The impact of a continuum of care intervention from prevention to treatment on child wasting compared with usual community group activities: a cluster-randomized controlled trial in Mali

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BACKGROUND: Child wasting is associated with a high mortality risk and remains a persistent public health challenge. OBJECTIVES: This study aimed to evaluate the impact of an intervention strengthening the continuum of care of child wasting from prevention, screening, and referral to treatment in Mali. METHODS: A 2-arm cluster-randomized controlled trial was conducted using 2 study designs to evaluate impact and pathways: 1) a longitudinal study of children enrolled at 6 mo (n = 2324) with monthly follow-up for 3-6 mo to assess wasting prevalence (primary outcome); 2) a longitudinal study of all children 6-23 mo admitted to outpatient therapeutic programs (OTP; n = 7104) assessing recovery and adherence. Additional OTP coverage surveys were conducted at the end of the study. In both study arms, nutrition activity support groups (NASG) screened children for wasting and provided caregiver behavior change communication (BCC). The intervention arm additionally received small-quantity lipid-based nutrient supplements (SQ-LNS), child-centered BCC, family-led screening, and follow-up on referred wasting cases to support OTP admission and adherence. RESULTS: The intervention did not impact wasting prevalence but reduced the incidence of wasting [relative risk (RR): 0.80, 95% confidence interval (CI): 0.64, 0.99] and severe acute malnutrition (SAM) (RR: 0.71, 95% CI: 0.57, 0.89). The intervention significantly increased wasting screening coverage by 37 percentage points (pp) (95% CI: 31, 44) and SAM treatment coverage by 15 pp (95% CI: 0.35, 30). No impacts of the intervention on OTP recovery or adherence were found. NASGs often replaced the monthly home visits with community gatherings to deliver the intervention. NASGs also often distributed SQ-LNS to children they identified with wasting instead of referring them to the OTP. CONCLUSIONS: Strengthening the continuum of care of wasting through community groups reduced the incidence of wasting and SAM and improved screening coverage, which translated into a modest gain in SAM treatment coverage. This trial was registered at clinicaltrials.gov as NCT04872088.

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