MODULE 12

Management of Moderate Acute Malnutrition

PART 3: TRAINER’S GUIDE

The trainer’s guide is the third of four parts contained in this module. It is NOT a training course. This guide provides guidance on how to design a training course by giving tips and examples of tools that the trainer can use and adapt to meet training needs. The trainer’s guide should only be used by experienced trainers to help develop a training course that meets the needs of a specific audience. The trainer’s guide is linked to the technical information found in Part 2 of the module.

Module 12 is about the management of moderate acute malnutrition (MAM) with an emphasis onemergency supplementary feeding programmes (SFP) and their implementation. The module describes the different types of SFPs and when, where and how to implement programmes. Management tips and methods of monitoring and evaluation are also covered. The module highlights the need for flexible programming in different emergency contexts as well as the challenging and controversial aspects of SFP programming.

Navigating your way around the guide

The trainer’s guide is divided into six sections.

  1. Tips for trainers provide pointers on how to prepare for and organize a training course.
  2. Learning objectives set out examples of learning objectives for this module that can be adapted for a particular participant group.
  3. Testing knowledgecontains an example of a questionnaire that can be used to test participants’ knowledge of SFPs either at the start or at the end of a training course.
  4. Classroom exercises provide examples of practical exercises that can be done in a classroom context by participants individually or in groups.
  5. Case studies contain examples of case studies (one from Africa and one from another continent) that can be used to get participants to think by using real-life scenarios.
  6. Field-based exercises outline ideas for field visits that may be conducted during a longer training course.

Contents

  1. Tips for trainers
  2. Learning objectives
  3. Testing knowledge

Exercise 1: What do you know about the management of moderate acute malnutrition in emergencies?

Handout 1a: What do you know about the management of moderate acute malnutrition in emergencies?: questionnaire

Handout 1b: What do you know about the management of moderate acute malnutrition in emergencies?: questionnaire answers

  1. Classroom exercises

Exercise 2: Assessing the adequacy of a ration

Handout 2a: Assessing ration adequacy – two case studies

Handout 2b: Assessing ration adequacy – two case studies:model answers

Exercise 3: Assessing SFP performance in relation to minimum standards

Handout 3a: Assessing SFP performance in relation to minimum standards

Handout 3b: Assessing SFP performance in relation to minimum standards:

model answers

Exercise 4: Criteria for admission into a targeted SFP

Handout 4a:Criteria for admission to a targeted SFP

Handout 4b:Criteria for admission to a targeted SFP: model answers

Handout 4c: Simplified field tables for girls and boys 2006 WHO Growth Standards

  1. Case studies

Exercise 5: Evaluating a targeted SFP in Ethiopia

Handout 5a: Case study I: Evaluating a targeted SFP in Ethiopia

Handout 5b: Case study I: Evaluating a targeted SFP in Ethiopia: model answers

Exercise 6:An analysis of high default rates in Wadjir, Kenya

Handout 6a: Case study II: An analysis of high default rates in Wadjir, Kenya

Handout 6b: Case study II: An analysis of high default rates in Wadjir, Kenya:

model answers

  1. Field-based exercises

Exercise 7: Evaluation of SFP

Handout 7a: Briefing document on SFP

1. Tips for trainers

Step 1: Do the reading!

  • Read Parts 1 and 2 of this module.
  • Familiarize yourself with the technical terms from the glossary.
  • Read through the following key documents (see full references and how to access them in Part 4 of this module):

Action Contre La Faim / Prudhon, Claudine (2002) Assessment and Treatment of Malnutrition in Emergency Situations. Manual of Therapeutic Care and Planning for a Nutritional Programme. Paris: ACF.

ENN (2009). Minimum Reporting Package for Emergency Supplementary Feeding Programmes: Guidelines. London: ENN (Draft).

The Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response: Chapter 3.Geneva: The Sphere Project.

UNHCR/WFP (2009). Guidelines for selective feeding: the management of malnutrition in emergencies.Geneva: UNHCR/WFP

WHO (2000) The management of nutrition in major emergencies Geneva. WHO.

Step 2: Know your audience!

  • Find out about your participants in advance of the training:

How many participants will there be?

Do any of the participants already have experience of implementing SFPs in either an emergency or stable context?

Could participants with experience in the management of MAM or SFPs be involved in the sessions by preparing a case study or contribute through describing their practical experience?

Step 3: Design the training!

  • Decide how long the training will be and what activities can be covered within the available time. In general the following guide can be used:

A 90-minute classroom-based training can provide a basic overview of SFPs.

A half-day classroom-based training can provide an overview of SFPs and include some practical exercises.

A one-day classroom-based training can provide a more in-depth understanding of SFPs and include a number of practical exercises and multiple case studies.

A two to three-day classroom including field-based training can provide a full training in order to implement an SFPs although trainees would still need considerable on-the-job training before they were proficient in SFP implementation. This would include case studies and practical work, but would need to be a four to five day training if it includes the 2 day evaluation of an SFP in the field.

  • Identify appropriate learning objectives. This will depend on your participants, their level of understanding and experience, and the aim and length of the training.
  • Decide exactly which technical points to cover based on the learning objectives that you have identified.
  • Divide the training into manageable ‘chunks’. One session should generally not last longer than an hour.
  • Ensure the training is a good mix of activities i.e. mix power-point presentations in plenary with more active participation through classroom-based exercises, mix individual work with group work.

Step 4: Get prepared!

a)Prepare PowerPoint presentations with notes (if they are going to be used) in advance and do a trial run. Time yourself! Recommended PowerPoint presentations that can be adapted from existing sources include (see full references and how to access them in Part 4 of this module):

FANTA (2008). Training guide for community-based management of acute malnutrition (CMAM). Washington DC. FANTA.

University of Nairobi, FSAU & FAO (2005). Training Package of Materials for the Course Food and Nutrition Surveillance and Emergency (Unit I through III). Nairobi: FSAU.

The Sphere Project (2004). Humanitarian and Minimum Standards in Disaster Response. Nutrition training module. Session 4.Moderate Malnutrition.

  • Prepare exercises and case studies. These can be based on the examples given in this trainer’s guide but should be adapted to be suitable for the particular training context.
  • Prepare a ‘kit’ of materials for each participant. These should be given out at the start of the training and should include:

Timetable showing break times (coffee and lunch) and individual sessions

Parts 1 and 2 of this module

Pens and paper

REMEMBER
People remember 20 per cent of what they are told, 40 per cent of what they are told and read, and 80 per cent of what they find out for themselves.
People learn differently. They learn from what they read, what they hear, what they see, what they discuss with others and what they explain to others. A good training is therefore one that offers a variety of learning methods which suit the variety of individuals in any group. Such variety will also help reinforce messages and ideas so that they are more likely to be learned.

2. Learning objectives

Below are examples of learning objectives for a session on management of MAM. Trainers may wish to develop alternative learning objectives that are appropriate to their particular participant group. The number of learning objectives should be limited; up to five per day of training is appropriate. Each exercise should be related to at least one of the learning objectives.

Examples of learning objectives

At the end of the training participants will:

  • Understand the objectives and basic design features of SFPs in emergencies.
  • Know when to implement SFPs and eligibility criteria.
  • Know when to close down SFPs.
  • Have knowledge of basic medical regimes in SFPs.
  • Have an understanding of basic management practices involved in programming.
  • Know how to monitor programmes and assess programme performance and impact.
  • Understand the need for, and context where, flexible programming may be necessary.
  • Understand the types of challenge that may arise in SFP implementation.
  • Know how to evaluate the design and implementation of an SFP.

3. Testing knowledge

This section contains one exercise which is an example of a questionnaire that can be used to test participants’ knowledge of SFPs either at the start or at the end of a training session. The questionnaire can be adapted by the trainer to include questions relevant to the specific participant group.

Exercise 1: What do you know about the management of moderate acute malnutrition in emergencies?

What is the learning objective?
  • To test participants’ knowledge about SFPs
When should this exercise be done?
  • Either at the start of a training session to establish knowledge level
  • Or at the end of a training session to check how much participants have learned
How long should the exercise take?
  • 20 minutes
What materials are needed?
  • Handout 1a: What do you know about the management of moderate acute malnutrition in emergencies?:questionnaire
  • Handout 1b: What do you know about the management of moderate acute malnutrition in emergencies?: questionnaire answers
What does the trainer need to prepare?
  • Familiarise yourself with the questions and answers.
  • Add your own questions and answers based on your knowledge of the participants and their knowledge base.
Instructions
Step 1:Give each participant a copy of Handout 1a.
Step 2:Give participants 15 minutes to complete the questionnaire working alone.
Step 3:Give each participant a copy of Handout 1b.
Step 4:Go through the responses in plenary and have participants mark their own questionnaires and clarify the answers where necessary.

Handout 1a: What do you know about the management of moderate acute malnutrition in emergencies?:questionnaire

Time for completion:15 minutes

Answer all the questions.

  1. What is/are two main differences between targeted and blanket SFPs?

a.

b.

  1. What are the advantages of take-home rations over on-site rations?Circle the correct answers.

a)Less opportunity cost to mother/carer

b)Less risk of ration sharing

c)Does not require set up of large scale kitchens

d)Less risk of cross-infection

e)Do not have to provide a ration for carers

  1. Under what circumstances might on-site feeding be appropriate?Circle the correct answers.

a)When the population has no cooking or food preparation resources

b)When there are no epidemics

c)At the time of year when there is limited agricultural work

d)When there are high levels of insecurity

  1. Under what circumstances would you implement a targeted SFP?Circle the correct answers.

a)When levels of wasting are between 5-9 per centwithout aggravating factors

b)When levels of wasting are expected to rise due to aggravating factors like poor general ration or epidemics or imminent hungry season

c)When levels of wasting are above 10 per cent

d)When levels of wasting are above 5 per cent with aggravating factors

  1. What are the eligibility criteria for a targeted SFP?Circle the correct answers.

a)Children 6-60 months with weight for height less than -2 Z score and greater than or equal to -3 Z-scores based on the 2006 WHO Growth standard

b)Children 6-60 months with MUAC of less than 12.5cm (125mm) and greater than or equal to 11.5cm (115mm)

c)Referrals from a therapeutic feeding programme

d)Children 6-60 months with a weight for height less than -3 Z scores

e)Adults with BMI greater than 18

f)Pregnant and lactating women and nursing mothers with MUAC of less than 21cm

  1. List five potential target groups for SFPs.

a)

b)

c)

d)

e)

  1. What is the normal caloric range for onsite and take-home rations for targeted SFPs?Circle the correct answer.

a)500–700 kcals onsite and 700–1000 kcals take-home

b)700–900 kcals onsite and 900–1100 kcals take-home

c)500–1000 kcals onsite and 1000–1200 kcals take-home

d)500–700 kcals onsite and 1000–1200 kcals take-home

  1. Which of the following are standard medical treatments as part of targeted SFP?Circle the correct answers.

a)Oral rehydration solution for diarrhoea

b)Anti-helminthic treatment

c)Diphtheria vaccination

d)Measles vaccination

e)Iodine supplementation

f)Vitamin A supplementation

g)Malaria prophylaxis

  1. What are the target levels for the three main indicators used for monitoring programme performance of targeted SFPs?Circle the correct answers.

a)recovery rate > 90%

b)recovery rate >75%

c)death rate < 10%

d)death rate <3%

e)defaulting rate < 15%

f)defaulting rate < 5%

  1. How would you assess programme impact?
  1. How would you assess programme coverage?
  1. What are three weaknesses and criticisms of supplementary feeding programmes in emergencies?

Handout 1b:What do you know about the management of moderate acute malnutrition in emergencies?: questionnaire answers

1.Targeted SFPs target moderately malnourished individuals while blanket SFPs target all those in ‘at risk groups’ regardless of nutritional status.

Or

Targeted SFPs are meant to be implemented in conjunction with adequate general rations while blanket SFPs are often implemented when GFDs have not been established or are inadequate.

Or

The objectives of targeted SFPs are primarily curative, while the objectives for blanket SFPs are primarily preventive.

2. a), c), d), e)

3.a), b), c)

4. c), d)

5. a), b), c), f)

6. a) Children under five

b)Pregnant and lactating women

c)Malnourished adults

d)The elderly

e)Adolescents

7. d)

8. a), b), d), f)

9. b), d), e)

10. Programme impact can be assessed by comparing results of nutrition surveys before and after the intervention but accounting for seasonal factors, changes in general food security and disease patterns.Programme impact can also be assessed by looking at programme indicators, e.g., recovery, death and default in conjunction with coverage data.

11. Programme coverage can best be assessed by adding a question to nutrition surveys to determine what percentage of children identified as malnourished in the survey are enrolled in the supplementary feeding programme e.g. the “direct” method.

The ‘indirect’ method compares the estimated number of children with MAM in the population based on malnutrition rates reported in the anthropometric survey to the actual number of children attending the programme. Increasingly a new methodology know as Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) is being used as an on-going monitoring tool to look a barriers to uptake in selective feeding programmes.

12.i) May be difficult to implement in conflict situations. Sphere targets may be unattainable.

ii)Requires considerable resources to allocate small quantities of food.

iii)Default rates may be high in many contexts. Reasons for default are not always well understood.

iv)May not impact levels of wasting at population level unless coverage is high.

v)Need to combine with other interventions but limited documentation of best practice and effectiveness of these linkages.

vi)RUSFs or commercial products may lead to better outcomes but use of such products raises issues of sustainability.

4.Classroom exercises

This section provides examples of practical exercises that can be carried out in a classroom context by participants individually or in groups. Practical exercises are useful between plenary sessions, where the trainer has done most of the talking, as they provide an opportunity for participants to engage actively in the session. The choice of classroom exercises will depend upon the learning objectives and the time available. Trainers should adapt the exercises presented in this section to make them appropriate to the particular participant group. Ideally, trainers should use case examples with which they are familiar.

Exercise 2: Assessing the adequacy of a ration

What is the learning objective?
  • To know how to assess the adequacy of a ration
When should this exercise be done?
  • After ration levels and ration adequacy have been introduced
How long should the exercise take?
  • 40 minutes
What materials are needed
  • Handout 2a: Assessing ration adequacy – two case studies
  • Handout 2b: Assessing ration adequacy – two case studies: model answers
  • Handout 2c: Nutrient value per 100g
  • Hand-held calculator
What does the trainer need to prepare?
  • Prepare a case study for an area that is familiar to the participants based on the template in Handout 2a or use the given handout.
Instructions
Step 1:Give each participant a copy of Handout 2a or similar and food tables.
Step 2:Give participants working in pairs 15 minutes to read one of the case studies and complete the table.
Step 3: Allow 25 minutes of discussion and feedback in plenary.
Discussion points for feedback in plenary
  • Compare and contrast the two rations particularly with regard to how they are adapted or not adapted to the context
  • Explore issues of ration sharing and substitution effect
  • Highlight the importance of information on the general ration in terms of setting ration levels

Handout 2a: Assessing ration adequacy – two case studies

Time for completion:40 minutes

Allow 15 minutes for this task and 25 minutes for feedback.Participants may work in pairs.Each pair should address questions from one of the two case studies.

Case study A: Wet feeding in Kuito, Angola

During October 1994, an SFP providing on-site feeding (“wet feeding”) was established in Kuito town. Both government (UNITA) and rebel(MPLA) forces were present within the city. The security situation was extremely poor and therefore mothers did not like to leave their other children at home for long periods.A wet SFP provided only one meal per day for the children so that they could return home quickly. The meal consisted of one cup (300ml) of high-energy milk (1kcal/1ml) and one traditional meal (60g rice, 30g beans and 10ml oil)).