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