Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger

Abstract

Background: Community health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes.

Methods: This pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger's Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed.

Results: A total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.).

Conclusions: Mothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs.

Trial registration: The trial is registered with clinicaltrials.gov (Trial number NCT01863394).

Keywords: Community management of acute malnutrition; Mid-upper arm circumference; Screening by mothers; Severe acute malnutrition.

Fig. 1

Example of color-coded mid-upper arm circumference tapes

Fig. 2

Flow of referrals from village to health center in health zones where malnutrition screening was performed by mothers or community health workers, Mirriah District, Niger between June 2013 and May 2014

Fig. 3

Distribution of MUAC at admission, children admitted for severe acute malnutrition treatment by MUAC <115 mm, in health zones where mothers or community health workers performed malnutrition screening, Mirriah District, Niger between June 2013 and May 2014. For the box plots presented in Fig. 3, the box extends between the upper and lower quartiles with the thicker line in the box marking the position of the median. The whiskers extend to 1.5 times the interquartile distance above and below the upper and lower quartiles. The isolated points mark the positions more extreme than the range of values covered by the whiskers. If the notches around the medians for each zone do not overlap then there is “strong evidence” that the two medians differ. [32]