cluster rcts in chad (cecile salpeteur, acf)

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


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


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


©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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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

Footer.ppt14/04/2023 11©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]

mailto:[email protected]



cluster rcts in chad (cecile salpeteur, acf)

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