Leveraging Community-based Platforms to Strengthen the Prevention and Treatment of Child Wasting in Mali and Chad
By: Elodie Becquey and Lieven Huybregts, senior research fellows, International Food Policy Research Institute
Wasting is a persistent public health problem affecting 45.4 million children under the age of five worldwide. It is responsible for the deaths of 875,000 children every year. Those who survive often suffer long-term damage to their cognitive and physical development. Member countries of the World Health Assembly (WHA) have agreed to reduce and maintain the prevalence of wasting to less than 5% by 2025. However, most Sahelian countries are off track to meet the WHA targets. This includes Mali and Chad, where the national rates of wasting are still unacceptably high at 9.3% and 14%.
While both wasting prevention and wasting treatment programs hold the potential to reduce child wasting, substantial synergies can be expected when prevention is integrated with screening, referral, and treatment services. Such integration should happen at the community level to maximize the accessibility of services for caregivers and their children.
In 2020, UNICEF and the International Food Policy Research Institute (IFPRI) partnered to implement the Integrated Research on Acute Malnutrition (IRAM). Within the IRAM partnership, studies in Mali and Chad aimed to assess the impact of integrated packages of services delivered through community-level platforms, designed to drastically reduce child wasting over a short timeframe. These packages were implemented from May 2022 to February 2023 by World Vision in Mali and the Sahel Association for Applied Research and Sustainable Development (ASRADD) in Chad, in coordination with local communities and the health system, under the supervision and technical support of UNICEF. Building on the IRAM partnership, IFPRI created a consortium with AFRICsanté, WorldVision, and ASRADD to conduct rigorous implementation research on these interventions. This operational mixed-methods study used the RE-AIM evaluation framework (Figure 1) to assess the sequencing, layering, and integration of preventive services, screening and referral, and prevention of post-treatment relapse activities implemented by community care groups.
Community care groups were trained and supported by World Vision in Mali and ASRADD in Chad to offer integrated services to the population during monthly group activities and home visits. Services included:
- Active screening of wasting using mid-upper arm circumference (MUAC) tapes and the introduction of family-led MUAC to caregivers and other household members showing an interest.
- Behavior change communication on infant and young child feeding practices, child health, the importance of attending preventive health services, and WASH practices.
- The distribution of preventive supplements for young children: small-quantity lipid-based nutrient supplements (SQ-LNS) in Mali and Corn-Soy blend (CSB++) in Chad. In Chad, bleach for drinking water treatment and soap for hand washing were also distributed because of the very poor water, sanitation, and hygiene (WASH) practices observed by previous surveys.
Community care group members were solicited to intensify home visits to households with identified cases of wasting or with children discharged from treatment to prevent or early-detect any relapse.
The main findings of the research are summarized in two policy notes for Mali and Chad. The high-level conclusions of this implementation research are that community care groups can be leveraged to deliver integrated preventive and screening services: this integration boosted treatment coverage in both countries. The intervention also prevented child wasting, severe acute malnutrition, and lowered the prevalence of anemia in Mali. In Chad, the intervention led to modest improvements in primary caregivers’ knowledge and practices related to health, hygiene, child feeding, and wasting.
The research identified several barriers to the adoption of proposed services by community care groups, which limited the delivery of these services at scale, thereby limiting their effectiveness. Across the two countries, the research highlighted areas for continued improvement related to the selection and training of volunteer care group members, the balance between workload and volunteer motivation, collaboration between community platforms and the health system, and integration, monitoring, and supervision of service delivery. Also, despite significantly higher screening coverage leading to more children being treated in health centers or by community health workers in Mali, we observed quite often that cases identified with wasting by community care group members were given preventive supplements instead of being referred to treatment services at the health center as recommended by national treatment protocol. Care group members found it difficult to refer caregivers of children with wasting empty-handed. Caregivers who did receive preventive supplements were less likely to enroll their child in treatment services.
In both countries, community care groups introduced and supported the family-led MUAC approach with various success. We conducted an in-depth analysis of this approach, detailed in a dedicated technical report. The main findings of this sub-study show that caregivers were able to measure their children’s MUAC accurately, and caregiver knowledge of family-led MUAC was moderate (Mali) to very high (Chad). However, family-MUAC was selectively adopted, and its marginal value was limited in a setting with frequent active screening by community care group members. We further observed that when caregivers identified an episode of wasting, this did not automatically lead to self-referral and admission to treatment. The report makes recommendations to further enable the continuous learning process leading to improvement of family-led MUAC over time.
Finally, we assessed the operationalization of the RE-AIM evaluation framework for complex interventions such as the ones implemented through IRAM in Mali. The findings of this analysis are presented in a technical brief. The RE-AIM evaluation framework allowed the research/implementer partnership to obtain a thorough understanding of the processes and services of the intervention. In our brief, we also proposed to extend the RE-AIM framework with the dimension of coherence aimed at formulating and evaluating complex interventions that are either sequenced, layered, or integrated. Compiling specific indicators covering the coherence dimension allowed us to assess the interactions between services and actors along the continuum of care of child wasting.
The IDEAL small grant allowed our researcher/implementer partnership to conduct rigorous implementation research using the RE-AIM evaluation framework. The findings produced a thorough understanding of the complex interplay of preventive, screening, and treatment services along the continuum of care of child wasting.
Elodie Becquey is a senior research fellow in the Nutrition, Diets, and Health Unit of the International Food Policy Research Institute (IFPRI), based in Dakar, Senegal. Lieven Huybregts is a senior research fellow in the Nutrition, Diets, and Health Unit of the International Food Policy Research Institute (IFPRI), based in Washington DC, USA. Both researchers were the principal investigators of the IRAM studies.
All project deliverables are available on the Food Security and Nutrition Network.
This operations research was made possible by a grant from The Implementer-Led Design, Evidence, Analysis and Learning (IDEAL) Activity. The IDEAL Small Grants Program is made possible by the generous support and contribution of the American people through the United States Agency for International Development (USAID). The contents of materials produced through the IDEAL Small Grants Program do not necessarily reflect the views of IDEAL, USAID, or the United States Government.
The program implementation and the impact study were made possible by a grant from the Foreign, Commonwealth & Development Office of the United Kingdom (FCDO) through UNICEF. The content of the documents produced does not necessarily reflect the views of FCDO or UNICEF.
