Date Published: August 27, 2019
Publisher: Public Library of Science
Author(s): Elodie Becquey, Lieven Huybregts, Amanda Zongrone, Agnes Le Port, Jef L. Leroy, Rahul Rawat, Mariama Touré, Marie T. Ruel, Lars Åke Persson
Abstract: BackgroundCommunity management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM’s effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children <2 years of age is conducted during well-baby consultations (consultation du nourrisson sain [CNS]) at health centers. We hypothesized that the integration of a preventive package including age-appropriate behavior change communication (BCC) on nutrition, health, and hygiene practices and a monthly supply of small-quantity lipid-based nutrient supplements (SQ-LNSs) to the monthly screening would increase AM screening and treatment coverage and decrease the incidence and prevalence of AM.Methods and findingsWe used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0–17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children’s average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10–26, P < 0.001; longitudinal study: +23 pp, 95% CI 17–29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09–16, P = 0.047; longitudinal study: +7.7 pp, 95% CI −1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75–1.3, P = 0.88), or AM prevalence (cross-sectional study: −0.46 pp, 95% CI −4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage.ConclusionsAdding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery.Trial registrationClinicalTrials.gov NCT02245152.
Partial Text: Wasting, an indicator of acute malnutrition (AM), affects 52 million children globally  and is a major cause of death in children under 5 years of age. Scaling up the effective management of AM to 90% coverage would save an estimated 435,000 lives each year . The community management of AM (CMAM) is the World Health Organization’s recommended approach for AM treatment [3,4] and is offered at scale in many low-income countries. It consists of the active screening for AM at the community level and the ambulatory treatment of uncomplicated cases of severe AM (SAM) and moderate AM (MAM) with ready-to-use therapeutic and supplementary foods, respectively. SAM cases with medical complications or without appetite are referred to inpatient treatment. Typically, active screening for AM is done by community health workers or volunteers in the communities. They refer identified cases to the health system to confirm the diagnosis and to enroll them in the CMAM program.
The study protocol was published previously . A summary of the methods is provided here.
Integrating a preventive package (age-appropriate BCC on nutrition, health, and hygiene practices and SQ-LNS) into screening for AM at CNS at health centers in Burkina Faso had a large significant impact on AM screening coverage. This was observed in both the cross-sectional (+18 pp) and the longitudinal study (+23 pp). Impacts on AM treatment coverage (about 8 pp), however, were not statistically significant in either study. No impact was found on overall AM prevalence or incidence.