نبذة مختصرة : Background Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. Methods and findings A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6–23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers’ participation and supplement children’s diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. Conclusions Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. Trial registration ClinicalTrials.gov NCT02323815.
Lieven Huybregts and colleagues show reduced incidence of acute malnutrition in children in Mali when supplements are provided at monthly screening sessions.
Author summary Why was this study done? Child acute malnutrition (AM) is a serious public health problem affecting 52 million children under the age of 5 years worldwide. Many low and middle-income countries have adopted the community-based management of acute malnutrition (CMAM) to treat AM. CMAM is a treatment model endorsed by the World Health Organization that relies on community workers, often volunteers, to conduct first-line screening in the community and refer identified cases to a health facility to enroll in treatment. AM cases without medical complications are treated using energy-dense therapeutic supplements through an outpatient treatment program. The effectiveness of CMAM in the field is often limited because of key barriers, including the low proportion of caregivers taking their child to the screening sessions and low enrollment in CMAM treatment. What did the researchers do and find? The researchers randomly allocated 48 health center catchment areas in two health districts in Mali to an intervention arm or a comparison arm. In both study arms, community health volunteers organized monthly meetings at village level to screen children 6–23 months of age for AM and conducted group behavior change communication (BCC) on child nutrition, health, sanitation, and hygiene. The intervention arm received small-quantity lipid-based nutrient supplements (SQ-LNSs) to incentivize caregivers to attend these monthly meetings and to increase the intake of energy and essential micronutrients in children. SQ-LNSs consist of a peanut-based spread fortified with vitamins and minerals. Researchers found that the intervention led to significantly more children being screened for AM (40 percentage points more than in the comparison arm) but that this result did not lead to more children being treated for AM. The intervention was effective in preventing AM, lowering the risk of developing AM by almost a third. What do these results mean? The SQ-LNSs provided a strong incentive for caregivers to attend the community-level monthly meetings and to get their children screened for AM. The lack of impact on AM treatment, despite the positive results on the percentage of children screened, suggests that there remain important barriers that prevent children who are screened and identified as suffering from AM from being referred, enrolled in the program, and treated. Providing SQ-LNSs to increase attendance at screening and BCC sessions offered at the community level is an important intervention to prevent child AM. However, more needs to be done to address the constraints that prevent AM children from receiving adequate referral and enrolling and completing CMAM treatment.
Processing Request
No Comments.