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

ABSTRACT: 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.

SUBMITTER: Charle-Cuellar P

PROVIDER: S-EPMC8700149 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundCommunity health worker (CHW)-delivered acute malnutrition treatment programs have been tested previously, but not with low-literate/-numerate cadres who operate in areas with the highest malnutrition burden and under-five mortality rates. The International Rescue Committee developed low-literacy-adapted tools and treatment protocol to enable low-literate/-numerate community-based distributors (CBD, the CHW cadre in South Sudan) to treat children for severe acute malnutrition (SAM) in their communities.MethodsWe conducted a prospective cohort study in March-September 2017, with 44 CBDs enrolling a total of 308 SAM children into treatment in their communities. Child treatment outcomes and length of treatment were documented. Uncomplicated SAM cases, defined for our study as children with mid-upper arm circumference (MUAC) of 90 to <115 mm or bilateral pitting oedema, without any medical complications, were treated for up to 16 weeks, and were considered fully recovered when they reached MUAC≥125 mm for two consecutive weeks.ResultsThe recovery rate from the severe to the moderate acute malnutrition (MAM) cut-off of MUAC 115 mm was 91% (95% confidence interval (CI) = 88%-95%). The median length of treatment was five weeks. The recovery rate of children from SAM to full recovery was 75% (95% CI = 69%-81%). The median time to full recovery was eight weeks. The recovery rates reported here exclude children referred for care from the denominator, per standard reporting of acute malnutrition treatment recovery rates. When the data were compared against routine monitoring and evaluation data from nearby static clinics, children treated by CBDs appeared to have improved continuity of care and shorter time to recovery.ConclusionsThe recovery rate for SAM children enrolled in acute malnutrition treatment by low-literate CBDs shows promise that deploying CHWs to treat SAM in areas with high prevalence and low treatment access may lead to higher recovery, better continuity of care in the transition between SAM and MAM, and shorter treatment time. Proper adaptations of tools and protocols can empower CHW cadres with low literacy and numeracy to successfully complete treatment steps. Key questions of scalability and cost-effectiveness remain.

Project description:BACKGROUND:The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS:Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS:In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS:This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.

Project description:Severe acute malnutrition (SAM) affects over 16.6 million children worldwide. The integrated Community Case Management (iCCM) strategy seeks to improve essential health by means of nonmedical community health workers (CHWs) who treat the deadliest infectious diseases in remote rural areas where there is no nearby health center. The objective of this study was to assess whether SAM treatment delivered by CHWs close to families' locations may improve the early identification of cases compared to outpatient treatment at health facilities (HFs), with a decreased number complicated cases referred to stabilization centers, increased anthropometric measurements at admission (closer to the admission threshold) and similarity in clinical outcomes (cure, death, and default). The study included 930 children aged 6 to 59 months suffering from SAM in the Kita district of the Kayes Region in Mali; 552 children were treated by trained CHWs. Anthropometric measurements, the presence of edema, and other medical signs were recorded at admission, and the length of stay and clinical outcomes were recorded at discharge. The results showed fewer children with edema at admission in the CHW group than in the HF group (0.4% vs. 3.7%; OR = 10.585 [2.222-50.416], p = 0.003). Anthropometric measurements at admission were higher in the CHW group, with fewer children falling into the lowest quartiles of both weight-for-height z-scores (20.2% vs. 31.5%; p = 0.002) and mid-upper arm circumference (18.0% vs. 32.4%; p<0.001), than in the HF group. There was no difference in the length of stay. More children in the CHW group were cured (95.9% vs. 88.7%; RR = 3.311 [1.772-6.185]; p<0.001), and there were fewer defaulters (3.7% vs. 9.8%; RR = 3.345 [1.702-6.577]; p<0.001) than in the HF group. Regression analyses demonstrated that less severe anthropometric measurements at admission resulted in an increased probability of cure at discharge. The study results also showed that CHWs provided more integrated care, as they diagnosed and treated significantly more cases of infectious diseases than HFs (diarrhea: 36.0% vs. 18.3%, p<0.001; malaria: 41.7% vs. 19.8%, p<0.001; acute respiratory infection: 34.8% vs. 25.2%, p = 0.007). The addition of SAM treatment in the curative tasks that the CHWs provided to the families resulted in earlier admission and more integrated care for children than those associated with HFs. CHW treatment also achieved better discharge outcomes than standard community treatment.

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

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