1. Background

The COVID-19 pandemic presents unique challenges with management of acute malnutrition right from diagnosis, management and follow up of malnourished children with acute malnutrition at health facility/nutrition site and at community level. The recently released global guidance on management of child wasting in the context of COVID-19 recommends reduced exposure to COVID-19 by shifting to MUAC only for anthropometric measurements in children and encouraging mothers/ caregivers to carry out MUAC and oedema assessments under the supervision of Nutrition site staff and CHNV’s. This recommendation has been adapted in several countries and increasingly during the COVID19 pandemic as key nutrition adaptation for safe continuity in the delivery of nutrition services in the context of COVID-19. Evidence has shown that minimally trained mothers and caregivers can screen their children as well as a community health worker would, when they are given adequate training and tools ’ . The 'Family MUAC' approach, also known as MUAC for mothers or Mother-MUAC, trains mothers and other caregivers to identify early signs of malnutrition in their children using a simple to use Mid-Upper Arm Circumference (MUAC) tape. The approach has been promoted in the recently developed Global guidelines for nutrition service delivery in the context of COVID-19. This Concept Note provides guidance to CMAM implementing partners on how to operationalize the approach, Family MUAC Experience in other Countries A State of Acute malnutrition webinar hosted ALIMA, GOAL, Save the Children UK and UNICEF provided the latest evidence and learning on Family MUAC internationally. Scale up and interest in the Family MUAC approach has intensified since the onset of the ongoing global COVID-19 pandemic with increasing global evidence on its role in early identification of wasting. The approach is considered easier and faster to apply at country level since it can be applied with minimal modifications to the existing IMAM country protocols. UNICEF is following up 38 countries that are implementing Family MUAC as an adaptation to the COVID19 context. Growing evidence shows that Mothers (or other family members), can do this task as effectively as Community Health Workers (CHWs) and malnutrition is expected to be detected earlier, and to lead to less hospitalizations. Family MUAC has shown to improve coverage of screening in the community. Some of the key challenges and lessons learnt cited include the ability of mothers to do correct measurements reduce with time thus refresher training or follow up is critical; a large supply of MUAC tapes should be planned; sometimes mothers and caregivers view the task as CHWs thus expect incentive; lack of access to nutrition services discourages self-referrals therefore access to nutrition services need to be considered; and lack of reporting tools to capture Family MUAC screening. Importantly, the need to ensure close integration and ownership of the approach with the existing health system and structures. Family MUAC Experience in Yemen: Currently, there is minimal experience on Family MUAC in Yemen. ACF piloted Family MUAC in Al Hodeida Governorate in northern Yemen in 2017 and extended the experience to the south of YEMEN in In Abyan governorate-Khanfer district and in Lahj Gov,TurAlbaha district in 2019 . The main aim of the family MUAC pilot was to increase coverage of management of acute malnutrition services and to optimize early diagnosis and treatment. The pilot targeted mothers and caregivers of children below 5 years old. Training of mothers and caregivers was lead by Health Educators nominated jointly by ACF and DHO. Community leaders, health workers and CHNVs were sensitized on their role in supporting and motivating mothers to participate in the trainings. Mothers and caregivers trainings were conducted through the Door-to-Door groups (Neighbourhood mothers) and MUAC tapes provided to screen children regularly and counselled to take children to health facilities when malnutrition is indicated. Trained mothers further sensitized neighbourhood mothers and screened their children for malnutrition using MUAC. Children found to be malnourished were referred to the nearest health facilities. A total of 20,777 mothers selected from 627 villages were trained and screened 29,456 children. As result, 1932 children were identified as suffering from Severe Acute Malnutrition (SAM) and 6,203 children identified as Moderate Acute Malnutrition (MAM) and referred to OTP and TSFP respectively. Key learning from the ACF pilot include; community leaders and authority sensitization is critical, mothers felt it was the responsibility of CHNVs and not theirs thus sensitization of community members including mothers and caregivers was good for greater acceptance, health educators taking up the role of training mothers instead of health workers and CHNVs was seen to confuse and lastly, cash incentives to mothers and caregivers participating in the programme is discouraged. The ACF pilot is still ongoing thus, lessons from this will further guide the roll out of the approach in Yemen. 2. Purpose of the Concept Note The purpose of this concept note is to provide an outline of key considerations and actions required to support the potential scale up of the FAMILY MUAC approach in Yemen. 3. Proposed Family MUAC Approach in Yemen: - Rationale or justification for the approach in Yemen: Continuous monitoring of nutritional status of children under five by mother, caregivers and family particularly in the COVID context. Increase coverage of services in low treatment coverage areas or areas with low CHNV coverage with the aim of complementing the work of CHNV’s but not replacing them. - Key activities: Community sensitization including leaders, Training/ sensitization of mothers, MUAC screening of children in respective households, Referral of children identified as malnourished, Monitoring and mentorship of mothers by CHNV/ health workers - Safety: MUAC measurement is quick, painless and safe - Benefits of the approach: Early detection of malnutrition and referral for treatment. Increasing access to services in underserved areas. Enhanced collaboration between mothers, CHNVs and health workers in preventing and treating malnutrition. Empowered mothers, caregivers and families in health and nutrition status of their children. - Priority geographical areas for the roll out of the approach: Areas with a high caseload of malnutrition and Inaccessible areas for health care providers and CHNV Entry Points for Family MUAC: Family MUAC screening will be implemented in the community, at home and health facility/nutrition site; - At Community: Mother to mother Support groups (MTMSGs) present a good opportunity to train and mentor mothers on MUAC and oedema screening as well peer motivation. CHNVs can link with MTMSGs for the training. Lead mothers trained on MUAC screening and Oedema checks can also be supported by CHNVs to train and mentor mothers. Training mothers in the neighbourhoods referenced by ACF experience in Yemen could also be considered. - At Home: For mother/caregiver to screen children under five for acute malnutrition to ensure timely identification, presentation to health and nutrition facilities, and treatment. If the measurement turns red or yellow, the CHNV is alerted by the mother, a second measurement is conducted by the mother under observation of the CHNV, and for confirmed results the CHNV completes a referral slip for the mother (refer to Yemen CMAM guidelines), with instructions to take the child to the nearest nutrition site. - At Health facility/Nutrition Site: For mother/caregiver to screen their own children to as part of anthropometric assessment at the site following no touch principle, under observation of the health/ nutrition staff to ensure it is correctly done. Children found with a red or yellow colour are admitted in the appropriate treatment program. Summary of Family MUAC Contact Points for Trainings: Contact point Service delivery point Who conducts the training Mode of training Health facility and Nutrition Site - Outpatient departments (OPD - Triage /screening points - Immunization centres - Maternal and child health department (MCH) - Antenatal care (ANC) and postnatal care (PNC) clinics - In-patient clinics or wards Nutrition and health workers providing nutrition and health services - Individual training to mother/caregiver child pair - In small groups (Maximum 10 mothers/caregivers) At community level - House-to-house (e.g. during home visits/follow up) - During regular EPI outreach days - Integrated outreaches/outreach clinics - Community activities such as MtMSG, markets etc. - IDPs sites CHNVs Health/ Nutrition Workers (where there no CHNVs) - Individual training to mother/caregiver child pair - In small groups (Maximum 10 mothers/caregivers) 4. Training, equipment and follow up This will be a two-stage cascade training. Firstly, the CHNVs are trained by the health/ nutrition staff at facility level on how train and mentor caregivers/ mothers to conduct MUAC measurement and oedema checks on a child 6 to 59 months old. Secondly, the trained CHNVs in turn conduct a one-to-one training and mentorship to mothers and other family members and issue a MUAC tape for each family. The primary focus is on mothers with children 6 – 59 months of age. Training and mentorship of mothers will take place at all service delivery points at the health facility, nutrition sites, and at home. The orientation package includes: • Weekly MUAC measurement and oedema assessment techniques, result interpretation and referral pathways, as per the National CMAM guidelines • COVID19 related messaging using the tools developed by the RCCE • MIYCN related messaging using the national counselling tools. The screening by mothers should be rolled out once they receive the training and are confident to screen and take the necessary action. The primary focus should be mothers/caregivers of children 6 – 59 months of age. Where possible and practical engage husbands and fathers to be to further generate community acceptance. Note: CHNVs are the major actors to train mothers on Family MUAC. Health care providers can also be used as an alternative to train mothers during health facility visits and outreach services. Training content for Mothers and Caregivers Trained CHNVs will lead the training of Family MUAC at home and in the community. Preferably the CHNVs should be provided with a refresher training on training and demonstrating to mothers how to conduct MUAC screening and Oedema checks. With reference to the Yemen National CMAM Guidelines and following the CHNVs Nutrition Training package the Family MUAC training for Mothers and Caregivers should cover the following issues: • Basic information causes, identification and treatment of malnutrition, key nutrition promotion and malnutrition prevention messages and Infant and Young Child Feeding (IYCF) • Danger signs of childhood illness (pneumonia, fever, and diarrhea) • Screening for acute malnutrition, care, referral, and follow-up of children with acute malnutrition; • Demonstrations on conducting MUAC and Oedema checks (Yemen CMAM Guidelines; Annex 2 Anthropometric measurements) Self-Referrals Mothers and caregivers with children found to have with acute malnutrition ((Yemen CMAM Guidelines; Annex 2 Anthropometric Measurements) as listed below should be taken immediately to the nearest health/nutrition site for further assessment and treatment; Children 6 to 59 months of age with: o Bilateral pitting oedema; o MUAC ≥11.5cm and < 12.5 cm (yellow colour code) or <11.5cm (red colour code) Mothers and caregivers should be informed that children taken to the health facility and nutrition sites following family screening will be further screened by health workers to ascertain the MUAC and/ or oedema before admission. It is critical that mothers and caregivers are informed there may be times that their measurement is in error and child may not be admitted. Continuous training and mentorship of mother at service delivery points, community and home will be key to increasing quality of screening by mothers and caregivers. 5. Follow up and Monitoring:  CHNVs will provide regular visits at the village/household level and randomly check the screened children (accuracy of the screening), and consistency of key messages disseminated to the neighbourhood mothers.  During the visit, mothers will be asked to share their experiences on the screening, any challenges faced, and finally asked to take the measurements of the children in the presence of the CHNV or supervisor  The CHNV or supervisor will ask the mother to explain their understanding of the colour code and what action they should take depending on the colour of MUAC.  The training sessions and occasional home visits will be accompanied by nutrition counselling and mentorship/ support.  CHNVs will also have a monthly meeting with the trained mothers in their respective village to share the number of screened children and discussed the challenges and ways forward  CHNVs will contact with health facility in-charges when they referred SAM/MAM children (to check the admission status)  SAM and MAM children referred to the health facilities will be also checked for accuracy, if there is any inconsistency of measurement, they will provide feedback to the CHNV and mothers.  Whenever possible Monitoring tools for CHINVs/ community level referrals as provided in the Yemen CMAM National Guidelines can be used - CHNVs will compile the following information and share in the catchment health facility every month o # of mothers actively engaged in the screening, o # of children screened with normal MUAC, o # of children identified as SAM and enrolled in the SAM treatment o # of children identified as MAM and enrolled in TSFP o # of SAM children referred to the nearby health facility (newly identified) o # of MAM children referred to the nearby health facility (newly identified) - The agencies will summarize the above information and share with nutrition cluster coordination every month

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