Skip to main content

Effectiveness of management of severe acute malnutrition (SAM) through community health workers as compared to a traditional facility-based model: a cluster randomized controlled trial

European Journal of Nutrition volume 60, pages 3853–3860 (2021)Cite this article

Abstract

Purpose

We compared the impact of management of severe acute malnutrition (SAM) by lady health workers (LHWs) at a community level with the standard CMAM program provided at the health facility.

Methods

A two-arm cluster randomised controlled trial was conducted in a rural district in sindh Pakistan. The primary outcome was recovery from SAM and secondary outcomes were relapse, defaulter and mortality rate.

Results

A total of 829 children were recruited in the trial (430 in intervention and 399 in control groups). No significant difference was noted in recovery rate between the intervention and control groups (79.2% vs 85.6%, p = 0.276). Similarly, no significant differences were noted in relapse (p = 0.757), weight gain (p = 0.609), deaths (p = 0.775) and defaulter rate (p = 0.324) across the groups. Compliance of RUTF was significantly higher in the control group (93%) than in the intervention group (87%), p < 0.000.

Conclusion

Our results showed no impact of SAM treatment on performance indicators of CMAM (recovery, relapse, death and default) between the standard CMAM programme performed at the health facility by the government and NGO staff and the programme performed at health house level by the LHWs in Pakistan. We recommend further robust trials in other settings to confirm our results.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. UNICEF, WHO, World Bank Group (2015) Levels and trends in child malnutrition: UNICEF, WHO, World Bank Group joint child malnutrition estimates

  2. Black RE, Victora CG, Walker SP et al (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 382:427–451

    Article  Google Scholar 

  3. World Health Organization (2010) Nutrition Landscape Information System (NLIS): Country Profile Indicators. Interpretation Guide, Geneva

    Google Scholar 

  4. UNICEF (2016) Levels and trends in child malnutrition: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates

  5. Government of Pakistan National Nutrition Survey (2011) Planning commission planning and development division. https://www.humanitarianresponse.info/en/operations/pakistan/document/national-nutrition-survey-2011. Accessed 12 February 2020

  6. Bureau of Statistics Planning and Development Department, Government of sindh. Multiple Indicator Cluster Survey (2014). http://sindhbos.gov.pk/mics/. Accessed 24 March 2020.

  7. Ahmed T, Hossain M, Mahfuz M et al (2014) Severe acute malnutrition in Asia. Food Nutr Bull 35:S14–S26

    Article  Google Scholar 

  8. Park SE, Kim S, Ouma C, Loha M, Wierzba TF, Beck NS (2012) Community management of acute malnutrition in the developing world. Pediatr Gastroenterol Hepatol Nutr 15:210–219

    Article  Google Scholar 

  9. USAID (2017) Community-based management of acute malnutrition: technical guidance brief. https://www.usaid.gov/what-we-do/global-health/nutrition/technical-areas/community-based-management-acute-malnutrition. Accessed 18 June 2020

  10. Rogers E, Myatt M, Woodhead S, Guerrero S, Alvarez JL (2015) Coverage of community-based management of severe acute malnutrition programmes in twenty-one countries 2012–2013. PLoS ONE 10:e0128666

    Article  Google Scholar 

  11. Akparibo R, Harris J, Blank L, Campbell MJ, Holdsworth M (2017) Severe acute malnutrition in children aged under 5 years can be successfully managed in a non-emergency routine community healthcare setting in Ghana. Matern Child Nutr 13:e12417

    Article  Google Scholar 

  12. World Vision (2017) Community-based Management of Acute Malnutrition Model 2012. http://www.wvi.org/nutrition/project-models/cmam. Accessed 23 May 2020

  13. UNICEF (2012) Evaluation of community management of acute malnutrition (CMAM): Pakistan country case study New York

  14. Blanchet K, Roberts B, Sistenich V et al (2013) An evidence review of research on health interventions in humanitarian crises. Final Report, London

  15. Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J (2008) Implementing community-based perinatal care: results from a pilot study in rural Pakistan. Bull WHO 86:452–459

    PubMed  PubMed Central  Google Scholar 

  16. Soofi S, Ahmed S, Fox MP et al (2012) Effectiveness of community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in matiari district, rural Pakistan: a cluster-randomised controlled trial. Lancet 379:729–737

    Article  Google Scholar 

  17. Sadler K, Puett C, Mothabbir G, Myatt M (2011) Community case management of severe acute malnutrition in southern Bangladesh. Boston Tufts University, Boston

    Google Scholar 

  18. Nishtar S (2006) The gateway paper; health system in Pakistan—A way forward. Pakistan’s Health Policy Forum and Heartfile, Islamabad

    Google Scholar 

  19. Zhu N, Allen E, Kearns A, Caglia J, Atun R (2014) Lady health workers in Pakistan: improving access to health care for rural women and families. Maternal Health Task Force, Boston

    Google Scholar 

  20. Action Against Hunger/ACF International (2013) Integrated SMART survey Dadu district, Sindh province

  21. National Institute of Population Studies Pakistan and ICF International (2013) Pakistan demographic and health survey 2012–13. Islamabad

  22. Donner A, Klar N (1996) Statistical considerations in the design and analysis of community intervention trials. J Clin Epidemiol 49:435–439

    CAS  Article  Google Scholar 

  23. Ministry of Health (2009) National guidelines for the management of acute malnutrition among children under five and pregnant and lactating women. Islamabad

  24. Somassè YE, Dramaix M, Bahwere P, Donnen P (2016) Relapses from acute malnutrition and related factors in a community-based management programme in Burkina Faso. Matern Child Nutr 12:908–917

    Article  Google Scholar 

  25. Puett C, Guerrero S (2015) Barriers to access for severe acute malnutrition treatment services in Pakistan and Ethiopia: a comparative qualitative analysis. Public Health Nutr 18:1873–1882

    Article  Google Scholar 

Download references

Acknowledgements

We are thankful to the District and Provincial authorities of National Program for Family Planning & Primary Health Care, Lady Health Worker Program, Sindh, Pakistan for providing support to conduct this study

Funding

This study was supported by Innocent Foundation through Action against hunger (ACF) International.

Author information

Authors and Affiliations

  1. Department of Pediatric and Child Health, Associate Director Center of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan

    Imtiaz Hussain, Atif Habib, Shabina Ariff, Gul Nawaz Khan, Arjumand Rizvi, Suhail Channar, Abid Hussain, Deepak Kumar & Sajid Bashir Soofi

  2. Action Against Hunger, Islamabad, Pakistan

    Shahid Fazal, Saul Guerrero & Angeline Grant

  3. Action Against Hunger, London, UK

    Jose Luis Alvarez

  4. Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan

    Sajid Bashir Soofi

Authors
  1. Imtiaz Hussain
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Atif Habib
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shabina Ariff
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gul Nawaz Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Arjumand Rizvi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Suhail Channar
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Abid Hussain
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shahid Fazal
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Deepak Kumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Jose Luis Alvarez
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Saul Guerrero
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Angeline Grant
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Sajid Bashir Soofi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SBS conceived the idea and reviewed final manuscript. SC were involved in the field implementation of the trial. AR analysed the data. IH, AH and SA contributed in the development and revision of the manuscript. AH, SF, GNK, DK, JLA, SG and AG critically reviewed the manuscript. All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Sajid Bashir Soofi.

Ethics declarations

Conflict of interest

This is an original study and has not been published elsewhere, and all authors have no conflict of interest related to the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hussain, I., Habib, A., Ariff, S. et al. Effectiveness of management of severe acute malnutrition (SAM) through community health workers as compared to a traditional facility-based model: a cluster randomized controlled trial. Eur J Nutr 60, 3853–3860 (2021). https://doi.org/10.1007/s00394-021-02550-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00394-021-02550-y

Keywords

  • Severe acute malnutrition
  • LHWs
  • Community-based management
  • Health facility management
  • RUTF