child is severely ill or has a major complication. However, if the cases are found and treated early, before complications set in, then the treatment is straightforward. Thus, early case finding in the community and the quality of service offered are the most important determinants of case fatality rates, programme coverage and the impact of the programme. In this regard, the prevalence of SAM is related to the treatment of moderate acute malnutrition (MAM) and the prevention of deterioration of the moderately malnourished child. Programmes for the prevention and treatment of MAM are all community based and should be part of the overall programme for tackling malnutrition; these programmes are important but not addressed in these guidelines. It is important for the community mobilisation not to focus solely upon identification of the SAM children, but to have a much wider remit so that these SAM and MAM activities are integrated with immunisation, community-IMCI, maternal and child health services, breast feeding support as well as food security, agriculture, micro-credit and income-generating programmes. These features of community mobilisation are beyond the scope of this guideline. 2. Planning the community programme In general the Ministry of Health and the officers within local government who will be responsible for the programme should be familiar, in general, with the communities under their jurisdiction: their anthropology, beliefs, customs, structure and language. Where the programme is being run by an international organisation, a Government for an ethnic minority group or where those responsible for the programme do not know the livelihood structure and constraints experienced by the community then it is necessary to obtain this information before planning and starting the programme. Those implementing a programme for the management of SAM should endeavour to have personnel who are already familiar with the community, speak the local language and are trusted by the community leaders, on their staff in a sufficiently senior position to influence the programme, veto any inappropriate aspects and negotiate directly with the community. This is because the community-based aspects of the programme must be tailored to the context in which it operates. It is important that the community leaders, traditional and modern health practitioners, other members of civil society and local organisations are fully informed and understand the nature and purpose of the programme and the nature of their involvement. The organisation of the programme and messages given will depend upon the usual formal and informal communication within the society, the literacy levels, who takes care of children, who determines the use of resources within the household (husband, mother-in-law, etc.), and the beliefs within the society about the causes of malnutrition as well as their usual health seeking behaviour. During the planning it is imperative that there is close co-operation between the different agencies and programmes 11 . In particular, the type and value of the incentives offered (travel, meal allowance, 11 During the planning process, it is important to have access to reasonable maps of the area and population statistics. This has normally been completed for other purposes. The planning team should take into account the experience of other programmes and how they have approached and solved the problems associated with outreach activities and logistics. If
ACF-In Guidelines for the integrated management of SAM Community 19 clothing, food, money etc.) is standardised so that there is no discrepancy between the programmes. The subsistence and travel allowances for training also need to be standardised. These aspects should be specified nationally (in a National Strategy for Community Development for example). The District Officer for Community Development and the District Medical Officer must both be involved to ensure that the various out-reach programmes do not compete with each other or overburden the village workers. 3. Community awareness and involvement Before implementation it is necessary for the community members to know about and approve of the programme. They should understand the objectives and the methods that will be used to identify and treat the children, the nature of their involvement, the cost and other inputs to the programme by the community 12 , for how long the programme has secure funding 13 and how the programme complements the other health programmes in the area. They should be sufficiently involved to take ownership of the programme once it is established and shown to be effective 14 . The information about the programme must include its aims, methods, organisation and the persons involved; they must be clear about how the programme will affect them and their community in practice: what will it do, who will be eligible to benefit and why they will be selected, who will not benefit or be excluded, where it will operate, who will implement it, how can people access it and what the programme will do for the selected individuals. Any misunderstanding at this stage can lead to frustration and disillusionment 15 . Full acceptance of the programme is not expected until it has already been implemented and the community sees it with their own eyes and assesses its value, therefore there should be a step-by-step approach with continuing dialogue, feedback and exchange between the programme staff and the community leaders. Such a programme should never be “imposed” upon a community. Simple messages and memorable slogans are designed that give the essence of the programme in a way that is understood by the poorest in the community. This is done by the local community itself (religious leaders, village elders, traditional healers and other authority figures such as teachers, CHW, community midwife, traditional birth attendants and health centre staff) who are then responsible for spreading the information within their communities. Visual aids can be produced after testing and fliers posted in key places, much in the same way that advertising companies operate. These should be developed nationally and be part of the national development strategy. However, it is often more effective to use informal methods of passing information about the programme. This is at places where people gather normally, particularly the market and where women collect water or wash clothes and men gather to drink and socialise. The use of women’s groups, possible the activities of the IMAM programme in the community should be integrated and coordinated with the other programmes. 12 Including the cost of taking over the programme and the nature and level of support that can be expected after control of the programme passes to the community. 13 Some NGOs, reliant upon external funding, can only make a short term commitment. Many communities have experienced broken promises or unfulfilled expectations. They are cautious about extravagant claims and promises and need to see positive outcomes, without cost to them, before they become fully committed. It is important not to raise expectations (often due to misunderstanding) to a level which may not be achieved and any commitment made must be completed to the satisfaction of the community. 14 The poor are very conservative: they cannot risk committing family resources (time, travel, goods, labour, and purchases) just because an educated stranger gives a persuasive argument (“education”). If the stranger is mistaken they may starve. It is only the better off, such as those that plan programmes, who can take such risk as a mistake and loss will not devastate their lives. 15 “Why did you choose this child, and not that child – they look the same to me” if often heard from community members who are sceptical about the programme and its aims.
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Cover photography: © ACF, Anne-Dom
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