The use of SQUEAC methodology to assess CMAM for Severe Acute Malnutrition (SAM) programme coverage in Bihar, India. E Marino, N Salse, A Jha, S Burza Médecins Sans Frontières – India / MSF-OCBA. Barcelona, Spain
Background MSF OCBA has been implementing a Community Management of Acute Malnutrition (CMAM) programme in Biraul block of Darbhanga district, Bihar, India since February 2009 . To evaluate program coverage, barriers to access and uptake, and identify reasons for high default rates (37%), a SQUEAC (Semi-Quantitative Evaluation of Access and Coverage) assessment was conducted for three weeks in April 2011 in the programme catchment area of Biraul Block.
Methods SQUEAC methodology: a two-stage sampling method. First stage: routine program data and qualitative data are collected to identify areas of low or high coverage and reasons for coverage failure, and a hypothesis is formulated. Second stage: small area surveys are conducted to confirm or refuse the hypothesis. Target Population: All children 6-59 months with SAM (defined as MUAC <115 and/or bipedal oedema), currently enrolled or not enrolled in the programme, and children 6-59 months non-SAM enrolled in the program identified using “active and adaptive” case finding. The target population for qualitative interviews included community key informants and mothers/caretakers. Data Collection: Quantitative and qualitative data was collected through the use of structured questionnaires, informal focus group discussions (FGD) and structured/semi-structured interviews. The assessment team comprised 10 enumerators, trained on anthropometry and selection criteria/field practices. Analysis: Estimates for point and period coverage were calculated using Bayesian SQUEAC formulas, and qualitative data was coded to identify barriers to service access and uptake and reasons for defaulting
Results
Reasons for non-coverage in previously covered cases
Non-respondent
Recently absent
Rejected
Cured
Defaulter
0%
10%
20%
30%
40%
Coverage: Low overall (SPHERE standard >50%), with point and period coverage of 20.3% (95% CI 12.6-29.9) and 24.3 % (95% CI 16.1 – 33.9) respectively. 30% of SAM uncovered cases had been previously enrolled in programme Main barriers: Low programme awareness, poor recognition of malnutrition as a disease, time constrain of caregivers and seasonal and agricultural patterns. Additional barriers amongst defaulters: Poor acceptance of RUTF by the child, and inappropriate perception of self recovery (92% of defaulters found SAM at the time of the survey). Advantages: Use of existing data and information minimizing the need for data collection; identification of precise barrier and geographical gaps to be targeted to increase coverage. Disadvantages: Need for accurate and consistent program and monitoring data; reliance on key informants ability to identify malnourished children in the community due to lack of recognition of SAM; the need of well trained staff to conduct interviews.
Conclusions The SQUEAC methodology is an effective, low resource and low cost tool to assess coverage of CMAM programmes in the Indian context and it provides invaluable qualitative data that can be used to direct programme priorities. This survey enabled MSF to suspect a high relapse rate, low population coverage and the need to strengthen outreach and IEC components with specific message delivery resulting in a more cost-effective and efficacious intervention.