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Cluster RCTs in Chad (Cecile Salpeteur, ACF)

A cluster Randomised Control Trial to assess the effectiveness and cost effectiveness of RUSF for the prevention of child wasting in Chad.

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Cluster RCTs in Chad (Cecile Salpeteur, ACF)

  1. 1. 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 ALNAP conference Evidence & Knowledge in Humanitarian Action March 6, 2013 - Washington, USA Nutrition Research Advisor, Cécile Salpéteur Research Officer, Chloe Puett14 mars 2013
  2. 2. 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 project14/03/2013 Footer.ppt 2
  3. 3. 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 insurance14/03/2013 Footer.ppt 3
  4. 4. 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 prevalence14/03/2013 Footer.ppt 4
  5. 5. ©ACF, F.Houngbe 201014/03/2013 Footer.ppt 5
  6. 6. ©ACF, F.Houngbe 201014/03/2013 Footer.ppt 6
  7. 7. 45 neighborhoods STUDY DESIGN Abéché town (N=110,000) Inclusion based on participatory approach (ACF-France, 2010) 7 most vulnerable neighborhoods Listing of vulnerable HH (n=3,000) Listing checks Division in 14 clusters and localisation of HH in each cluster Randomization of clusters 7 Clusters 7 clusters Control Group Intervention GroupFood Assistance FA + RUSF N=458 N=613 Footer.ppt 7
  8. 8. ©ACF, F.Houngbe 201014/03/2013 Footer.ppt 8
  9. 9. Global timeframe + 1 year for scientific publication 2010 2011 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Phase 1: Preparation 4.5 mo 8 mo Phase 2 : Implementation Acceptability Test RUSF Inclusions + 5 distributions Food intake Survey KAP survey Mums’ knowledge Follow up +1 mo & + 3 mo Phase 3: data cleaning and analyses >12 mo Phase 4 : Dissemination of results 6 mo SMART surveys SteerCo meetings External Evaluation14 mars 2013 Footer.ppt 9
  10. 10. 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 Chad14/03/2013 Footer.ppt 10
  11. 11. ©ACF, F.Houngbe 201014/03/2013 Footer.ppt 11
  12. 12. ©ACF, F.Houngbe 2010 Footer.ppt 12
  13. 13. ©ACF, F.Houngbe 2010 Footer.ppt 13
  14. 14. ©ACF, F.Houngbe 2010 Footer.ppt 14
  15. 15. ©ACF, F.Houngbe 2010 Footer.ppt 15
  16. 16. ©ACF, F.Houngbe 2010 Footer.ppt 16
  17. 17. ©ACF, F.Houngbe 201014/03/2013 Footer.ppt 17
  18. 18. ©ACF, F.Houngbe 2010 Footer.ppt 18
  19. 19. Footer.ppt ©ACF, F.Houngbe 2010 19
  20. 20. RESULTS on RUSF effectiveness No effect on wasting incidence Marginal positive effect on length Positive effect on hemoglobin Positive effect on diarrhea/fever episodes Footer.ppt
  21. 21. 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 component3/14/2013 Footer.ppt 21
  22. 22. Program costs Cost outcome € Total program costs (FA+RUSF) 1,009,106 € Incremental cost of RUSF Component 229,017 € (23%) Incremental cost per child 374 €3/14/2013 Footer.ppt 22
  23. 23. Cost components Community, 5% Local office, 2% Personnel, 27% Logistics, 8% Program activities, 58%3/14/2013 Footer.ppt 23
  24. 24. 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 context3/14/2013 Footer.ppt 24
  25. 25. 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 perfect3/14/2013 Footer.ppt 25
  26. 26. 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 research14/03/2013 Footer.ppt 26
  27. 27. 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 effectiveness14/03/2013 Footer.ppt 27
  28. 28. 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 - csalpeteur@actioncontrelafaim.org - Chloe Puett, Cost Effectiveness Expert, NY – cpuett@actionagainsthunger.org - Lieven Huybregts, Principal Investigator, Gent - lieven.huybregts@ugent.be14/03/2013 Footer.ppt 28

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A cluster Randomised Control Trial to assess the effectiveness and cost effectiveness of RUSF for the prevention of child wasting in Chad.

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