A Mixed-Methods Cluster-Randomized Controlled Trial of a Hospital-Based Psychosocial Stimulation and Counseling Program for Caregivers and Children with Severe Acute Malnutrition

Allison I Daniel, Mike Bwanali, Josephine Chimoyo Tenthani, Melissa Gladstone, Wieger Voskuijl, Isabel Potani, Frank Ziwoya, Kate Chidzalo, Emmie Mbale, Anna Heath, Celine Bourdon, Jenala Njirammadzi, Meta van den Heuvel, Robert H J Bandsma, Allison I Daniel, Mike Bwanali, Josephine Chimoyo Tenthani, Melissa Gladstone, Wieger Voskuijl, Isabel Potani, Frank Ziwoya, Kate Chidzalo, Emmie Mbale, Anna Heath, Celine Bourdon, Jenala Njirammadzi, Meta van den Heuvel, Robert H J Bandsma

Abstract

Background: Children with severe acute malnutrition (SAM) who require nutritional rehabilitation unit (NRU) treatment often have poor developmental and nutritional outcomes following discharge. The Kusamala Program is a 4-d hospital-based counseling program for caregivers of children with SAM that integrates nutrition, water, sanitation, and hygiene and psychosocial stimulation, aimed at improving these outcomes.

Objectives: The aim was to evaluate the effects of the Kusamala Program on child development and nutritional status in children with SAM 6 mo after NRU discharge. The other aim was to qualitatively understand perceptions and experiences of caregivers who participated in the intervention.

Methods: A cluster-randomized controlled trial was conducted with caregivers and their children 6-59 mo of age with SAM admitted to the Moyo NRU in Blantyre, Malawi. The primary outcome of the trial was child development according to Malawi Developmental Assessment Tool (MDAT) composite z-scores of gross motor, fine motor, language, and social domains. A qualitative component with focus group discussions and in-depth interviews was also completed with a subset of caregivers who participated in the trial.

Results: Sixty-eight caregivers and children were enrolled to clusters by week and randomly assigned to the comparison arm and 104 to the intervention arm. There were no differences in child development, with mean MDAT composite z-scores in the comparison arm of -1.2 (95% CI: -2.1, -0.22) and in the intervention arm of -1.1 (95% CI: -1.9, -0.40) (P = 0.93). The qualitative evaluation with 20 caregivers indicated that the 3 modules of the Kusamala Program were appropriate and that they applied many of the lessons learned at home as much as possible.

Conclusions: The Kusamala Program did not result in improved developmental or nutritional outcomes, yet it was viewed positively by caregivers according to qualitative results. Future research should evaluate more intensive interventions for caregivers and children with SAM. This trial was registered at www.clinicaltrials.gov as NCT03072433.

Keywords: HOME Inventory; SAM; child development; nurturing care framework; nutrition; psychosocial stimulation; severe acute malnutrition.

© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.

Figures

FIGURE 1
FIGURE 1
Study flow chart for the cluster-randomized controlled trial.
FIGURE 2
FIGURE 2
Developmental outcomes according to MDAT composite z-scores in children 6 mo after discharge from inpatient treatment of severe acute malnutrition between the comparison and intervention arms. The point above the intervention boxplot represents an outlier. MDAT, Malawi Developmental Assessment Tool.
FIGURE 3
FIGURE 3
Nutritional status according to weight-for-age z-scores in children 6 mo after discharge from inpatient treatment of severe acute malnutrition between comparison and intervention arms. The point above the intervention boxplot represents an outlier.

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