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López-Ejeda N, Charle-Cuéllar P, Samake S, Dougnon AO, Sánchez-Martínez LJ, Samake MN, Bagayoko A, Bunkembo M, Touré F, Vargas A, Guerrero S. Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali. Front Public Health 2024; 12:1283148. [PMID: 38450139 PMCID: PMC10915236 DOI: 10.3389/fpubh.2024.1283148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs). Methods A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units. Results The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%). Implications Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.
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Affiliation(s)
- Noemí López-Ejeda
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | - Salimata Samake
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Mahamadou N’tji Samake
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Aliou Bagayoko
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Magloire Bunkembo
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | - Fanta Touré
- West and Central Africa Regional Office, Action Against Hunger, Dakar, Senegal
| | - Antonio Vargas
- Nutrition and Health Department, Action Against Hunger, Madrid, Spain
| | - Saul Guerrero
- Child Nutrition and Development Office, UNICEF, New York, NY, United States
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Sánchez-Martínez LJ, Charle-Cuéllar P, Gado AA, Dougnon AO, Sanoussi A, Ousmane N, Lazoumar RH, Toure F, Vargas A, Hernández CL, López-Ejeda N. Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger. Front Nutr 2023; 10:1253545. [PMID: 38099186 PMCID: PMC10719846 DOI: 10.3389/fnut.2023.1253545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers. Methods This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers. Results The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff. Conclusion The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.
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Affiliation(s)
- Luis Javier Sánchez-Martínez
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey, Niger
| | | | | | - Fanta Toure
- Action Against Hunger, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Candela Lucía Hernández
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Noemí López-Ejeda
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
- EPINUT Research Group (Ref. 920325), Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Zacks R, Ververs M, Hwang C, Mahdi A, Leidman E. Child nutritional status as screening tool for identifying undernourished mothers: an observational study of mother–child dyads in Mogadishu, Somalia, from November 2019 to March 2020. BMJ Nutr Prev Health 2021; 4:501-509. [PMID: 35028519 PMCID: PMC8718858 DOI: 10.1136/bmjnph-2021-000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022] Open
Abstract
Background Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible to undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves. Methods The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6–59 months, parity and gestational status for women aged 19–50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <−2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m2 for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status. Results A total of 93.6% (2142/2288) of enrolled dyads met inclusion criteria. Wasting was observed among 57.5% of children; 20.2% of pregnant mothers, 20.0% of lactating mothers and 7.95% of non-PLMs were undernourished. Models suggest significant, positive associations between child and maternal anthropometrics; a one-unit increase in WHZ and a 1 cm increase in child MUAC were associated with 0.22 kg/m2 (95% CI 0.22 to 0.24) and 0.19 kg/m2 (95% CI 0.16 to 0.21) increases in maternal BMI, respectively, and 0.20 cm (95% CI 0.18 to 0.22) and 0.24 cm (95% CI 0.23 to 0.25) increases in maternal MUAC, respectively. Adjusted R2 values were low (range 0.06–0.10). Conclusions Undernutrition among non-PLMs illustrates the importance of expanding screening. However, while significant, the strength of association between mother and child anthropometrics does not support child nutritional status as a screening tool for identifying at-risk mothers.
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Affiliation(s)
- Rachael Zacks
- Emergency Response and Recovery Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mija Ververs
- Emergency Response and Recovery Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cindy Hwang
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Adan Mahdi
- Save the Children Somalia, Mogadishu, Somalia
| | - Eva Leidman
- Emergency Response and Recovery Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Dalglish SL, Seni Badou M, Sirat A, Abdullahi O, Adalbert MFE, Biotteau M, Goldsmith A, Kozuki N. Combined protocol for severe and moderate acute malnutrition in emergencies: Stakeholders perspectives in four countries. MATERNAL AND CHILD NUTRITION 2019; 16:e12920. [PMID: 31773867 PMCID: PMC7083443 DOI: 10.1111/mcn.12920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/07/2019] [Accepted: 11/11/2019] [Indexed: 12/29/2022]
Abstract
Each year, acute malnutrition affects an estimated 52 million children under 5 years of age. Current global treatment protocols divide treatment of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) despite malnutrition being a spectrum disease. A proposed Combined Protocol provides for (a) treatment of MAM and SAM at the same location; (b) diagnosis using middle‐upper‐arm circumference (MUAC) and oedema only; (c) treatment using a single product, ready‐to‐use‐therapeutic food (RUTF), and (d) a simplified dosage schedule for RUTF. This study examines stakeholders' knowledge of and opinions on the Combined Protocol in Niger, Nigeria, Somalia, and South Sudan. Data collection included a document review followed by in‐depth interviews with 50 respondents from government, implementing partners, and multilateral agencies, plus 11 global and regional stakeholders. Data were analysed iteratively using thematic content analysis. We find that acute malnutrition protocols in these countries have not been substantially modified to include components of the Combined Protocol, although aspects were accepted for use in emergencies. Respondents generally agreed that MAM and SAM treatment should be provided in the same location, however they said MUAC and oedema‐only diagnosis, although more field‐ready than other diagnostic measures, did not necessarily catch all malnourished children and may not be appropriate for “tall and slim” morphologies. Similarly, using only RUTF presented inherent logistical advantages, but respondents worried about pipeline issues. Respondents did not express strong opinions about simplified dosage schedules. Stakeholders interviewed indicated more evidence is needed on the operational implications and effectiveness of the Combined Protocol in different contexts.
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Affiliation(s)
- Sarah L Dalglish
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Amin Sirat
- Nutrition Department, International Rescue Committee, Maiduguri, Nigeria
| | - Omar Abdullahi
- Nutrition Department, International Rescue Committee, Mogadishu, Somalia
| | | | - Marie Biotteau
- Nutrition Department, International Rescue Committee, Bamako, Mali
| | - Amelia Goldsmith
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Naoko Kozuki
- Nutrition Department, International Rescue Committee, Washington, DC, USA
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