Menu ENN Search

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

This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored 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).

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).

Background

Globally, 47 million children under five years of age suffer from moderate or severe wasting and only one in four have access to treatment. The COVID-19 pandemic threatens to exacerbate this further. Integrated community case management (iCCM) equips community health workers (CHWs) to deliver pneumonia, diarrhoea and malaria treatment in their communities. However, malnutrition is not currently included in the recommended treatment package. Between 2017 and 2019, International Rescue Committee served as the technical lead of the RISE study, a multi-partner, multi-country initiative that aimed to generate evidence around a simplified treatment protocol for CHWs to treat uncomplicated severe acute malnutrition (SAM) as part of iCCM.1 This article describes operational lessons learned.

RISE study protocol and summary results

Studies were conducted in Nigeria and Malawi to assess the feasibility and acceptability of CHW-led community-based treatment for uncomplicated cases of childhood wasting. In Kenya, a cluster randomised control trial compared iCCM CHW-led treatment to facility-based treatment. The performance of CHWs was evaluated and treatment outcomes were tracked over time. Perceptions of CHW-led treatment and programme experiences were also documented.

In Malawi and Nigeria, uncomplicated SAM cases were admitted based on a mid-upper arm circumference (MUAC) of 9 to <11.5 cm and ready-to-use therapeutic food (RUTF) was provided through recovery or until discharged. In Kenya, CHWs also admitted children with moderate acute malnutrition (MAM) or MUAC 11.5 to <12.5 cm without complications. MAM cases were given ready-to-use supplementary food (RUSF) through recovery or until discharged.

In Kenya, CHWs showed high adherence to a simplified protocol for SAM and MAM treatment, regardless of their literacy level, and achieved treatment outcomes that met Sphere humanitarian standards. Across all contexts, community members appreciated the proximity of access to treatment. However, some CHWs experienced frustration from caregivers whose children were not eligible for treatment. CHWs felt that providing iCCM+ nutrition treatment increased their workload and suggested various incentives to support their work.

Operational insights

Insights from the RISE study suggest that government and non-government actors aiming to implement CHW-led treatment in other contexts should consider the following:

Underlying epidemiology: Actors should first consider how applicable CHW-led treatment is in the given context. In contexts where the burden of acute malnutrition is low, a CHW-led approach may not be cost-effective. In high burden contexts, implementers should consider the logistical implications of treating only SAM compared to both SAM and MAM cases. CHWs could also be used to offer surge capacity in areas with seasonal fluctuations in prevalence.

Reasons for poor coverage: Implementers should be certain that CHW-led treatment will adequately address the main barriers to treatment in their context. Lack of physical access to treatment may not be the primary reason for poor coverage. Other important barriers may exist around cultural practices or preferences that impact care-seeking and CHW-led treatment may not improve access for mobile pastoralist families.

Community health system: CHW-led treatment approaches should only be considered in contexts where clear links already exist (or can be made) between community outreach services and clinical health facilities.  Integration with iCCM also requires mechanisms that enable CHWs to treat childhood illnesses.

Feasibility and sustainability of the supply chain: Even in contexts where supply chains for programmes like iCCM exist, CHW-led treatment can only be sustained if supplies consistently reach community-level. Supplies for wasting treatment are typically bulky and expensive and can be difficult to store and transport so current processes need to be re-imagined. CHWs should record and report supply usage and central stores and/or health facilities should be equipped to pre-position, store and transport ready-to-use foods. Critically, CHWs should be able to safely and adequately store supplies in easily accessible locations.  

Supervision structures: Adding CHW-led treatment for uncomplicated wasting to CHW workloads must be accompanied by frequent supervision and consideration should be given to how supervision structures can be enhanced within the health system to enable long-term, sustainable support.

Funding: Implementers should consider whether funding is sufficient to support implementation costs. The time required for implementation must also be weighed against the time it will take to meet treatment objectives and the funding available to maintain the programme.

Programmatic recommendations

Once a CHW-led treatment approach is deemed appropriate for a given context, government and non-government implementers should consider doing the following to optimise implementation and uptake:

Simplify the CHW-led community-based treatment protocol. Implementers should adopt a simplified treatment protocol for SAM and/or MAM that incorporates procedures from simplified national iCCM protocols. These include an assessment of medical complications, the adoption of MUAC-only anthropometry criteria and the use of one treatment product (either RUTF or RUSF). While the RISE study did not test a combined treatment protocol for SAM and MAM cases, new evidence shows that combined, simplified treatment is as effective as standard treatment and saves money.

Simplify and integrate existing tools. CHWs should be equipped with simplified tools and job aids that accommodate CHW capacity, such as the low-literacy toolkit tested in the RISE study. Simplified treatment registers also help CHWs to document, monitor and interpret children’s nutritional status over time. These tools should be integrated with others used by CHWs into one simplified toolkit 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 are correctly referred to appropriate health facilities. Support could include providing transportation to ease referral completion.  

Consider appropriate motivation or incentives for CHWs. CHWs should receive a salary in line with minimum national guidelines. Incentives that support CHWs to provide treatment from their homes, and certification and/or recognition for those who acquire the extra skills needed for CHW-led treatment, should also be considered.

Track reasons for default and adapt programming to reduce defaulting. Implementers should establish a tracking system that includes the collection of data to explain default rates and allows for the identification of programme adaptations to address barriers to continuing treatment.

Consider training enhancements. Implementers should evaluate CHWs’ performance before they are deployed. They should also monitor whether additional or innovative training is required during supervision visits.

Improve communication and involve communities. Implementers should engage communities early to build shared knowledge and reduce misinformation about the CHW-led approach. Support from community leaders, caregivers and other medical providers is essential to communicating key nutrition messages, promoting adherence to treatment, securing the motivation of CHWs and supporting the movement and storage of medicines and RUTF.

Conclusions

Results from the RISE study demonstrate that CHWs can accurately and effectively provide treatment for uncomplicated wasting at the community level. However, the considerations and recommendations developed by the study partners should be applied further to inform the operational feasibility, scalability and sustainability of CHW-led treatment under typical programme conditions and Ministry of Health management. The RISE study consortium and partners have now developed a toolkit for CHW community-based treatment of uncomplicated wasting for children aged 6-59 months in the context of COVID-192 that incorporates some of the considerations and recommendations outlined in this article. The RISE study consortium also now co-leads a Simplified Approaches working group with UNICEF that aims to support partners and organisations to implement approaches, including CHW-led treatment, to improve coverage and reduce costs.   

For more information, please contact Bethany Marron at Bethany.marron@rescue.org

Read more...

1 Funded by the Eleanor Crook Foundation (ECF), the study consortium included 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).

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

More like this

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

View this article as a pdf Lisez cet article en français ici By Bethany Marron on behalf of the RISE study consortium Bethany Marron is a nutrition advisor and former...

en-net: Simplified Approaches in the context of COVID 19 (questions escalated to the GTAM Wasting TWG)

a. What can we do to quickly communicate that this [simplified approaches] is an acceptable adaptation to make in the circumstances to enable governments to make this...

FEX: Management of severe acute malnutrition by community health workers: Early results of Action Against Hunger research

View this article as a pdf Lisez cet article en français ici By Pilar Charle-Cuellar, Noemi Lopez-Ejeda, Magloire Bunkembo, Abdias Ogobara Dougnon and Hassane Toukou...

FEX: Can low-literate community health workers treat severe acute malnutrition? A study of simplified algorithm and tools in South Sudan

Summary of research1 By Naoko Kozuki, Casie Tesfai, Annie Zhou and Elburg van Boetzelaer The authors would like to acknowledge financial support from the Eleanor Crook...

Resource: Toolkit for CHW community-based treatment of uncomplicated wasting for children 6-59 months in the context of COVID-19

The recent brief from UNICEF and GNC on the management of child wasting in the context of COVID-19 states that in partial or full population mobility restrictions, whenever...

FEX: Linking integrated community case management of sick children and nutrition: experiences and meeting report

On 11-12 December 2014, a meeting of a broad range of stakeholders with experience in nutrition and/or integrated community case management (iCCM) was convened to explore...

FEX: Enabling low-literacy community health workers to treat uncomplicated SAM as part of community case management: innovation and field tests

By Casie Tesfai, Bethany Marron, Anna Kim and Irene Makura Casie Tesfai is a Nutrition Technical Advisor at the International Rescue Committee in New York, where she provides...

FEX: ComPAS trial in South Sudan and Kenya: Headline findings and experiences

View this article as a pdf Lisez cet article en français ici By Bethany Marron, Pamela Onyo, Eunice N Musyoki, Susan Were Adongo and Jeanette Bailey Bethany Marron is...

FEX: A series of three related published papers share findings regarding quality of care, treatment outcomes and cost-effectiveness of uncomplicated SAM treatment delivered by community health workers (CHWs) in rural Mali.

By Eleanor Rogers, Karen Martínez, Jose Luis Alvarez Morán, Franck G. B. Alé, Pilar Charle, Saul Guerrero, Natalie Sessions and Chloe Puett Quality of...

FEX: Cost-efficiency of a simplified protocol for wasting treatment in Mali

View this article as a pdf Derek Lee is a Best Use of Resources Advisor for Nutrition at International Rescue Committee (IRC). Cesaire Ouedraogo is a Nutrition Research...

FEX: Simplified approaches website

View this article as a pdf Wasted children are up to 11 times more likely to die than those who are well nourished and currently treatment services only reach a third of...

en-net: Where can I find simplified tools for community-level treatment of acute malnutrition?

Today, the International Rescue Committee (IRC) is launching a set of simplified tools we developed to guide low-literate CHWs through the diagnosis and treatment of acute...

FEX: Adaptations to community-based acute malnutrition treatment during the COVID-19 pandemic

View this article as a pdf Lisez cet article en français ici By Maria Wrabel, Sarah King and Heather Stobaugh Maria Wrabel is CMAM Adaptations Project Officer with...

FEX: Testing an adapted severe acute malnutrition treatment protocol in Somalia

View this article as a pdf Lisez cet article en français ici Summary of research1 By Naoko Kozuki, Jama Mohamud Ahmed, Mukhtar Sirat and Muna Abdirizak Jama Naoko...

FEX: The Eleanor Crook Foundation

Name: The Eleanor Crook Foundation Address: Suite 1110, 150 Fayetteville Street Raleigh, NC 27601 Tel: (512) 609-0694 Email: info@eleanorcrookfoundation.org No of staff...

en-net: Relationship between MUAC and weight changes in children aged 6–59 months

Just FYI. Here is an article on MUAC and weight change during treatment for SAM. Share and enjoy! Casie Tesfai, Senior Technical Advisor for Nutrition (IRC), mentioned...

FEX: Simplified approaches for the treatment of child wasting: A rapid evidence review

View this article as a pdf Report summary1 By Emilie Buttarelli, Grace Funnell and Sophie Woodhead Dr Emilie Buttarelli is a bio-cultural anthropologist currently working...

en-net: How do we put in place Simplified protocols for management of acute malnutrition in the context of covid 19?

Welcome to share with you the training of trainers, online and offline that Action against Hunger, has developed to train community health workers in acute malnutrition...

en-net: MAM treatment in Covid-19 pendemic

Dear all, It is higlighted that no new CMAM program is needed in this Covid-19 pandemic. Reference: GTAM-Existing CMAM programmes should be supported to continue if...

FEX: Traitements administrés par les agents de santé communautaires dans les cas d’émaciation sans complications : enseignements tirés de l’étude RISE

Read an English version of this article here Par Bethany Marron, pour le compte du consortium d'étude RISE Bethany Marron est conseillère en nutrition et...

Close

Reference this page

Community health worker-led treatment for uncomplicated wasting: insights from the RISE study. FEX 64 digest , May 2021. www.ennonline.net/fexdigest/64/healthworkersrisestudy

(ENN_7065)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.