14 avril 2023
Nutrition Research Advisor, Cécile Salpéteur
Research Officer, Chloe Puett
ALNAP conference Evidence & Knowledge in Humanitarian Action
March 6, 2013 - Washington, USA
A cluster RCT to assess the effectiveness and cost effectiveness of RUSF for the prevention of child wasting in Chad: a
successful collaboration between a humanitarian aid organization and
academics
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Context & rationale of Chad project
Humanitarian crisis expected in Sahel Gap in evidence on how to prevent acute
malnutrition A Conducive environment ?
ACF providing support to CMAM programme ACF internal funding & research policy since 2008 A strong scientific partner – Univ. of Ghent, Belgium
An impossible challenge Timeframe very tight High turnover of ACF key staff Insecurity, floods, sandstorm …
A strong project set up Specific governance of project
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Project set up & governance A special coordinator directly under the Executive
Director A big internal funding
A working group in HQ / weekly meetings A steering committee A Research Officer on the field
MoU with University of Ghent, Belgium Univ. Of Gent responsible for research aspects Ethical committee of Univ. of Ghent + local
authorities Registration on clinicaltrial.org Research insurance
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Research question & outcomes
Main Objective:• To measure the effectiveness of RUSF added to
a food ration in reducing incidence of wasting among children aged 6 to 36 months living in Abeche town during the hunger gap
Primary Outcome:• Cumulative incidence of wasting
Secondary Outcomes: • Anemia prevalence and hemoglobin level• Linear growth • Morbidity prevalence
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©ACF, F.Houngbe 2010
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©ACF, F.Houngbe 2010
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STUDY DESIGN45 neighborhoods
Abéché town(N=110,000)
Inclusion based on participatory approach (ACF-France, 2010)
7 most vulnerable neighborhoods
Division in 14 clusters and localisation of HH in each cluster
Randomization of clusters
7 clustersIntervention Group
7 ClustersControl Group
Listing of vulnerable HH (n=3,000)
Listing checks
N=458 N=613
Food Assistance FA + RUSF
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©ACF, F.Houngbe 2010
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Global timeframe
AprMarFeb
2011
NovOct
2010
SepAugJunMay Jul AprMarFebJanDec
Phase 3: data cleaning and analyses
4.5 mo
6 mo
>12 mo
Phase 2 : Implementation Acceptability Test RUSF Inclusions + 5 distributions Food intake Survey KAP survey Mums’ knowledgeFollow up +1 mo & + 3 mo
8 mo
Phase 1: Preparation
SteerCo meetings
May
Phase 4 : Dissemination of resultsSMART surveys
External Evaluation
+ 1 year for scientific publication
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A key success factor: communication to participants & partners
• Communication to • authorities (MoH, CNNTA, DONG)• partners at Nutrition Cluster meeting• Abeche city authorities & chiefs of
neighborhoods
• Daily Radio Call-In about what is ACF doing, what is research, what is RUSF, etc.
• Cartoon explaining research to population• Scheme of circuit for participants - flyer
• Results presented to same audience in July 2011 in Chad
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©ACF, F.Houngbe 2010
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©ACF, F.Houngbe 2010
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RESULTS on RUSF effectiveness
No effect on wasting incidence
Marginal positive effect on length
Positive effect on hemoglobin
Positive effect on diarrhea/fever episodes
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CEA context & methods
CEA as part of ACF technical development Methods for this study:
• Used secondary outcomes (diarrhea, anemia)—Cost per case averted
• Retrospective analysis• Societal perspective (community + institutions)• Accounting records + interviews
—Community costs, in-kind donations, etc.• Incremental cost effectiveness: comparing
additional effects with additional costs of RUSF component
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Program costs
Cost outcome €
Total program costs (FA+RUSF) 1,009,106 €
Incremental cost of RUSF Component229,017 €
(23%)
Incremental cost per child 374 €
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Cost components
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Personnel; 27%
Program activities; 58%
Logistics; 8%
Local office; 2%
Community, 5%
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CEA Results & Interpretation
Cost per case averted was >100x more than other common programs preventing diarrhea, anemia, e.g.:• Water, sanitation, hygiene infrastructure• School-based helminth control
These programs not comparable with our results different cost structure, i.e. food = 50% of costs
in Chad emergency context
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CEA Lessons & Recommendations
Use of secondary outcomes (anemia, diarrhea) Relevant for RUSF component Less relevant for general food distributions Doesn’t reflect effectiveness of the global operation
RUSF can address multiple outcomes in emergency contexts in the short-term, where other infrastructure is unavailable, but…
Further research needed to determine the contexts in which RUSF is most effective & cost-effective
C-E data in ACF decision-making is a work in progress, will take time to perfect
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RCT lessons
Plan adequate timeframe• Continue communication around the project to all
audiences (pop, authorities, partners)• Plan a feasibility trial 2-3 months • Better Roles & Resp btw Field HQ• Cheaper procurement
• Renewal of contract with WFP in the middle of intervention > risk for research
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Conclusions
RUSF added to food rations did not prevent wasting during hunger gap
RCT not a « routine » method Relevant for ACF when need to generate evidence
on a strategic key question to influence policy Need for more scientific approaches to measure
better effectiveness
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Thank you !
Reference Huybregts L, Houngbe F, Salpeteur C, Brown R, Roberfroid D, et al. (2012) The Effect of Adding Ready-to-Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster-Randomized Controlled Trial. PLoS Med 9(9): e1001313. doi:10.1371/journal.pmed.1001313
Contact for more information: - Cécile Salpéteur, Nutrition Research Advisor, Paris -
[email protected] Chloe Puett, Cost Effectiveness Expert, NY – [email protected] - Lieven Huybregts, Principal Investigator, Gent - [email protected]