Table 3 Summary table of study characteristics and findings (ordered alphabetically)

Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone

Maust et al. [34]

Sierra Leone

-—-—-—-

CASP

Low

Evaluate coverage & recovery rates for GAM of an integrated protocol with RUTF compared to a standard protocol

1957 children under 5 years old

Cluster-RCT

Intervention

Integrated management of GAM included mother peer-counselling care groups with nutrition messaging delivered both on-site & at home visits; MUAC for admission and discharge, with a MUAC < 12.5 cm defining malnutrition

Comparator

Standard management included messaging on-site & no home visits; treated MAM with fortified blended flour and SAM with RUTF, with WFH as the admission tool to treatment programme

Coverage (calculated from number of children who received treatment over number of children eligible for treatment); recovery, remaining malnourished, death, or lost to follow up; *recovery not equivalent between two study arms because used different anthropometric measurements to determine malnutrition (MUAC in intervention, WHZ in control)

Majority of children in the intervention arm had MAM (774 of 1100; 70%) versus most children in the control arm having SAM (537 of 857; 63%; P = 0.0001). Coverage for the intervention group was 71%, versus 55% in the control group (P = 0.0005); GAM recovery was 910 of 1100 (83%) children in the intervention group and 682 of 857 (79%) children in the control group; care group participation was associated with higher recovery rates, suggesting that sensitising & emphasising good nutrition & hygiene practices may be important to integrate alongside feeding programmes for children with GAM. This observation is seen to be preliminary due to lack of data collection on care group attendance or experiences

GAM

Improving nutrition in Afghanistan through a community-based growth monitoring and promotion programme: A pre-post evaluation in five districts

Mayhew et al. [40]

Afghanistan

-—-—-—-

CASP

Moderate

Determine impact of community-based growth monitoring and promotion (cGMP) programme on the nutritional status of young, Afghan children

828 caretakers & children; 414 children under 2 years old, 414 caretakers

Cross-sectional comparison of mean WAZ between participants and non-participants, matching assigned sex at birth, age, & geography; retrospective comparison between initial & final survey of WAZ in cohort of cGMP participants meeting evaluation’s inclusion criteria

Intervention

cGMP where CHWs deliver regular growth-monitoring sessions for children under 5 years old and nutrition counselling for caretakers

Comparator

Non-participants selected based on demographic criteria matching and consent from caretaker for child to be included in the evaluation

WAZ; programme acceptability

Children participating in the cGMP programme had a statistically significant higher mean WAZ, − 0.9 (95% CI − 1.0, − 0.8), than those that didn’t participate, − 1.2 (95% CI − 1.3, − 1.1). For the intervention children, mean WAZ change was the same for both the last cGMP visit and evaluation visit, a statistically significant increase of 0.3 (95% CI 0.2, 0.5) WAZs. There was no association between nutritional outcomes and the literacy level of caretakers. The programme was accepted by communities. The cGMP programme in Afghanistan for illiterate women can help improve child nutrition, specifically in underweight children who enter the programme at under 9 months old and attend half of the sessions or more

Underweight

Barriers to CHWs: low literacy levels, lack of job aids/ tools to address malnutrition, insecurity, and cultural norms requiring women to be accompanied by a male relative when in public

Barriers to beneficiary community: distance from programme site; don’t believe in programme

Facilitators: extensive community consultation; culturally acceptable programme design and implementation; high levels of participation amongst targeted children early in the programme; children entering programme at under 9 months old; regular attendance (facilitated by occurring villages and homes); pictorial tools for illiterate CHWs

Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe

Paul et al. [48]

Zimbabwe

-—-—-—-

CASP

Moderate

Evaluate feasibility of improving infant diets using (1) only locally available resources & (2) locally available resources plus 20 g of LiNS

32 children, two age groups (6–8 months and 9–12 moths); 8 per age group per round

Qualitative acceptability & feasibility study of BCC; conducted 2 rounds of 2-week home interventions: 1st round to discern how infant diets in rural Zimbabwe could be improved without introducing a novel commodity; 2nd round to introduce LiNS, Nutributter® & also improve diet quality with local foods

Intervention

Supplementation with lipid-based nutrient supplements (LiNS), complementary feeding messaging, & counselling from VHWs

Comparator

Pre-intervention (baseline indicators)

Whether consumption of key complementary foods increased after counselling; intakes of energy, protein, vitamin A, folate, calcium, iron and zinc from complementary foods; acceptability of the programme from the community

Energy, protein, vitamin A, folate, calcium, iron and zinc intake from complementary foods increased a significant amount after counselling & wasn’t dependent on being given Nutributter (P < 0.05). Intakes of fat, folate, iron, and zinc increased solely (fat) or at an increased amount (folate, iron, and zinc) when given Nutributter (P < 0.05). While providing LiNS was essential to making sure sufficient intakes of iron and zinc, educational messages that addressed context-specific barriers & addressed mothers directly were key to improving underlying diet and behaviour change; Nutributter was acceptable to mothers and children

Micronutrient deficiencies

Facilitators: context specificity of VHWs working with mothers; community ownership/knowledge sharing spurred by VHW engagement; infant feeding messages context-specific about local foods

Nutritional training in a humanitarian context: Evidence from a cluster randomized trial

Kurdi et al. [32]

Yemen

-—-—-—-

CASP

Low

Assess the Yemen Cash for Nutrition programme’s impact on the knowledge and practices related to breastfeeding & water treatment for impoverished women that are pregnant or have young children

1945 impoverished women either pregnant or with children under 2 years old in 190 clusters randomly assigned to treatment versus control

Data from cluster-RCT; primary outcome: child HFA; secondary immediate outcomes IYCF knowledge & behaviour change; panel household questionnaire to collect data

Intervention

The Cash for Nutrition programme was a pilot conditional cash transfer programme with the objective of reducing the high prevalence of child malnutrition, through targeting impoverished women who had children under 2 years or were pregnant at the time of enrolment. Participants received monthly cash transfers conditional on showing up to monthly, CHV-led nutrition sensitisations. Each CHV had a catchment area of several villages and were recruited to become CHVs for the programme from among women living in the targeted area between 18 and 35 years and educated up to secondary school. CHVs conducted quarterly screening sessions using MUAC to detect and refer malnutrition cases

Impact of programme on self-reported practices of early initiation of breastfeeding, EBF, water treatment, & complementary feeding; knowledge of topics covered in nutritional training sessions

Similar impacts on knowledge and breastfeeding between literate and illiterate women; community nutritional training sessions in a cash transfer humanitarian response model can be effective at changing behaviour; programme increased probability of breastfeeding initiation within the first hour after delivery by 15.6% points (p < .05; control = 74.4% and treatment = 83.6%), the probability of exclusive breastfeeding during the first 6 months by 14.4% points (control = 13.5% and treatment = 25.3%), the probability of households treating water consumed by adults by 16.7% points (p < .01; control = 13.9% and treatment = 23.4%), and treating water consumed by children under two by 10.3% points (p < .10; control = 31.2% and treatment = 37.9%)

Not specified

Facilitators: trainings provided by women from local community, allowed trusting relationship between the participants and CHVs and for programme to be run without strict oversight

Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial

Lelijveld et al. [35]

Sierra Leone

-—-—-—-

CASP

Low

Discern if giving RUTF and antibiotics alongside nutritional counselling to children at “high-risk” of MAM (HR-MAM) would lead to better recovery and less deterioration than solely nutrition counselling

Children aged 6–59 months

22 cluster sites; Intervention; 573 children Control: 714 children Sample size: around 800 with MAM across 20 cluster sites

Cluster-RCT; outcomes compared with intention-to-treat analysis

Intervention

Children classified as high-risk MAM (HR-MAM) or low-risk MAM (LR-MAM). HR-MAM group given 1 daily packet of RUTF (until MUAC > 12.4 cm achieved) & amoxicillin; children attended clinic every other week until treatment complete & returned for follow-up at 12 & 24 weeks post-enrolment. Caretakers participated in mother support groups delivered by a community respected elder twice a week, with 4 nutrition sessions on optimising IYCF, cooking, WASH, health care seeking, child development, & MUAC for mothers

Comparator

6 weeks of nutrition counselling only in the form of mother support groups where community respected elders delivered sessions to caretakers, every other week, 4 nutrition sessions about optimizing IYCF, cooking demonstrations, WASH, health care seeking, child development, & training on MUAC for mothers

HR-MAM defined as having ≥ 1 of the following criteria: MUAC < 11.9 cm, WAZ <  − 3.5, mother not primary caregiver, or child < 2 years not breastfed; recovery rate; risk of SAM; risk of death; MUAC; WAZ

Intervention: 317 (55%) classified as HR-MAM; greater short-term recovery at intervention sites; children had lower risk of progressing to SAM (18% intervention compared with 24% control; RD: − 0.07; 95% CI − 0.11, − 0.04), lower risk of death (1.8% intervention compared with 3.1% control; RD: − 0.02; 95% CI − 0.03, − 0.00), and greater increases in MUAC and weight than control children. However, by 24 weeks, the risk of SAM between the intervention and control groups were similar

MAM (HR-MAM and LR-MAM); SAM

An integrated infant and young child feeding and small‐quantity lipid‐based nutrient supplementation programme in the Democratic Republic of Congo is associated with improvements in breastfeeding and handwashing behaviours but not dietary diversity

Locks et al. [37]

DRC

-—-—-—-

CASP

Low

Analyse impact of enhanced IYCF programme, an integrated IYCF—SQ-LNS programme, on IYCF and hand washing practices

Children aged 6–18 months

Baseline:

N-intervention = 650;

N-control = 638;

Endline:

N-intervention = 654; N-control = 653

Cross‐sectional preintervention and postintervention surveys conducted; difference in differences (DiD) analyses used mixed linear regression models

Intervention

Enhanced IYCF programme: community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices; monthly SQ‐LNS distributions for children 6–12 months; additional investments in CHW platform including bike provision, enhanced training, updated CHW guidebook with images on IYCF; logbooks; standardised roles and responsibilities expectations; & improved/standardised supervision

Comparator

National IYCF programme: facility‐based IYCF counselling with no SQ‐LNS distributions, no investments in MM & IEC, no additional investments in CHW platform

Breastfeeding practices in the first 6 months; handwashing practices during food & defecation in previous day; dietary diversity (proportion of children fed minimum dietary diversity or minimum acceptable diet)

Greater increases in proportion of intervention mothers compared to control mothers recalling: initiating breastfeeding within 1 h of birth (Adjusted DiD [95% CI]: + 56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to give water (+ 66.9% [60.6, 73.2], P < 0.001) and complementary foods (+ 56.4% [49.3, 63.4], P < 0.001), meeting minimum meal frequency the day prior (+ 9.2% [2.7, 15.7], P = 0.005); knowledge about anaemia (+ 16.9% [10.4, 23.3], P < 0.001); having soap (+ 14.9% [8.3,21.5], P < 0.001); & washing hands after going to the bathroom, before preparing food, & before child feeding the day prior (+ 10.5% [5.8, 15.2], + 12.5% [9.3, 15.6] and + 15.0% [11.2, 18.8], respectively, p < 0.001 for all). Enhanced IYCF associated with positive changes in IYCF practices, but not dietary diversity (minimum dietary diversity and minimum acceptable diet were similar and below 10% for both groups); intervention mothers had a high likelihood of recalling getting IYCF messages from CHWs; in the intervention site, mothers with high programme (and CHW) exposure were more likely to wait until 6 months to introduce water or complementary foods versus mothers with low programme exposure

Micronutrient deficiencies

Barriers: lack of access or purchasing power to acquire nutrient dense/dietarily diverse foods; health workers may not emphasize messages because they know the foods are difficult to get

Facilitators: training; appropriate supervision in IYCF; bike as transport support and incentive

Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali

Isanaka et al. [54]

Mali

-—-—-—-

CASP

High

Approximate health outcomes, costs, & cost-effectiveness 4 dietary supplements used to treat MAM in children 6–35 months old

95 study villages; 12 community health centres

Incremental cost-effectiveness analysis within a cluster-RCT; costs estimated from the healthcare provider perspective; categorising & costing was done for all resources for bimonthly community-based screenings & MAM treatment; estimations were done with an ingredients approach

Intervention

CVs conducted community-based screening for MAM and SAM using MUAC every 2 months

12 community health centres randomised to deliver one of 4 dietary supplements:

RUSF: ready-to-use, enriched soy protein, peanut paste

CSB +  + : corn–soy blend with soybean flour, maize flour, dried skimmed milk, soy oil & micronutrients

Misola (MI): locally produced, micronutrient-fortified, cereal-legume blend with millet or maize, soy, & peanut flour

LMF: locally milled flour mixture, including millet, beans, oil & sugar

Comparator

No dietary supplement

Cost per MAM or SAM child identified

Key findings: Community-based screening has the potential to promote early case detection and increase treatment referrals and makes up a relatively small sum in the management of AM

Costs for bi-monthly community-based screening:

For MAM treatment: 1.89 USD per MAM child identified, including 1.46 USD for personnel (77% of total activity), 0.26 USD for infrastructure and logistical support (14% of total activity), 0.17 for management and administration (9% of totally activity); constituted 1.7–1.9% of costs for MAM treatment arms

For SAM treatment only: 14.51 per SAM child identified, including 11.19 USD for personnel, 2.00 USD for infrastructure and logistical support, and 1.32 USD for management and administration; constituted 4.7% of costs of ‘Treat SAM only’ arm

Acute malnutrition (MAM and SAM)

Cost-effective

Behavior Change Interventions Delivered through Interpersonal Communication, Agricultural Activities, Community Mobilization, and Mass Media Increase Complementary Feeding Practices and Reduce Child Stunting in Ethiopia

Kim et al. [39]

Ethiopia

-—-—-—-

CASP

Moderate

Assess the impact of an intensive BCC intervention compared with standard interventions on child feeding practices, caregiver knowledge, & anthropometric outcomes

Sample size of 2700 (1350/group) children; baseline total (n = 2646); endline total (n = 2720)

Children aged 6–23.9 months

Cluster-randomised, nonblinded impact evaluation design with cross-sectional surveys

Intervention

Intensive BCC interventions: HEWs and health development team leaders (HDTLs) sensitised through interpersonal communication activities (IPC) on IYCF during health post visits and home visits and food demonstrations; AEWs promoted nutrition-sensitive agricultural activities (AG) that help with agriculture and child growth; religious leaders delivered IYCF-focused community mobilisation (CM) activities about adequate child feeding during fasting, & CBOs facilitated enhanced community conversations about IYCF. There was also a mass media (MM) campaign on IYCF practices

COMPARATOR

Nonintensive areas: HEWs, HDTLs, and AEWs provided the regular services; few, if any IYCF CM activities; no directed MM

Primary outcome: WHO core CF practices: minimum dietary diversity; minimum meal frequency; minimum acceptable diet; consumption of iron-rich or iron-fortified foods; timely introduction of solid, semisolid, or soft foods. Based on maternal 24-h recall of foods consumed

Secondary outcomes: maternal knowledge about CF and stunting prevalence among children; assessed based on mothers’ responses to a set of 12 questions about CF; anthropometric data: HAZ, WAZ, and WHZ

Intensive group endline: IPC exposure was 17.8–32.3%, AG exposure was 22.7–36.0%, CM exposure was 18.6–54.3%, MM exposure was 35.4%; minimum dietary diversity and minimum acceptable diet increased significantly but remained low at endline (24.9% and 18.2%, respectively). There were significant differential declines in stunting prevalence (DDE: − 5.6 percentage points; P < 0.05) in children 6–23.9 months old, decreasing from 36.3% to 22.8% in the intervention group. Dose–response analyses showed higher odds of minimum dietary diversity (OR: 3.3; 95% CI 2.2, 4.8) and minimum meal frequency (OR: 1.9; 95% CI 1.4, 2.6) and higher HAZ (β: 0.24; 95% CI 0.04, 0.4) among women exposed to 3 or 4 of the IYCF BCC platforms. Path analyses revealed a strong relation between AG and egg consumption, which led to increased HAZ and child dietary diversity

Barriers: Disruptions in programme implementation due to state of emergency for 10 months

Nutritional Monitoring of Preschool-Age Children by Community Volunteers during Armed Conflict in the Democratic Republic of the Congo

Bisimwa et al. [38]

DRC

-—-—-—-

CASP

Low

Evaluate CVs' effectiveness in child growth monitoring in an area of endemic malnutrition & armed conflict in South Kivu

5479 children aged under 5 years old

Cross-sectional comparison; effectiveness evaluation

A community-based nutrition programme in the Lwiro Health sector, lasting for 32 months, and including a public awareness campaign, recruitment & training of CVs, & arrangement of monthly community weighing sessions

WFA, oedema, median percentage of children weighed per village for children of 12–59 months old; percentage of children weighed per village for children under 12 months; median percentage of children 12–59 months old per village ranked as highly susceptible to malnutrition by CVs

Key findings: CVs can be an important support to the health system through effectively decentralizing nutritional monitoring of pre-school aged children at the community level

Median percentage of children 12–59 months old weighed per village: between 80 and 90%

Median percentage of children < 12 months old weighed per village: between 80 and 100%

Median percentage of children 12–59 months old per village ranked as highly susceptible to malnutrition: decreased from 4.2% (range, 0% to 35.3%) in 2004 to 2.8% (range, 0.0% to 18.9%) in 2005

Endemic malnutrition, acute malnutrition

Barriers: malnutrition rates varied seasonally; interruption of health facility services by active conflict

Facilitators: sessions proximate to home (CVs lived in same area); weighing sessions in friendly family context, effective social mobilization; incentives: motorbikes, DHO agreed to employ CVs whenever there was a paid activity; support from community leaders; community knowledge & involvement in child growth monitoring

Scaling severe acute malnutrition treatment with community health workers: a geospatial coverage analysis in rural Mali

Charle-Cuéllar et al. [47]

Mali

-—-—-—-

CASP

Moderate

Investigate the most effective supervision model for providing SAM treatment through CHWs

6112 children aged 6–59 months

Prospective non-randomized community intervention trial; three arms: two intervention arms & one control arm, distinguished by different levels of supervision

Intervention

High supervision arm: supportive supervision for iCCM as well as nutrition-specific supervision

Light supervision arm: supportive supervision based on iCCM package

Comparator

No specific supervision

Primary outcome: cure rate, WHZ ≥ −1.5 or MUAC ≥ 125 mm & absence of nutritional oedema for two consecutive visits

Secondary outcomes: defaulters, deaths, referrals with complications, quality of care delivered by CHWs

Proportion of children cured: 81.4% in the high supervision group, 86.2% in the light supervision group, & 66.9% in the control group. Children treated by CHWs with some form of supervision had better outcomes than those treated by CHWs with no supervision (p < 0.001). There was no significant difference between light & high supervision groups. CHWs with high supervision did perform better in the majority of tasks assessed

SAM

The SHINE Trial Infant Feeding Intervention: Pilot Study of Effects on Maternal Learning and Infant Diet Quality in Rural Zimbabwe

Desai et al. [49]

Zimbabwe

-—-—-—-

CASP

Low

Evaluate the independent and compounded effects of improved WASH & infant feeding on child stunting and anaemia; infant feeding intervention was pilot-tested to asses comprehension of messages and tools, as well as feasibility of a VHW- delivered intervention

9 VHWs delivered programme to 19 mother-infant dyads

Infants aged 7–12 months

Mixed methods; effectiveness evaluation, knowledge assessment, feasibility evaluation

Intervention

All 4 treatment arms: VHWs make 15 visits to mother–infant dyads, providing specific health messages, with four visits on EBF promotion

Intervention arms: VHWs provide lessons on WASH, IYCF, or WASH + IYCF, with specific lessons depending on intervention randomised to (WASH, IYCF, or WASH + IYCF)

Comparator

VHWs make 15 visits to mother–infant dyads, providing specific health messages, with four visits on EBF promotion, but no visits providing specific promotion of WASH, IYCF, or both

Maternal knowledge about infant feeding; self-reported nutrient consumption of children (24 h recall)

Maternal knowledge on infant feeding improved after the dissemination of each lesson; responses showed knowledge absorption and retention on important feeding practices; consumption of each nutrient taught about and measured increased significantly; all infants received adequate vitamin A & fat; most infants consumed sufficient daily energy (79%), protein (95%), calcium (89%), & zinc (89%); percentage of infants achieving folate requirement was only 68%, though this was double the previous percentage. Infants reaching iron requirement increased from 0 to 68%

Stunting, micronutrient deficiencies

Health Extension Workers’ diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross‐sectional study

Getachew et al. [42]

Ethiopia

-—-—-—-

CASP

Moderate

Investigate HEWs' ability to correctly diagnose childhood illnesses of diarrhoea, febrile disorders, acute respiratory tract infection, malnutrition, & ear infection

186 HEWs; 620 children 2–59 months observed and re-examined

Cross-sectional survey; observations of HEWs’ diagnosis were followed by a re-examination of the child by a trained health officer

ICCM delivered by HEWs; assessment, classification, and diagnosis of childhood illnesses by HEWs

HEW ability to correctly identify and classify childhood illnesses

Malnutrition diagnostics: WFH/L, oedema, MUAC, medical complications, ability to finish RUTF for children older than 6 months, existence of breastfeeding issue for children younger than 6 months

Key findings: More research is needed on whether HEWs accurately assess and classify childhood illnesses; study results suggest a significant number of sick children were not correctly diagnosed, which could lead to lack of or incorrect treatment; efforts are needed to improve HEWs’ diagnostic ability for childhood illnesses and their adherence to the guidelines for the examination, classification and treatment of childhood illnesses

Diagnosis by HEWs had a 39% & specificity 99% for malnutrition

Acute malnutrition:

MAM, uncomplicated SAM, complicated SAM defined with WHO growth standards

Effect of complementary feeding behaviour change communication delivered through community‐level actors on infant growth and morbidity in rural communities of West Gojjam Zone, Northwest Ethiopia: A cluster‐randomized controlled trial

Ayalew et al. [33]

Ethiopia

-—-—-—-

CASP

Low

Investigate effect of complementary feeding BCC disseminated through community-level actors on infant morbidity & growth

Children under 6 months at start of trial

Baseline total: 612 (N-intervention: 306, N-control: 306); Follow-up total: 554 (N-intervention: 272, N-control: 282); Sample size total: 612 (N-intervention: 306, N-control: 306)

Cluster-randomized control trial

Intervention

Infants, caregivers of infants, & family members in intervention clusters received complementary feeding BCC from community-level actors for 9 months. 3-part intervention: training of women development army (WDA) leaders; group training of mothers by WDA leaders; home visits

Comparator

Infants, caregivers of infants, & family members in control clusters received standard health and nutrition care

Effect on infant growth (stunting, underweight, wasting); effect on infant morbidity

Key findings: complementary feeding BCC disseminated by community-level actors significantly improved gains in infant length & weight. It also decreased rates of stunting & underweight

Intervention infants had significantly higher weight gain (MD: 0.46 kg; 95% CI 0.36–0.56) and length gain (MD: 0.96 cm; 95% CI 0.56–1.36) versus control infants. The intervention infants also had a reduced rate of stunting by 7.5 percentage points (26.5% vs. 34%, RR = 0.68; 95% CI 0.47–0.98) and underweight by 8.2 percentage points (17% vs. 25.2%; RR = 0.55; 95% CI 0.35–0.87)

Stunting

(HAZ < −2), underweight (WAZ < −2), wasting (WHZ < −2)

Facilitators: ability to influence change and feeding practices; intervention targeted family members in addition to mothers of infants—influencing the overall household environment to encourage change in behaviour; cooking demonstrations

Précis of nutrition of children and women in Haiti: analyses of data from 1995 to 2012

Ayoya et a. [51]

Haiti

-—-—-—-

CASP

Low

Address the information gap for nutrition issues in Haiti, research: trends and determinants of IYCF practices; micronutrient deficiencies; status of SAM in children; links between women’s empowerment, healthcare access, WASH, & child nutrition; community-based child nutrition initiatives; & nutrition governance status

Not specified

Mixed methods: secondary data analysis of national data sets; household survey; site visits; stakeholder interviews; document review; multivariate analyses to distinguish relationships between potential determinants of primary outcomes; baseline surveys; literature review

Intervention

IYCF counselling; dispensation of MNPs to fortify complementary foods at home; and CMAM for children under 5 and pregnant and lactating women; GMC; vaccinating children; vitamin A for children, and deworming for children under 5 years old

CHW role is key to achieving an integrated health system; CHW role is key to achieve integrated health system; CHWs with substantial institutional support were among the most motivated and dedicated team members; CHWs played an essential role in screening and follow-up for services not delivered at the community level; numerous delivery platforms (including BCC) are required to implement a comprehensive nutrition programme; engaging community members in programme delivery can foster community involvement and encourage peer support for behaviour change

Micronutrient deficiencies, SAM, acute malnutrition

Facilitators: ability to ensure children in catchment area access all available services; strong institutional support; foster community engagement and peer support for behaviour change

Community volunteers can improve breastfeeding among children under six months of age in the Democratic Republic of Congo crisis

Balaluka et al.[44]

DRC

-—-—-—-

CASP

Moderate

Assess the effectiveness of CHWs in encouraging EBF from birth in a context of endemic malnutrition

Children under 6 months old

Intervention: 208 children

Comparator: 178 children

Cohort study; impact evaluation

Intervention

Katana district: selected villages given team of 5 CHWs trained in promoting optimal breastfeeding practices. CHWs promoted EBF through door-to-door visits & community meetings. From 2004 to 2006, CHWs also helped supervise infant growth by arranging monthly community weighing sessions (supervised by district health officers) with a nutrition sensitisation to raise mothers' awareness about the importance of breastfeeding & EBF from birth to 6 months

Comparator

Walungu district: far apart and not adjoining Katana district. No community-based nutrition project or CHWs, no programme specifically about breastfeeding practices

Proportion of infants receiving EBF by age

Length of EBF time from birth was higher in the intervention group (median, range): Intervention was 6 months (2 to 7) versus comparator was 4 months (1 to 6) (p < 0.001)

Proportion of infants receiving EBF at 6 months old was high in the intervention group: Intervention was 57.7% (95%: CI, 50.9 to 64.5) versus comparator 2.7% (95%: CI, 1.1 to 6.6) (p < 0.001)

Endemic malnutrition, GAM

Facilitators: level of education of CHWs; proximity of CHWs to breastfeeding mothers; CHWs driven by the knowledge and gravity of malnutrition in the area; community involvement and engagement

Combined infant and young child feeding with small-quantity lipid-based nutrient supplementation is associated with a reduction in anemia but no changes in anthropometric status of young children from Katanga Province of the Democratic Republic of Congo: a quasi-experimental effectiveness study

Addo et al. [36]

DRC

-—-—-—-

CASP

Moderate

Evaluate impact of IYCF–SQ-LNS intervention on anaemia & growth in children

2995 children aged

6–18 months

Cross-sectional comparison; quasi-experimental effectiveness design

Interveniton

Enhanced IYCF package: standard IYCF package plus improved counselling on IYCF, daily SQ-LNS for infants 6–12 months, community-based nutrition education for mothers and pregnant women, & reinforced CHW role through enhanced training & community-based outreach counselling by CHWs on IYCF & SQ-LNS

Comparator

Standard IYCF package: iron–folic acid supplementation, antimalarial medication, individual IYCF counselling during ANC visits; individual counselling on IYCF & child health by CHWs during clinic visits; monthly group counselling on IYCF & child health at health clinics only; & IYCF counselling during HW outreach clinics

Anaemia prevalence; haemoglobin; iron levels, vitamin A levels; anthropometry measures (WAZ & LAZ); stunting prevalence

Key findings: Enhanced IYCF intervention was associated with a reduction in anaemia prevalence, increase in haemoglobin, but no effect on anthropometry or iron or vitamin A deficiencies. Intervention children who received ≥ 3 monthly SQ-LNS batch distributions had higher anthropometry measures and haemoglobin and lower prevalence of stunting than control children

Enhanced IYCF intervention associated with 11.0% point (95% CI − 18.1, − 3.8; P < 0.01) adjusted relative reduction in anaemia prevalence and a mean + 0.26-g/dL (95% CI 0.04, 0.48; P = 0.02) increase in haemoglobin but no effect on anthropometry, iron, or vitamin A deficiencies

Endline in the intervention: compared with those who didn’t receive any, children 8–13 months who received ≥ 3 monthly SQ-LNS batch distributions had higher anthropometry measures (LAZ: + 0.40, P = 0.04; WAZ: + 0.37, P = 0.04) and haemoglobin (+ 0.65 g/dL, P = 0.007) and a lower adjusted prevalence difference of stunting (− 16.7%, P = 0.03)

Stunting

Quality of care for treatment of uncomplicated severe acute malnutrition delivered by community health workers in a rural area of Mali

Alvarez Morán et al. [45]

Mali

-—-—-—-

CASP

Moderate

Assess quality of care delivered by CHWs for uncomplicated SAM

17 CHWs; 125 cases of children under the age of 5 years old assessed and treated by CHWs

Observational, clinical prospective multicentre cohort study

Interveniton

CHWs trained & equipped to treat uncomplicated SAM cases in children under 5 in the community. Pilot assessed effectiveness of treatment, measuring clinical outcomes, quality of care (technical competence) provided by CHWs, treatment coverage, & cost-effectiveness. Observers of CHWs were medical health professionals familiar with malnutrition treatment protocols

Comparator

Existing outpatient health facility treatment of SAM

CHW quality of care (capacity to evaluate, classify, & treat uncomplicated SAM; provide nutritional counselling to caretakers of children receiving treatment for SAM, malaria, pneumonia, or diarrhoea; & correctly refer complicated SAM); CHW technical competence (screening for SAM; diagnosis of SAM; provision of antibiotics, vitamin A, and anti-parasitic medication for SAM; delivery of RUTF until child has recovered); CHW interpersonal skills (how CHW interacts with carer and child)

Key findings:

1) Well‐trained & supervised CHWs can manage uncomplicated SAM, including treatment and correct dosing with a high quality of care

2) Direct management of SAM cases by CHWs can enable increased access to quality SAM treatment in Mali & possibly other contexts

3) Need further research into resources required for continuous service delivery at the community level

100% of CHWs were observed as interacting correctly with patients & carers; 97.6% of children were correctly assessed for presence of cough, diarrhoea, fever, & vomiting; 78.4% oedema correctly assessed; 100% height measured correctly; 100% correctly classified for SAM; 77.8% correctly performed appetite test; 75% SAM cases administered correct medical treatment with Amoxicillin, Albendazole, & vitamin A; 94.3% of caretakers given essential nutrition counselling; 83.3% caretakers given demonstration on first treatment doses & correctly provided information on all treatments and dosage; 100% of cases assessed correctly administered RUTF; 79.5% of cases achieved composite indicator including all essential tasks to provide high-quality treatment for SAM (child appropriately assessed for key indicators, correctly classified & treated, and received key counselling)

Uncomplicated SAM in children under 5 years old defined by national protocaol as MUAC < 11.5 cm, WHZ <  − 3, and/or nutritional oedema

Barriers: balancing increased workload when scaling up a programme

Facilitators: supervision; good training

The effectiveness of treatment for Severe Acute Malnutrition (SAM) delivered by community health workers compared to a traditional facility based model

Alvarez Morán et al. [46]

Mali

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CASP

Moderate

Investigate potential for integrating SAM identification & treatment delivered by CHWs to improve SAM treatment coverage

Children between 6–59 months old with SAM in neighbouring sectors of Kita district Intervention: 699 children Control: 235 children

Multicentre, randomised and rationalised intervention study

Interveniton

Treatment for uncomplicated SAM from health centres or CHWs

Comparator

Outpatient treatment for uncomplicated SAM from health centres

Clinical outcomes:

cure (child with WHZ ≥ −1.5 or MUAC > 125 mm and absence of nutritional oedema for 14 days), defaulter, & death ratios;

Other outcomes: quality of care; treatment coverage (using the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) methodology)

Key findings: CHWs are effective in treating uncomplicated SAM in children & have non-inferior outcomes compared to traditional outpatient therapeutic feeding (OTP) treatment models. CHWs-delivered SAM treatment supported improved access to treatment

Intervention cure ratio 94.2% compared to 88.6% in control (RR 1.07 [95% CI 1.01; 1.13]); defaulter ratios twice as high in control compared to intervention (10.8% vs 4.5%; RR 0.42 [95% CI 0.25; 0.71]); differences in mortality ratios not statistically significant (0.9% intervention compared to 0.8% control); coverage rates 86.7% intervention compared to 41.6% control (p < 0.0001)

Uncomplicated SAM in children defined by national protocol as children aged 6–59 months, MUAC < 115 cm, WHZ <  − 3, and/or nutritional oedema

Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study

Tappis et al. [55]

Yemen

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CASP

Very low

Investigates how facility- and community-based RMNCAH + N services have been delivered since 2015, and factors influencing service implementation

3 governorates (Sana's City, Aden, Taiz); 181 individuals interviewed

Case study; content analysis methods for publicly available documents & datasets; 94 individual & group interviews with government officials, humanitarian agency staff, & facility-based healthcare providers; 6 FGDs with community health midwives & CHVs

Intervention

Facility- and community-based RMNCAH + N services

Factors affecting RMNCAH + N service delivery, service availability, service coverage, and service quality

Humanitarian work and programmes centred on supporting and continuing the provision of basic services a facilities, & using mobile clinics, outreach teams, & CHVs to address emergency needs when the conflict environment allowed for movement & outreach to communities. The focus of specific sub-elements of RMNCAH + N depended on location, with these geographic changes due to differing priorities across different government offices or catchments, the level of active conflict, the ability to access affected populations; & qualified workforce availability; Overall, services for women’s health and child were prioritized. Otherwise, controlling cholera outbreaks & treatment of acute malnutrition were prioritized over other services

Acute malnutrition (MAM and SAM)

Barriers: Insecurity; resource-constraint of health facilities; challenges in importation distribution of supplies; politicization of aid; weak health system capacity; costs of care seeking; ongoing cholera epidemic; distrust & subsequent lack of demand

Facilitators: Resilient healthcare workers

Performance of low-literate community health workers treating severe acute malnutrition in South Sudan

Van Boetzelaer et al. [50]

South Sudan

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CASP

Moderate

Evaluate if low‐literate CBDs can adhere to a simplified SAM treatment protocol and to investigate the community acceptability of CBDs delivering treatment

57 CBDs; 141 performance checklists

Mixed methods pilot study; feasibility & acceptability study

Intervention

CBDs trained and aided with tools adapted for low literacy as well as a simplified SAM treatment protocol. CBDs then returned to their communities where they passively screened for children suffering from uncomplicated SAM

Performance of the low‐literate CBDs in adhering to the treatment protocol

Low‐literate CBDs in South Sudan could adhere to a simplified treatment protocol for uncomplicated SAM through the use of low-literacy adapted tools. The number of performance checklists completed for a CBD was significantly associated with the last performance score recorded for the CBD. For each performance checklist completed, the final score of the CBD rose by absolute 2.0% (95% CI 0.3%–3.7%)

SAM

Barriers: High food insecurity & demand for RUTF led to conflict or suspicion in community around when a child was decided to not be eligible for treatment

Facilitators: Manageable workload (SAM treatment provided on fixed day per week); community trust in CBDs; training: use of songs, practical exercises, role plays effective for training; supervision; proximity

Sustainable under nutrition reduction program and dietary diversity among children’s aged 6–23 months, Northwest Ethiopia: Comparative cross-sectional study

Worku et al. [41]

Ethiopia

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CASP

Moderate

Compare level of dietary diversity among children aged 6–23 months in districts covered and not covered by the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme in West Gojjam zone

832 mother–child pairs;

Children aged 6–23 months

Sample size: 832

Community-based, comparative cross-sectional study; mother and child pairs were selected by the simple random sampling technique. A pretested and structured interviewer-administered questionnaire was used to collect data. A binary logistic regression model was fitted to identify factors associated with dietary diversity. Crude odds and adjusted odds ratios with 95% CI calculated to assess the strength of associations and significance of the identified factors for dietary diversity score

Intervention

SURE government-led, multi-sectoral programmes for the improvement of nutrition outcomes that particularly focuses on the integration of the health and agriculture sectors. It provided nutrition education using the BCC approaches. The project has three main components: enhancing community-based nutrition (CBN) to address inadequate complementary feeding, improving household dietary diversity through IYCF, and familiarising nutrition-sensitive agriculture

Comparator

Areas of similar demography not exposed to SURE programme

dietary diversity (number of different food groups consumed by the child in 24 h prior to assessment);

SURE programme covered districts 2.5 times more likely to have adequate dietary diversity than uncovered ones. The overall proportion of adequate dietary diversity among children aged 6–23 months was 29.9% (95% CI 27.0–33.0), whereas in SURE covered and uncovered districts it was 33.4% (95% CI 29.0–38.and 26.4%(95% CI 22.0, 31.0), respectively. ANC (Antenatal care) (AOR = 1.7; 95% CI 1.16, 2.55) and postnatal care services (AOR = 2.1; 95% CI 1.38, 3.28), participating in food preparation programmes (AOR = 1.9; 95% CI 1.19, 2.96), GMP (AOR = 2.74,95% CI 1.80, 4.18), vitamin A supplementation (AOR = 2.10,95% CI1.22, 3.61) and household visits by health extension workers (AOR = 2.0; 95% CI 1.25, 3.21) were significantly associated with dietary diversity

Undernutrition

Facilitators: women participating in food preparation programmes, household visits from HEWs, ANC visits, PNC follow-ups

Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali

Rogers et al. [53]

Mali

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CASP

Moderate

Evaluate costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care for SAM

Modelling number of children aged 6–59 months treated in each arm using sample size in intervention (n = 617);

18 CHWs; interviews (n = 59); FGDs (n = 10, 5 per arm); carers with a child in treatment or recently exited (n = 68)

Costs & cost-effectiveness assessment based off of a prospective multicentre clinical cohort trial conducted to evaluate treatment of uncomplicated SAM by CHWs versus existing outpatient facility-based care

Intervention

18 CHWs screening for SAM, making referrals to health clinics for complicated cases, & treating uncomplicated cases in the community; CHWs delivered nutrition sensitisations to communities. Alongside the CHW programme, 3 outpatient health facilities managed SAM cases

Comparator

16 CHWs screened & delivered nutrition education sessions. They adhered to the Malian CMAM protocol in place at the time, and thus referred all cases to the outpatient facility for treatment or further referral to an inpatient care facility

Costs & cost-effectiveness

Costs were higher in the intervention than the control. CHW costs in the intervention arm were close to 3 × higher than the control, due to the greater amount of labour and involvement from CHWs in delivering services. Beneficiary costs were higher in the intervention group as a result of higher enrolment in the programme. However, at the individual household level, intervention households spent less time and money receiving treatment than control households. The base case analysis indicates outpatient facility-based care is more expensive than CHW-delivered care, both for providers and for beneficiaries. CHW-delivered care households spent almost half the time receiving treatment and 3 × less money compared with the outpatient facility-based arm (2.15 h versus 3.92 h; 0.60 USD versus 1.70 USD). Higher costs and time spent were attributed to transportation to the facility. Cost-effectiveness in the base case with the observed number of children treated, the average cost per child treated by CHWs was 244 USD compared to 442 USD in the outpatient facility. The cost per child recovered was 259 USD by CHWs and 501 USD in the outpatient facility

Uncomplicated SAM

Facilitators: Cost effective, lower beneficiary costs due to lower transport costs and time; lower provider costs in CHW arm

Lipid-Based Nutrient Supplementation Reduces Child Anemia and Increases Micronutrient Status in Madagascar: A Multiarm Cluster-Randomized Controlled Trial

Stewart et al. [31]

Madagascar

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CASP

Moderate

Determine the effectiveness of LNS supplementation administered daily on child anaemia and micronutrient status within the context of an nutrition programme that is already running and has been scaled up

125 communities with children aged 0–24 months

Multiarm cluster-RCT

Intervention

Treatment arms: (T1): T0 + home visits for intensive nutrition counselling (with additional CNWs); (T2): T1 + LNS for children aged 6–18 months (with & distributed by CNWs); (T3): T2 + LNS for pregnant and lactating women; (T4): T1 + early childhood stimulation and parenting messages

Comparator

(T0): Status quo treatment arm: based on standard Madagascan growth monitoring and nutrition education protocol

Key messages: maternal nutrition, early initiation of breastfeeding, EBF for the first 6 months, continued breastfeeding through 2 years, & age-appropriate complementary feeding & hygiene behaviours. CNWs demonstrated cooking with local ingredients that were complementary foods. The government also distributed vitamin A biannually for children < 5 years old. Pregnant women were also given iron–folic acid supplements during ANC visits

Haemoglobin; anaemia; iron status; vitamin A status; all analyses were intention-to-treat

Children in the LNS groups (T2 and T3) had an approximately 40% lower prevalence of anaemia, 25% lower prevalence of iron deficiency than children in the control group (T0) (P < 0.05 for all). There were no differences in any of the biomarkers when comparing children in the T4 group with those in T0; nor were there differences between T3 and T2

Micronutrient deficiencies

Supplementary Feeding of Moderately Wasted Children in Sierra Leone Reduces Severe Acute Malnutrition and Death When Compared with Nutrition Counseling: A Retrospective Cohort Study

Rajabi et al. [43]

Sierra Leone

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CASP

High

Investigate if supplementary feeding versus counselling alone for children with moderate wasting was able to prevent progression to SAM or death

1791 children under 5 years old; sample size: 1092

Retrospective dual cohort study; 1791 children with moderate wasting taken from 2 RCTs that had occurred in the same location; 1077 children received supplementary feeding; 714 children received counselling only; children in both RCTs were followed for ≥ 24 weeks from enrolment

Intervention

Supplementary feeding cohort was taken from a cluster-RCT (called FFS trial) comparing 4 different foods in the treatment of moderate wasting

Comparator

Counselling alone cohort taken from a cluster-RCT (called Hi-MAM trial) testing effectiveness of giving supplementary feeding and amoxicillin to higher-risk children with moderate wasting compared with counselling alone. Caretakers participated in mother support groups twice a week delivered by a trained community respected elder for 4 sessions which covered IYCF, cooking demonstrations, WASH, health care seeking, child development, & MUAC training for mothers

Primary outcome: time to SAM or death; SAM defined by MUAC < 11.5 cm and/or development of bilateral pedal pitting oedema

Secondary outcomes: proportions of children with healthy MUAC, moderate wasting, SAM, and death; rates of gain in weight, MUAC, and length at 3 time points after enrolment: 6 weeks, 12 weeks (range: 8–18 weeks), and 24 weeks (range: 20–30 weeks)

In the counselling group (Hi-MAM), 47% attended all sessions and only 12% missed more than 1 session. Intervention children had a lower risk of developing SAM or dying over 24 weeks of follow-up, as well as greater rates of gain in weight and MUAC. For the entire follow-up period, children who received supplementary feeding were less likely to develop SAM or die (HR: 0.53; 95% CI 0.44, 0.65; P < 0.001). Children who received supplementary feeding were more likely to have a healthy MUAC at 6 & 12 weeks. They were also less likely to develop SAM at 6, 12, & 24 weeks & had higher rates of weight gain and MUAC gain at 6 & 12 weeks

Moderate wasting; SAM

Facilitators: Integration with or inclusion of supplementary feeding element

Assessing the Impact of Integrated Community-Based Management of Severe Wasting Programmes in Conflict-Stricken South Sudan: A Multi-Dimensional Approach to Scalability of Nutrition Emergency Response Programmes

Renzaho et al. [52]

South Sudan

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CASP

Moderate

Analyse & report best practices & identify evidence on the effectiveness & scalability of CMSW programmes to support future nutrition interventions in South Sudan

1,105,546 children admitted to CMSW programmes over period of 5 years;

targeted children under 5 years old, but still admitted older children with severe wasting

Multi-dimensional approach to assess impact, scalability, integration used to assess CMSW programmes’ impact. Used three data sources: standardised monitoring and assessment of relief and transitions (SMART), food security and nutrition monitoring system (FSNMS) surveys, & CMSW programmes’ performance data

Community-based management of severe wasting (CMSW) programmes

CMSW Programme Scalability: harmonisation of implementation; delivery system; technical assistance; organisational capacity; development & sharing of M&E evidence to guide policy & programmes; community ownership; partnership facilitation & coordination; defining of roles & responsibilities; financial resources & sustainability

Findings suggest strong CMSW programme implementation was associated with a timely manner and with quality care through an integrated, harmonised, multi-agency, and multidisciplinary approach. Between 2014 and 2019, wasting prevalence fluctuated with agriculture seasonality, remaining above the 15% emergency threshold during the lean season. But during the same period, under-five and crude mortality rates (10,000/day) declined respectively from 1.17 and 1.00 to 0.57 and 0.55. These two indicators remained below the emergency thresholds, suggesting emergency response was effectively managed. Over a five-year period, 1,105,546 children were enrolled into to CMSW programmes. The pooled performance indicators were as follows: 86.4 (18.9%) for recovery, 2.1 (7.8%) for deaths, 5.2 (10.3%) for defaulting, 1.7 (5.7%) for non-recovery, 4.6 (13.5%) for medical transfers, 2.2 (4.7%) for relapse, 3.3 (15.0) g/kg/day for weight gain velocity, and 6.7 (3.7) weeks for the length of stay in the programme. All key performance indicators, except the weight gain velocity, met or exceeded the Humanitarian Charter and Minimum Standards in Humanitarian Response

CMSW Performance: Compared CMSW programme outcomes with SPHERE minimum standards using the following indicators: recovered, died, defaulted, medical transfers, not recovered, relapse, weight gain velocity, length of stay

Severe wasting

Barriers:

Weak community mobilisation; poor context-specificity; insecurity & active conflict; resource constraints; reliance on imported RUTF emergency funding, & external assistance; weak health system; limited integration of programmes into public health systems; few opportunities for learning & knowledge transfer

Facilitators: Development of comprehensive national protocols & standardisation of programme implementation; training & education for primary caregivers, government staff, NGO partner staff, and health workers on IYCF; multi-agency technical assistance & coordination; integrated, harmonised, & multidisciplinary programme & policy