Integrated and simplified approaches to community management of acute malnutrition in rural Kenya: a cluster randomized trial protocol

Abstract Background In many low income countries, the majority of acutely malnourished children are either brought to the health facility late or never at all due to reasons related to distance and associated costs. Integrated community case management (iCCM) is an integrated approach addressing disease and malnutrition through use of community health volunteers (CHVs) in children under-5 years. Evidence on the potential impact and practical experiences on integrating community-based management of acute malnutrition as part of an iCCM package is not well documented. In this study, we aim to investigate the effectiveness and cost effectiveness of integrating management of acute malnutrition into iCCM. Methods This is a two arm parallel groups, non-inferiority cluster randomized community trial (CRT) employing mixed methods approach (both qualitative and quantitative approaches). Baseline and end line data will be collected from eligible (malnourished) mother/caregiver-child dyads. Ten community units (CUs) with a cluster size of 24 study subjects will be randomized to either an intervention (5 CUs) and a control arm (5 CUs). CHV in the control arm, will only screening and refer MAM/SAM cases to the nearby health facility for treatment by healthcare professionals. In the intervention arm, however; CHVs will be trained both to screen/diagnose and also treat moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) without complication. A paired-matching design where each control group will be matched with intervention group with similar characteristics will be matched to ensure balance between the two groups with respect to baseline characteristics. Qualitative data will be collected using key informant and in-depth interviews (KIIs) and focused group discussions (FGDs) to capture the views and experiences of stakeholders. Discussion Our proposed intervention is based on an innovative approach of integrating and simplifying SAM and MAM management through CHWs bring the services closer to the community. The trial has received ethical approval from the Ethics Committee of AMREF Health Africa - Ethical and Scientific Review Committee (AMREF- ESRC), Nairobi, Kenya. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, and presented to local and international conferences. Trial registration PACTR201811870943127; Pre-results. 26 November 2018.

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Community case management of chest indrawing pneumonia in children aged 2 to 59 months by community health workers: study protocol for a multi-country cluster randomized open label non-inferiority trial

International Journal of Clinical Trials ◽

10.18203/2349-3259.ijct20201719 ◽

2020 ◽

Vol 7 (2) ◽

pp. 131

Author(s):

Yasir Bin Nisar

Keyword(s):

Case Management ◽

Health Facility ◽

Health Workers ◽

Intervention Group ◽

World Health ◽

Control Group ◽

Community Case Management ◽

Open Label ◽

Oral Amoxicillin ◽

Cluster Randomized

Background: The World Health Organization (WHO) integrated management of childhood illness (IMCI) protocol recommends treatment of chest indrawing in 2-59 months old children with oral amoxicillin by trained health facility workers. Whereas, the WHO/UNICEF integrated community case management (iCCM) protocol recommends referral by community level health workers (CLHWs) to a health facility. This study aims to evaluate whether CLHWs can treat chest indrawing pneumonia effectively and safely.Methods: This multi-centre cluster randomized controlled open label, non-inferiority trial will be conducted in Bangladesh, Ethiopia, India and Malawi. All sites will use a common protocol with the same study design, participants, intervention, control and outcomes. CLHWs will identify 2-59 months old children with chest indrawing. Study supervisors, trained in the iCCM protocol, will confirm CLHWs’ findings. Pulse oximetry will be used to identify hypoxaemic children. In the intervention group, enrolled children will be treated with oral amoxicillin for 5 days, and in the control group they will be referred to a health facility, after providing first dose of oral amoxicillin. An independent outcome assessor will visit each enrolled child on days 6 and 14 of enrolment, to assess study outcomes.Conclusions: If CLHWs can effectively and safely treat chest indrawing pneumonia in 2-59 months old children, it will increase access to pneumonia treatment substantially, as in many settings, health facilities and trained health workers are not easily accessible. Moreover, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with the IMCI protocol.Trial Registration: The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.

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Incidence Correction Factors for Moderate and Severe Acute Child Malnutrition From 2 Longitudinal Cohorts in Mali and Burkina Faso

American Journal of Epidemiology ◽

10.1093/aje/kwaa139 ◽

2020 ◽

Vol 189 (12) ◽

pp. 1623-1627

Author(s):

Francisco M Barba ◽

Lieven Huybregts ◽

Jef L Leroy

Keyword(s):

Burkina Faso ◽

Low Income ◽

Severe Acute Malnutrition ◽

Acute Malnutrition ◽

Cross Sectional ◽

Incidence Data ◽

Moderate Acute Malnutrition ◽

Cluster Randomized ◽

Definition Of ◽

Mid Upper Arm Circumference

Abstract Child acute malnutrition (AM) is an important cause of child mortality. Accurately estimating its burden requires cumulative incidence data from longitudinal studies, which are rarely available in low-income settings. In the absence of such data, the AM burden is approximated using prevalence estimates from cross-sectional surveys and the incidence correction factor $K$, obtained from the few available cohorts that measured AM. We estimated $K$ factors for severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) from AM incidence and prevalence using representative cross-sectional baseline and longitudinal data from 2 cluster-randomized controlled trials (Innovative Approaches for the Prevention of Childhood Malnutrition—PROMIS) conducted between 2014 and 2017 in Burkina Faso and Mali. We compared K estimates using complete (weight-for-length z score, mid-upper arm circumference (MUAC), and edema) and partial (MUAC, edema) definitions of SAM and MAM. $K$ estimates for SAM were 9.4 and 5.7 in Burkina Faso and in Mali, respectively; K estimates for MAM were 4.7 in Burkina Faso and 5.1 in Mali. The MUAC and edema–based definition of AM did not lead to different $K$ estimates. Our results suggest that $K$ can be reliably estimated when only MUAC and edema-based data are available. Additional studies, however, are required to confirm this finding in different settings.

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A Feasibility Study to Assess Non-clinical Community Health Workers’ Capacity to use Simplified Protocols and Tools to Treat Severe Acute Malnutrition in Niger State Nigeria

10.21203/rs.3.rs-577712/v1 ◽

2021 ◽

Author(s):

Olatunde Adesoro ◽

Olusola Oresanya ◽

Helen Counihan ◽

Prudence Hamade ◽

Dare Eguavon ◽

...

Keyword(s):

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Severe Acute Malnutrition ◽

Full Recovery ◽

Childhood Mortality ◽

Acute Malnutrition ◽

Community Case Management ◽

Integrated Community Case Management ◽

Clinical Community

Abstract Background: Severe acute malnutrition (SAM) is a major determinant of childhood mortality and morbidity. Although integrated community case management (iCCM) of childhood illnesses is a strategy for increasing access to life-saving treatment, malnutrition is not properly addressed in the guidelines. This study aimed to determine whether non-clinical Community Health Workers (called Community-Oriented Resource Persons, CORPs) implementing iCCM could use simplified tools to treat uncomplicated SAM.Methods: The study used a sequential mixed-method design and was conducted between July 2017 and May 2018. Sixty CORPs already providing iCCM services were trained and deployed in their communities with the target of enrolling 290 SAM cases. Competency of CORPs to treat and the treatment outcomes of enrolled children were documented. SAM cases with MUAC of 9cm to < 11.5cm without medical complications were treated for up to 12 weeks. Full recovery was at MUAC≥12.5cm for two consecutive weeks. Supervision and quantitative data capturing were done weekly while qualitative data were collected after the intervention.Results: CORPs scored 93.1% on first assessment and increment of 0.11 (95% CI: 0.05 – 0.18) points per additional supervision conducted. The cure rate from SAM to full recovery, excluding referrals from the denominator in line with the standard for reporting SAM recovery rates, was 73.5% and the median length of treatment was seven weeks. SAM cases enrolled at 9cm to <10.25cm MUAC had 29% less likelihood of recovery compared to those enrolled at 10.25cm to <11.5cm. CORPs were not burdened by the integration of SAM into iCCM and felt motivated by children’s recovery. Operational challenges like bad terrains for supervision, supply chain management and referrals were reported by supervisors, while Government funding was identified as key for sustainability.Conclusion: The study demonstrated that with training and supportive supervision, CORPs in Nigeria can treat SAM among under-fives, and refer complicated cases using simplified protocols as part of an iCCM programme. This approach seemed acceptable to all stakeholders, however, the effect of the extra workload of integrating SAM into iCCM on the quality of care provided by the CORPs should be assessed further.

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Effectiveness of screening and treatment of children with severe acute malnutrition by community health workers in Simiyu region, Tanzania: a quasi-experimental pilot study

Scientific Reports ◽

10.1038/s41598-021-81811-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Calistus Wilunda ◽

Fortihappiness Gabinus Mumba ◽

Giovanni Putoto ◽

Gloria Maya ◽

Elias Musa ◽

...

Keyword(s):

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Severe Acute Malnutrition ◽

Intervention Group ◽

Control Area ◽

Acute Malnutrition ◽

Control Group ◽

Treatment Coverage ◽

Quasi Experimental

AbstractHealth system constraints hamper treatment of children with severe acute malnutrition (SAM) in Tanzania. This non-inferiority quasi-experimental study in Bariadi (intervention) and Maswa (control) districts assessed the effectiveness, coverage, and cost-effectiveness of SAM treatment by community health workers (CHWs) compared with outpatient therapeutic care (OTC). We included 154 and 210 children aged 6–59 months with SAM [mid-upper arm circumference (MUAC) < 11.5 cm] without medical complications in the control and intervention districts, respectively. The primary treatment outcome was cure (MUAC ≥ 12.5 cm). We performed costing analysis from the provider’s perspective. The probability of cure was higher in the intervention group (90.5%) than in the control group (75.3%); risk ratio (RR) 1.17; 95% CI 1.05, 1.31 and risk difference (RD) 0.13; 95% CI 0.04, 0.23. SAM treatment coverage was higher in the intervention area (80.9%) than in the control area (41.7%). The cost per child treated was US$146.50 in the intervention group and US$161.62 in the control group and that per child cured was US$161.77 and US$215.49 in the intervention and control groups, respectively. The additional costs per an additional child treated and cured were US$134.40 and US$130.92, respectively. Compared with OTC, treatment of children with uncomplicated SAM by CHWs was effective, increased treatment coverage and was cost-effective.

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Effectiveness and Coverage of Treatment for Severe Acute Malnutrition Delivered by Community Health Workers in the Guidimakha Region, Mauritania

Children ◽

10.3390/children8121132 ◽

2021 ◽

Vol 8 (12) ◽

pp. 1132

Author(s):

Pilar Charle-Cuéllar ◽

Noemí Lopez-Ejeda ◽

Hassane Toukou Souleymane ◽

Diagana Yacouba ◽

Moussa Diagana ◽

...

Keyword(s):

Community Health ◽

Community Health Workers ◽

Outpatient Treatment ◽

Health Workers ◽

Severe Acute Malnutrition ◽

Intervention Group ◽

Acute Malnutrition ◽

Control Group ◽

Control Zone ◽

Significant Difference

Geographical and economic access barriers to health facilities (HF) have been identified as some of the most important causes of the low coverage of severe acute malnutrition (SAM) treatment. The objective of this study is to assess the effectiveness and coverage of SAM treatment delivered by community health workers (CHWs) in the Guidimakha region in Mauritania, compared to the HF based approach. This study was a nonrandomized controlled trial, including two rural areas. The control group received outpatient treatment for uncomplicated SAM from HF, whilst the intervention group received outpatient treatment for uncomplicated SAM from HF or CHWs. A total of 869 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 82.3% in the control group, and 76.4% in the intervention group, we found no significant difference between the groups. Coverage in the intervention zone increased from 53.6% to 71.7%. In contrast, coverage remained at approximately 44% in the control zone from baseline to end-line. This study is the first to demonstrate in Mauritania that the decentralization model of CHWs treating SAM improves acute malnutrition treatment coverage and complies with the international quality standards for community treatment of acute malnutrition. The non-randomized study design may limit the quality of the evidence, but these results could be used by political decision-makers as a first step in revising the protocol for acute malnutrition management.

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Impact of Integration of Severe Acute Malnutrition Treatment in Primary Health Care Provided by Community Health Workers in Rural Niger

Nutrients ◽

10.3390/nu13114067 ◽

2021 ◽

Vol 13 (11) ◽

pp. 4067

Author(s):

Abdias Ogobara Dougnon ◽

Pilar Charle-Cuéllar ◽

Fanta Toure ◽

Abdoul Aziz Gado ◽

Atté Sanoussi ◽

...

Keyword(s):

Community Health ◽

Community Health Workers ◽

Group Treatment ◽

Outpatient Treatment ◽

Health Workers ◽

Severe Acute Malnutrition ◽

Intervention Group ◽

Acute Malnutrition ◽

Control Group ◽

Treatment Coverage

The present study aimed to assess the effectiveness and impact on treatment coverage of integrating severe acute malnutrition (SAM) treatment at the health hut level by community health workers (CHWs). This study was a non-randomized controlled trial, including two rural communes in the health district of Mayahi: Maïreyreye (control) and Guidan Amoumoune (intervention). The control group received outpatient treatment for uncomplicated SAM from health facilities (HFs), while the intervention group received outpatient treatment for uncomplicated SAM from HFs or CHWs. A total of 2789 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 72.1% in the control group, and 77.2% in the intervention group. Treatment coverage decreased by 8.3% in the control area, while the group of CHWs was able to mitigate that drop and even increase coverage by 3%. This decentralized treatment model of acute malnutrition with CHWs allowed an increase in treatment coverage while maintaining a good quality of care. It also allowed the early inclusion of children in less severe conditions. These results may enhance the Niger Ministry of Health to review the management of SAM protocol and allow CHWs to treat acute malnutrition.

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Omitting edema measurement: how much acute malnutrition are we missing?

American Journal of Clinical Nutrition ◽

10.3945/ajcn.115.108282 ◽

2015 ◽

Vol 102 (5) ◽

pp. 1176-1181 ◽

Cited By ~ 14

Author(s):

Severine Frison ◽

Francesco Checchi ◽

Marko Kerac

Keyword(s):

Low Income ◽

Large Scale ◽

Severe Acute Malnutrition ◽

Acute Malnutrition ◽

Low Income Countries ◽

Public Health Issue ◽

Data Sets ◽

Cross Sectional Survey ◽

Prevalence Estimates ◽

The Impact

ABSTRACT Background: Acute malnutrition is a major public health issue in low-income countries. It includes both wasting and edematous malnutrition, but the terms wasting and acute malnutrition are often used interchangeably. Little is known about the burden of edematous malnutrition, and few large-scale surveys measure it. Objective: Most acute malnutrition might be captured by the measurement of wasting alone, but this is unknown. This article aims to fill this gap. Design: This article presents a secondary data analysis of 852 nutrition cross-sectional survey data sets of children aged 6–59 mo. The data sets assembled included surveys from East, West, South, and Central Africa; the Caribbean; and Asia. The overlap between edematous malnutrition and wasting was assessed, and the impact of including/excluding edema on acute malnutrition prevalence estimates was evaluated. Results: The prevalence of edematous malnutrition varied from 0% to 32.9%, and children were more likely to have bilateral edema in Central and South Africa (OR: 4; 95% CI: 2.8, 5.6). A large proportion of children with edematous malnutrition were not wasted [62% and 66% based on midupper arm circumference (MUAC) and weight-for-height (WFH), respectively], and most were not severely wasted (83% and 86% based on MUAC and WFH, respectively). When wasting and global acute malnutrition prevalence estimates as well as severe wasting and severe acute malnutrition prevalence estimates overall were compared, the differences between estimates were small (median of 0.0% and mean of 0.3% based on WFH and MUAC for global estimates and slightly higher median of 0.1% and mean of 0.4% based on MUAC and WFH, respectively, for the severe forms), but the picture was different at the regional level. Conclusions: The terms acute malnutrition and wasting should not be used interchangeably. The omission of the measurement of edema can have important repercussions, especially at the nutrition program level.

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A feasibility study to assess non-clinical community health workers’ capacity to use simplified protocols and tools to treat severe acute malnutrition in Niger state Nigeria

BMC Health Services Research ◽

10.1186/s12913-021-07118-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Olatunde Adesoro ◽

Olusola Oresanya ◽

Helen Counihan ◽

Prudence Hamade ◽

Dare Eguavon ◽

...

Keyword(s):

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Severe Acute Malnutrition ◽

Full Recovery ◽

Childhood Mortality ◽

Acute Malnutrition ◽

Community Case Management ◽

Integrated Community Case Management ◽

Clinical Community

Abstract Background Severe acute malnutrition (SAM) is a major determinant of childhood mortality and morbidity. Although integrated community case management (iCCM) of childhood illnesses is a strategy for increasing access to life-saving treatment, malnutrition is not properly addressed in the guidelines. This study aimed to determine whether non-clinical Community Health Workers (called Community-Oriented Resource Persons, CORPs) implementing iCCM could use simplified tools to treat uncomplicated SAM. Methods The study used a sequential multi-method design and was conducted between July 2017 and May 2018. Sixty CORPs already providing iCCM services were trained and deployed in their communities with the target of enrolling 290 SAM cases. Competency of CORPs to treat and the treatment outcomes of enrolled children were documented. SAM cases with MUAC of 9 cm to < 11.5 cm without medical complications were treated for up to 12 weeks. Full recovery was at MUAC≥12.5 cm for two consecutive weeks. Supervision and quantitative data capturing were done weekly while qualitative data were collected after the intervention. Results CORPs scored 93.1% on first assessment and increment of 0.11 (95% CI, 0.05–0.18) points per additional supervision conducted. The cure rate from SAM to full recovery, excluding referrals from the denominator in line with the standard for reporting SAM recovery rates, was 73.5% and the median length of treatment was 7 weeks. SAM cases enrolled at 9 cm to < 10.25 cm MUAC had 31% less likelihood of recovery compared to those enrolled at 10.25 cm to < 11.5 cm. CORPs were not burdened by the integration of SAM into iCCM and felt motivated by children’s recovery. Operational challenges like bad terrains for supervision, supply chain management and referrals were reported by supervisors, while Government funding was identified as key for sustainability. Conclusion The study demonstrated that with training and supportive supervision, CORPs in Nigeria can treat SAM among under-fives, and refer complicated cases using simplified protocols as part of an iCCM programme. This approach seemed acceptable to all stakeholders, however, the effect of the extra workload of integrating SAM into iCCM on the quality of care provided by the CORPs should be assessed further.

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