TABLE 1.
Summary of Published Research Studies Included in Review (n=11)
| Reference | Objective | Thematic Category and Platform | Design, Training, and Remuneration | Key Findings |
|---|---|---|---|---|
| Alé et al. 201611 | To compare the efficacy and cost-effectiveness of maternal measurement of child MUAC and edema with CHW measurement (Niger) | Caregiver detection, CHW diagnosis (Community platform, rural) | Design: Intervention efficacy study with 2 experimental groups comparing the performance of 12,893 mothers with 36 CHWs Training and remuneration: 30-minute group training plus follow-up individual training for mothers, 6 hours theoretical and 2 hours practical training for CHWs. CHWs were part of established national network and may have been volunteers (payment unknown). |
Mothers' MUAC measurements were in agreement with those of health workers more frequently than those made by CHWs (risk ratio 1.88, P<.0001). Case detection was earlier in the mothers' group (median MUAC of cases 1.6 mm higher than CHW group), with fewer children requiring inpatient care relative to the CHW group. |
| Alvarez-Moran et al. 201719 | To assess CHW capacity to evaluate, classify, and treat uncomplicated cases of SAM, and to appropriately refer complicated cases, as part of an integrated iCCM package (Mali) | CHW diagnosis and treatment, Integration (iCCM/community platform, rural) |
Design: Cross-sectional observational study (no comparison group) of 17 CHWs assessing 125 children Training and remuneration: CHWs had a median of 6 months of job training; no additional training for this study. CHWs were part of Mali's established network and received a salary according to national regulations. |
CHWs assessed MUAC correctly in 97% of children, assessed edema correctly in 78%, administered medical treatment correctly in 75% of SAM cases, and managed RUTF supplies correctly in 100% of cases. |
| Amthor et al. 200922 | To describe a rapidly adapted home-based SAM therapy approach in which village health aids diagnosed and treated SAM (MUAC and/or edema) in the context of a food crisis with inadequate health system support (Malawi) | CHW diagnosis and treatment (Emergency community platform, rural) |
Design: Retrospective descriptive study of the clinical outcomes of 826 children with SAM who received treatment at home from village health aids Training and remuneration: 5 hours of training plus 5 days job shadowing a nurse. Village health aids were part of an established network; payment unknown. |
Recovery rates of children with SAM treated by village health aids were high (94%), without any intervention by medical professionals aside from training. quality of care. |
| Blackwell et al. 201510 | To determine whether minimally trained mothers could identify children with SAM, using either arm and without measuring the specific midpoint (Niger) | Caregiver detection (Community platform, rural) |
Design: Nonrandomized non-blinded evaluation study of 2 experimental groups (103 mother-child pairs using simplified protocol and CHWs using standard protocol) Training: Intended to be 5 minutes with each individual, was instead done communally. CHWs were part of a nationally established network and may have been volunteers (unknown). |
Mothers' ability to classify GAM and SAM had high sensitivity (>90% of GAM and >73% of SAM cases correctly identified as such) and high specificity (>80% of GAM and >98% of non-cases correctly identified as such). The simplified protocol (either arm and visual ascertainment of midpoint) performed as well as the standard protocol. |
| Grant et al. 201812 | To test the sensitivity of 3 MUAC classification devices when used by caregivers/mothers (Kenya) | Caregiver detection (Community platform, rural) |
Design: Prospective nonrandomized clinical diagnostic trial comparing the performance of 3 “Click-MUAC” devices and an MUAC insertion tape across 21 health facilities and 1,040 mother-child pairs Training and remuneration: NA |
All devices yielded high sensitivity (>93%) for detecting SAM. Sensitivity for SAM was highest (100%) with the standard MUAC insertion tapes. Specificity was also high for all devices (>96%), with no significant differences observed between the insertion tape and the “Click-MUAC” devices. |
| Linneman et al. 200723 | To assess clinical outcomes of children with acute malnutrition receiving home-based RUTF therapy from community health aids in an operational setting (Malawi) | CHW diagnosis and treatment (Community platform, rural) |
Design: Observational study of 3 intervention groups with varying levels of decision-making and SAM treatment authority given to community health aids (12 health centers, >3,000 children with acute malnutrition) Training and remuneration: 1 month plus 4 days job shadowing a nurse. Community health aids were part of an established network; payment unknown. |
SAM cases who received treatment from community health aids had the same rate of recovery (90%) as those treated by medical professionals (87%). Note that community health aids appear to have delivered some of the care under supervision in clinic settings. |
| Maust et al. 201527 | To evaluate an integrated MAM/SAM program in terms of coverage, number of children treated, and recovery of children (Sierra Leone) | Integration (Integrated CMAM platform, rural) |
Design: Cluster randomized controlled trial with an intervention group (integrated protocol using MUAC for admissions and discharge, RUTF used for MAM and SAM) and a control (standard protocol using W/H Z, RUTF for SAM, and FBFs for MAM) Training and remuneration: NA |
Coverage of the integrated program was higher (71% compared with 55% using standard protocol), and recovery rates were comparable (83% vs. 79%). |
| Nyirandutiye et al. 201128 | To evaluate integration of MUAC screening into National Nutrition Week activities (Mali) | Integration (National Nutrition event platform, rural) |
Design: Cross-sectional survey of health centers (2) and interviews with health center staff (45), CHWs (17), and caregivers (1543) Training and remuneration: MUAC training was incorporated into event training; CHWs were unpaid volunteers. |
Integrating MUAC screening into other activities led to a greater proportion of kids screened (52% of eligible children) than via community screening (5%) or via health center screening (22%), and was viewed as beneficial by caregivers and health care providers. Screening rates were low in clinics, even where staff had been trained in the CMAM protocol. |
| Puett et al. 201220 | To assess the quality of CHW care of uncomplicated SAM cases, including technical competence and acceptability, as part of an iCCM health platform (Bangladesh) | CHW diagnosis and treatment, Integration (iCCM/community platform, rural) |
Design: Observational cohort study of 55 CHWs who provided SAM care, and focus group discussions with 29 caregivers whose children received SAM care from CHWs Training and remuneration: 2 days plus monthly refresher trainings. CHWs were part of an established network and received payment. |
Trained and supervised CHWs delivered high-quality care to uncomplicated SAM cases; they correctly assessed MUAC and advised caregivers of children with SAM appropriately (90% of cases were managed error-free). Antibiotics correctly administered in 90% of pertinent cases. See also Puett et al. 201321 and Sadler et al. 2011.25 |
| Puett et al. 201321 | To assess the cost-effectiveness of SAM management (diagnosis and treatment) by CHWs as part of a community nutrition program, compared with inpatient treatment (Bangladesh) | CHW diagnosis and treatment, Integration (iCCM/community platform, rural) |
Design: Nonrandomized intervention study of 724 SAM cases treated by CHWs in the community and 633 SAM cases treated as inpatients Training and remuneration: 2 days plus monthly refresher trainings, CHWs were part of an established network and received payment. |
CHWs delivered the full spectrum of SAM identification and treatment at a lower overall program cost than inpatient treatment. Supervision was the greatest expense in the CHW group (40% of total, compared with 28% of total budget in inpatient group). See also Puett et al. 201220 and Sadler et al. 2011.25 |
| Rogers et al. 201724 | To assess the quality of care for uncomplicated SAM by female health workers (Pakistan) | CHW diagnosis and treatment, Integration (iCCM/community platform, rural) |
Training: Observational cross-sectional study of 17 female health workers providing care for 61 cases of uncomplicated SAM Training and remuneration: 3 days plus a refresher 3–6 months later. CHWs were part of an existing network and received salaries according to national regulations. They did not receive additional pay for the added SAM care responsibilities. |
MUAC and edema were correctly measured for 57% and 88% of children, respectively. 68% of cases received correct medical and nutrition treatment, but only 4% also received key nutritional counseling messages. |
Abbreviations: CHW, community health worker; CMAM, community-based management of acute malnutrition; FBF, fortified blended flour; GAM, global acute malnutrition; iCCM, integrated community case management; MAM, moderate acute malnutrition; MUAC, mid-upper arm circumference; NA, not available; RUTF, ready-to-use therapeutic food; SAM, severe acute malnutrition; W/H Z, weight-for-height z score.