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Community health worker-led treatment for uncomplicated wasting: insights from the RISE study

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By Bethany Marron on behalf of the RISE study consortium

Bethany Marron is a nutrition advisor and former RISE study project lead at the International Rescue Committee (IRC) where she oversees the nutrition operational research portfolio and provides technical assistance on simplified approaches and the integration of nutrition into integrated community case management.

RISE study consortium: Naoko Kozuki (International Rescue Committee), Olatunde Adesoro, Helen Counihan, Prudence Hamade, Olusola Oresanya (Malaria Consortium), Regine Kopplow (Concern Worldwide), Jemimah Wekhomba, Pilar Charle Cuellar (Action Against Hunger), Emily Keane, James Njiru (Save the Children)

We would like to acknowledge and thank the community health workers, caregivers and children in Niger State, Nigeria, Nsanje District, Malawi and Isiolo County and Turkana County, Kenya for their participation. Without their trust, this study would not have been possible. The donor for this work was the Eleanor Crook Foundation under their RISE (Research, Innovate, Scale, Establish) for Nutrition Portfolio.

Location: South Sudan, Nigeria, Malawi, Kenya

What we know: Delivery of treatment for uncomplicated wasting by community health workers (CHWs) is a simplified approach that can ensure continuity of detection and treatment, particularly in the context of the COVID-19 pandemic.

What this article adds: This article summarises operational insights developed by the RISE study consortium, a multi-partner, multi-country initiative to develop and test a simplified treatment protocol, tools and job aids for literate and low-literate CHWs to deliver treatment for uncomplicated wasting treatment services through the integrated community case management (iCCM) platform in several locations. The following operational aspects must be considered before embarking on this model: context-specific underlying epidemiology (burden of malnutrition and seasonality), extent to which the model will remove top barriers to treatment in the context, existence of a community health system to embed the model within and the presence of a supply chain, supervision and financing. Once deemed appropriate, recommendations to improve implementation and uptake include the simplification of protocols to streamline CHW decision-making, the simplification and integration of CHW tools, the strengthening of referral mechanisms for complicated cases, the provision of motivations and incentives for CHWs, the tracking and addressing of defaulting, enhancing CHW training and supervision and engagement of communities. Full quantitative and qualitative results will be submitted for peer review publication in 2021. Further application of the considerations and recommendations listed here is needed to inform the operational feasibility, scalability and sustainability of the approach. 

Background

According to the latest Joint Child Malnutrition Estimates, 47 million children under five years of age suffer from moderate or severe wasting (UNICEF, World Bank, WHO, 2020). Yet, with treatment currently only available in health facilities, life-saving services are largely inaccessible. According to global coverage data, only one in four children who need treatment has access to it (Puett et al, 2013; Rogers et al, 2015). The current COVID-19 pandemic threatens to undermine access to nutrition treatment even further. According to the Lancet, UNICEF reports estimate a 30% overall reduction in the coverage of essential nutrition services reaching 75 to 100% in lockdown contexts (Headey et al, 2020).

Community-based service delivery models have been used to increase access to treatment for other childhood illnesses. In particular, the integrated community case management (iCCM) approach equips community health workers (CHWs) to deliver treatment outside health facilities in their communities for the major causes of death in under-five children: pneumonia, diarrhoea and malaria (WHO, 2012). Malnutrition, which underlies approximately half of these deaths, is not currently included in the recommended iCCM treatment package.

Several studies have explored whether iCCM CHWs can effectively provide treatment for uncomplicated wasting although none have equipped low-literate CHWs (López-Ejeda et al, 2019). Since 2015, the International Rescue Committee (IRC) has been developing and field-testing tools and a simplified treatment protocol that enables literate and low-literate CHWs to treat uncomplicated severe acute malnutrition (SAM) as part of iCCM (Tesfai et al, 2016). Following an initial study in Northern Bahr El Ghazal State, South Sudan, the simplified package was further adapted and piloted by four other organisations in contexts where children have limited access to facility-based treatment (Kozuki, 2020; Van Boetzelaer, 2019). From 2017 to 2019, the IRC served as technical lead of the RISE study, a multi-partner, multi-country initiative funded by the Eleanor Crook Foundation (ECF) to generate additional evidence on the CHW-led treatment approach. The RISE study consortium included study partners from global headquarters and field offices in Niger State, Nigeria (Malaria Consortium), Nsanje District, Malawi (Concern Worldwide), Isiolo County, Kenya (Action Against Hunger) and Turkana County, Kenya (Save the Children).1

RISE study protocol

The RISE study protocol largely mirrored the initial proof of concept study implemented in South Sudan. Study partners in Nigeria and Malawi conducted prospective mixed-method studies on the feasibility and acceptability of CHW-led community-based treatment and outcomes for uncomplicated cases of childhood wasting in their context. Study partners in Kenya evaluated feasibility of the approach within a cluster randomised control trial (RCT) comparing iCCM CHW-led treatment to facility-based treatment (Kimani-Murage et al, 2019). The performance of CHWs was evaluated by supervisors using a pre-defined checklist and children were tracked over time to capture treatment outcomes. Focus group discussions and in-depth interviews were conducted in order to understand perceptions toward CHW-led treatment and the logistical successes and challenges of the programme.

The treatment protocol used by CHWs in the RISE studies also followed the simplified treatment protocol tested in South Sudan. Minor modifications to assessment procedures for danger signs (medical complications) and discharge criteria were based on national iCCM and wasting treatment protocols. In Malawi and Nigeria, CHWs admitted children with SAM without complications who had mid-upper arm circumference (MUAC) of 9 to <11.5 cm. Treatment for SAM was provided according to weight using ready-to-use therapeutic food (RUTF) through recovery or until discharged. In Kenya, in accordance with the RCT study objectives, CHWs additionally admitted children with moderate acute malnutrition (MAM) or MUAC 11.5 to <12.5 cm without complications. New MAM cases were given one sachet of ready-to-use supplementary food (RUSF) per day through recovery or until discharged. As an additional safeguard, all study partners instituted transfer criteria requiring CHWs to discontinue treatment and refer children whose MUAC had either regressed or not improved within a pre-determined timeframe.  See Table 1 for a summary of the treatment protocols used in each context.

Table 1. RISE Study Treatment Protocol (summarised)

Study Results

Following completion of the studies in Nigeria, Malawi and Kenya, the consortium met in February 2020 to review quantitative and qualitative results and discuss the potential of CHW-led treatment beyond the study period. During the two-day workshop, study partners concluded that CHWs showed high adherence to a simplified treatment protocol for SAM as well as MAM treatment in Kenya, regardless of CHW literacy level, achieving treatment outcomes that meet Sphere humanitarian standards (Table 2 and 3). Also, qualitative data revealed that community members across all contexts generally appreciated the proximity of access to treatment, although some CHWs experienced frustration from caregivers whose children were not eligible for treatment. CHWs felt that providing iCCM+ nutrition treatment was an additional workload and suggested various incentives to support their work.

This article includes a summary of CHW performance and treatment results from the RISE study in order to provide context for the operational insights presented. Full quantitative and qualitative results will be submitted for peer review publication in 2021.

Table 2. CHW Performance (summarised)

*Note, CHWs were assessed using a pre-defined checklist of various context-specific assessment and treatment tasks. Therefore, the above composite CHW performance scores do not provide the full picture of CHW performance or comparability across study sites. Full CHW performance results will be published as part of future peer review publication.   

Table 3. Treatment Outcomes (summarised)

*Sphere minimum standards for SAM to MAM: death 10%, cured 75%, default 15%; for MAM to full recovery: death 3%, cured 75%, default 15%.

**Discharge criteria varied by context (see Table 1) which limits comparability across study sites.

Operational insights

In addition to building evidence on the feasibility and acceptability of CHW-led treatment, the RISE study experience offers valuable lessons learned on how to operationalise the approach across multiple contexts. Study partners acknowledged their significant role in strengthening programme implementation during the study period and agreed on several considerations and recommendations to ease future implementation under ‘typical’ programmatic settings and/or Ministry of Health management.

Initial considerations – what to think about before implementing CHW-led community-based treatment

The following considerations should be vetted by government and non-government implementers to determine whether a CHW-led treatment approach like the programmes piloted through the RISE studies is appropriate for the context in question.

Underlying epidemiology

CHW-led treatment should address the underlying epidemiology of the context. As a community-based programme utilising a simplified treatment protocol, the burden of malnutrition which can be addressed by CHW-led treatment should be determined according to prevalence by MUAC. Given the logistical challenges of implementing community health programmes, a CHW-led treatment approach may not be cost-effective if the burden of malnutrition is too low. On the other hand, if the burden is high, implementers must consider the logistical implications of treating only new SAM or treating both new SAM and new MAM. Similarly, if prevalence is known to fluctuate with seasonality, CHW-led treatment may be either unnecessary or could heavily strain the community health system during certain times of the year. Mobilising CHWs to provide treatment as surge capacity could be explored as an alternative to resourcing year-round CHW-led treatment.

Reasons for poor coverage

Implementers should be certain that CHW-led treatment will adequately address the top barriers for families to access and utilise treatment services in their context. Implementers should not assume that physical access to treatment, which CHW-led treatment aims to reduce, is the primary driver of poor coverage. CHW-led treatment will not in and of itself address other barriers which are persistent in many community-based management of acute malnutrition (CMAM) programmes. For example, the availability of CHW-led treatment does not transform the cultural practices or preferences that impact care-seeking nor does it necessarily improve access for mobile pastoralist families. In fact, an important question to ask before exploring this approach at all should be whether there are reasonable alternatives, including consideration of whether the quality and desirability of services at an outpatient facility could be improved.

Community health system

A CHW-led treatment approach should only be considered in a context where an explicit link can be made (or already exists) between the community health system and the institutional health system. Implementers should have an experience-based understanding of the realistic coverage and capacity of the community health system and cadre, knowledge of existing policies and procedures which govern working with CHWs and pre-identified referral points to send children for additional medical care. Related, a CHW-led treatment approach which is integrated with iCCM will rely on pre-existing support and/or a reasonable policy environment that would allow CHWs to treat childhood illnesses.

Feasibility and sustainability of the supply chain 

Even in contexts where supply chains for programmes like iCCM exist, the addition of bulky, expensive ready-to-use therapeutic treatment supplies will strain the current system. Sustaining CHW-led treatment will require reimaging current processes and resources to ensure that commodities consistently reach the community-level. Reporting tools and mechanisms for CHWs to record usage and forecast should be adapted with some flexibility to provide buffer stock. Also, central supply stores and/or health facilities that channel commodities to CHWs must be equipped to pre-position, store and transport ready-to-use foods. Finally, CHWs must have safe and adequate options to store commodities in their homes and/or in close proximity to where they provide treatment.

Supervision

Adding CHW-led treatment for uncomplicated wasting to the workload of CHWs must be accompanied by frequent supervision at the beginning of the programme to correct performance issues and help CHWs to establish clear community expectations of the programme. Implementers should not rely solely on typical Ministry of Health (MoH) resources or protocols to train, compensate or support supervisors involved in the rollout phase. In the longer-term, implementers should consider how supervision structures can be re-designed or enhanced within the health system so that CHWs are also supported more strategically and frequently by knowledgeable staff from referral health facilities and/or CMAM programmes.

Funding

Implementers should carefully consider whether there is sufficient funding to resource the necessary phases of implementation of CHW-led treatment, including start-up activities like strengthening links to the institutional health system, creating and/or updating job aids and tools for CHWs, restructuring supply chains and commodity tracking and CHW and supervisor training. The estimated amount of time to complete these activities needs to be weighed against how long it will reasonably take to meet the objectives set for CHW-led treatment and how much funding is available to sustain the maintenance costs of the programme.

Programmatic recommendations – how to optimise CHW-led community-based treatment

Once a CHW-led treatment approach is deemed appropriate for the context in question, implementers should consider the following recommendations to improve implementation and uptake.

Simplify the CHW-led community-based treatment protocol

Implementers should adopt a simplified treatment protocol for CHW-led treatment of uncomplicated SAM and/or MAM in order to streamline decision-making by CHWs, ease assessment procedures and improve continuity of care. Implementers should incorporate assessment procedures from national iCCM protocols which are already simplified for CHWs to check for medical complications, adopt MUAC-only anthropometry criteria for admission, monitoring and treatment and treat children who are admitted for SAM through full recovery using one treatment product. While the RISE study did not test using a combined treatment protocol for SAM and MAM cases, implementers should consider using a protocol which uses one treatment product for SAM and MAM instead of two products typically used in facility-based treatment. New evidence indicates that combined, simplified treatment for SAM and MAM is as effective as standard treatment and saves money (Bailey et al, 2020).

Simplify and integrate existing tools used by CHWs to provide treatment

Implementers should equip CHWs with simplified tools and job aids such as the low-literacy toolkit tested in the RISE study. These tools were specifically designed according to a user-centred design process to accommodate CHWs’ capacity and preferences whilst guiding them through admission, follow-up and discharge processes using colour references and pictorial icons. Also, the simplified treatment register was essential for empowering CHWs to document, monitor and interpret children’s status over time – a task which typically requires high literacy. Finally, implementers should integrate other tools and job aids used by CHWs whenever possible. For example, iCCM tools and CHW-led treatment tools should be repackaged into one simplified toolkit in order to consolidate step-by-step procedures for treating illness and wasting.

Strengthen referral to appropriate health facilities and stabilisation centres

Implementers should strengthen and/or develop strategies to ensure that children with medical complications complete referral to appropriate health facilities. For example, implementers should leverage CHW-community relationships to design context-specific messaging, counselling and mechanisms that adequately communicate the limit of CHW-led treatment and the seriousness of medical referral when prescribed as well as design feasible support mechanisms, such as providing transportation, to ease referral completion. Implementers should also build and support two-way communication and/or formal referral tracking to confirm adherence and completion or to inform necessary programme improvements.

Consider appropriate motivation or incentives for CHWs

CHWs should receive a salary in line with the minimum national guidelines for CHWs as well as incentives such as chairs and/or a small table to greet caregivers and water, sanitation and hygiene supplies to support them to provide treatment from their homes. Implementers should also develop a way to certify and/or recognise CHWs for acquiring the extra skills and responsibility of CHW-led treatment. Particularly in future contexts, where only selected CHWs are trained and equipped to provide treatment, certification will be important for differentiating CHWs who provide SAM or MAM treatment from other CHWs. Also, legitimising CHWs may address scepticism and accusations of favouritism that CHWs face from caregivers whose children do not qualify for treatment.

Track reasons for default and adapt programming to reduce default

Since the CHW-led treatment approach presumes to reduce barriers to accessing treatment, implementers should establish a default tracking system that includes the collection of quantitative and qualitative data to explain default and, if high defaulting persists, identify feasible programme adaptations to address this.

Consider training enhancements to improve CHW performance

In order to ensure CHWs are ready to administer treatment, implementers should evaluate CHWs’ performance before they are deployed through a practical exam with at least one opportunity to improve their performance after receiving feedback from a supervisor. During supervision visits, implementers should closely monitor if there are critical tasks which require additional or innovative training. For instance, CHW cadres who provide both iCCM and wasting treatment may benefit from periodic refresher training or specialised job aids on how to treat and document co-morbidities.   

Improve communication and involve communities in an effort to support CHW-led treatment

Implementers should engage communities early on to build shared knowledge, commitment and accountability of CHW-led treatment and to reduce misinformation about the approach. Support from community leaders, caregivers and other medical providers is essential to communicate key nutrition messages and promote adherence to treatment as well as secure the motivation of CHWs and support the movement and safe storage of medicines and RUTF. Improved communication also ensures that caregivers understand referral procedures and mechanisms in order to reduce frustration directed at CHWs.

Conclusions

Quantitative and qualitative results from the RISE study suggest that, globally, CHWs can be trained and equipped to provide treatment accurately and effectively for uncomplicated wasting at the community level. However, further application of the considerations and recommendations developed by study partners is needed to inform the operational feasibility, scalability and sustainability of CHW-led treatment under typical programme conditions and MoH management. More recently, CHW-led treatment has been endorsed and promoted by UNICEF, the World Health Organization (WHO) and the Global Nutrition Cluster as a recommended approach to ensure continuity of wasting treatment in the context of COVID-19 (UNICEF, GTAM, GNC, 2020). While the RISE study consortium explored feasibility before the pandemic, study partners acknowledge the potential of CHW-led treatment to address the unique challenges associated with COVID-19. In June 2020, the RISE study consortium expanded membership to include additional child health and nutrition experts and UNICEF in order to develop a ‘Toolkit for CHW community-based treatment of uncomplicated wasting for children 6-59 months in the context of COVID-19.2 The toolkit includes updated guidance which reflects the considerations and recommendations in this article as well as integrating additional simplified approaches such as Family MUAC and a combined, simplified treatment protocol.

The RISE study consortium continues to explore the promise of CHW-led treatment to increase access to wasting treatment as the Simplified Approaches working group. This working group, now co-led by UNICEF and supported by additional implementing organisations, aims to support partners and organisations in the implementation of multiple approaches designed to improve coverage and reduce the costs of providing treatment, including CHW-led treatment, by providing a platform on which to share and discuss operational successes, challenges and experiences and to identify and collaborate on the development of tools, guidance learning and evidence generation. 

For more information please contact Bethany Marron.

 

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Endnotes

https://www.acutemalnutrition.org/en/Simplified-Approaches-Tools

https://www.acutemalnutrition.org/en/Simplified-Tools-Covid

References

Bailey, J., Opondo, C., Lelijveld, N., Marron, B., Onyo, P., Musyoki, E.N., et al. (2020) A simplified, combined protocol versus standard treatment for acute malnutrition in children 6–59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan. PLoS Med 17(7): e1003192. https://doi.org/ 10.1371/journal.pmed.1003192

Headey, D., Heidkamp, R., Osendarp, S, et al. Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality. Lancet. 2020; (published online July 27.) https://doi.org/10.1016/S0140-6736(20)31647-0

Kimani-Murage, E.W., Pythagore, H., Mwaniki, E. et al. Integrated and simplified approaches to community management of acute malnutrition in rural Kenya: a cluster randomized trial protocol. BMC Public Health 19, 1253 (2019) https://doi.org/10.1186/s12889-019-7497-3

Kozuki N., Van Boetzelaer E., Tesfai C., Zhou, A. Severe acute malnutrition treatment delivered by low-literate community health workers in South Sudan: A prospective cohort study. J Glob Health. 2020;10(1):010421. doi:10.7189/jogh.10.010421

López-Ejeda, N., Charle Cuellar, P., Vargas, A., Guerrero, S. Can community health workers manage uncomplicated severe acute malnutrition? A review of operational experiences in delivering severe acute malnutrition treatment through community health platforms. Matern Child Nutr. 2019; 15:e12719. https://doi.org/10.1111/mcn.12719

Puett, C., Hauenstein Swan, S., Guerrero, S. (2013). Access for All, Volume 2: What factors influence access to community based treatment of severe acute malnutrition? (Coverage Monitoring Network, London, November 2013)

Rogers, E,, Myatt, M., Woodhead, S., Guerrero, S., Alvarez, JL. Coverage of community-based management of severe acute malnutrition programmes in twenty-one countries, 2012-2013. PLoS One. 2015;10:e0128666. 10.1371/journal.pone.0128666

UNICEF, World Bank, & WHO. (2020). Joint Child Malnutrition Estimates 2020. Retrieved from:https://data.unicef.org/resources/joint-child-malnutrition-estimates-interactive-dashboard-2020/

UNICEF, Global Nutrition Cluster, Global Technical Assistance Mechanism for Nutrition (GTAM) (2020). Management of child wasting in the context of COVID-19. www.ennonline.net/covid19wastingbrief

WHO. UNICEF. Integrated community case management (iCCM): an equity-focused strategy to improve access to essential treatment services for children. Geneva: WHO; 2012.

Tesfai, C., Marron, B., Kim, A., Makura, I. (2016). Enabling low-literacy community health workers to treat uncomplicated SAM as part of community case management: innovation and field tests. Field Exchange 52, June 2016. p3. www.ennonline.net/fex/52/communityhealthworkerssam

Van Boetzelaer, E., Zhou, A., Tesfai, C., Kozuki, N. Performance of low-literate community health workers treating severe acute malnutrition in South Sudan. Matern Child Nutr. 2019; 15( S1):e12716. https://doi.org/10.1111/mcn.12716

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By Bethany Marron on behalf of the RISE Study Consortium (). Community health worker-led treatment for uncomplicated wasting: insights from the RISE study. Field Exchange 64, January 2021. p84. www.ennonline.net/fex/64/healthworkersrisestudy

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