Evaluation of Integrated Management of Acute Malnutrition (IMAM), POSHAN-II in Rajasthan, India: A Quasi-Experimental Study

According to National Family Health Survey (NFHS) the percentage of severely wasted children has increased from 6.4 percent (NFHS-3, 2005-06) to 7.5 percent (NFHS-4, 2015-16). In 2018, National Health Misison (NHM), Government of Rajasthan implemented Integrated Management of Acute Malnutrition (IMAM), POSHAN -II in 20 distrcts of Rajasthan. The research study is aimed to evaluate the effectiveness of IMAM POSHAN-II with respect to the percentage of cured, non-recovered and defaulted children and rate of weight gain. Community based quasi experimental pre post test research study was conducted among 1105 SAM children aged 6-59 months. The baseline study conducted during enrollement of SAM children, mid line and endline study was conducted after eight and twelve weeks of treatment. Socio demographic factors and nutritional status of children was collected from primary caregivers and sampled children of the study.


Results
After 8 weeks of treatment, the outcomes were 42.4 percent of cured cases, 4.1 percent of defaulters and 53.5 percent continued in the program. After 12 weeks of treatment, outcomes were -66.9 percent of cured cases, 8.1 percent of defaulters and 25 percent of non-recovered cases. The mean rate of weight gain among cured cases at 8 weeks was 3.2 g/kg/day. Binary logistic regression model indicates that after 8 and 12 weeks of treatment, the odds of SAM children getting cured increases with increasing family income. Children of educated mothers were 6.3 times more likely to recover than children of mothers with no education. Compliance towards EDNS is signi cantly associated with recovery of children at 8 and 12 weeks.

Conclusion
The IMAM POSHAN-II program being rst of its kind to be implemented on large scale in India demonstrate a piece of evidence that SAM children without medical complications can be treated successfully at community and household level. The program deserves be integrated with the existing primary health system of the state. The program was successful with high level of political commitment and collobration with partner agencies for technical and nancial assistance.

Background
As per the Global Nutrition Report 2020, India has 17.3 per cent of children under 5 years of age who are wasted, higher than the average for the Asia region (9.1 per cent) and highest in the world (1). In 2018, World Health Organization (WHO) report on child nutrition states that globally 21.9 percent (149 million) U5 children are stunted, followed by 7.3 percent (49 million) U5 children are wasted and 5.9 percent (40 million) U5 children are overweight (2). According to National Family Health Survey (NFHS) the percentage of wasted and severely wasted children has increased from 19.8 percent and 6. 4  percent) contribute to the major burden of wasting in India. (3)(4)(5) Severe wasting is also termed as Severe Acute Malnutrition (SAM). SAM is a life-threatening factor for children because of their lack of immunity to infections and diseases. Severely wasted children show poor growth and cognitive developmental delays. They also re ect the poor nutritional status of women during pregnancy, poor breastfeeding and complementary feeding practices, poor dietary intake and lack of adequate health services.(6) Children with SAM are 11.6 times more likely to die and children with MAM are three times more likely to die than the normal children. (7) As per WHO guidelines children with SAM are identi ed using Weight for Height Z score (WHZ) below -3 Standard Deviation (SD) and or Mid Upper Arm Circumference (MUAC) less than 11.5cm. (8,9) Treatment guidelines for SAM has evolved from facility-based to Community Management of Acute Malnutrition (CMAM). (8,10) It was found that inpatient or facility-based engagement of SAM children required skilled health personnel and expensive treatments. In addition, accessibility to Malnutrition Treatment Centers (MTC) or Nutrition Rehabilitation Centers (NRC) is a challenge in rural areas. (11,12) Also, often community and families are not aware that the severely wasted children require immediate medical attention to prevent them from further morbidity and mortality. (4,12) With this background, many countries adopted community-based management for uncomplicated cases of SAM. (13)(14)(15) CMAM is an evidence-based approach implemented in more than 70 countries to manage and treat SAM and MAM U5 children. (16) CMAM categorizes SAM into children with medical complications and children without medical complications. (17,18) Children without an appetite and/or with any medical complications are treated using inpatient facility. (17,18) Children without medical complications and with appetite fall under uncomplicated cases. Such uncomplicated SAM cases are treated using Ready to Use-Therapeutic Food (RUTF) [1] with a weekly or biweekly visit to a nearby health facility. (17,18) CMAM follows a decentralized approach, empowering the community health workers by increasing the availability and accessibility for effective treatment of acute malnutrition. (18,19) In 2000, CMAM was rst tested as a pilot study in humanitarian emergencies. (20) Later in 2007, it was supported and recommended by the United Nation (UN) agencies that CMAM could be used as a standard procedure for treating and managing severe acute malnutrition in emergency and developmental contexts. (8) In India, Community Management of Acute Malnutrition (CMAM) is adopted by many states and the outcomes were tested in pilot studies. (21) Initially, in 2009, CMAM was introduced in India as an emergency response in Bihar during Kosi oods. (4) Later, pilot studies were conducted in Maharashtra, Rajasthan, Odisha and Jharkhand to treat SAM children either community based or combination of both facility and community-based management. (4,11,12,22,23) In 2015, National Health Mission, Government of Rajasthan implemented CMAM by adopting POSHAN (Proactive and Optimum care of children through Social Household Approach for Nutrition) strategy to treat SAM children without medical complication using Medical Nutrition Therapy (MNT) Kit [2]. (24,25) The community-based intervention was implemented in two phases. The CMAM POSHAN-I was implemented from 2015-16 covering 10 High Priority Districts (HPD) and 3 tribal districts of Rajasthan. Around 234,404 children aged 6-59 months were screened and 9,640 children were identi ed as SAM and enrolled for treatment. (24,25) After treating the enrolled SAM children using Energy Dense Nutrition Supplement(EDNS) for 8 to 12 weeks, 88 percent of children recovered 7 percent did not recover and were referred to MTCs. (24,25) With this achievement of internationally comparable success rate, the second phase of POSHAN-II was implemented in 2018, covering 20 districts of Rajasthan. (24) In Integrated Management of Acute Malnutrition (IMAM), POSHAN-II around 375,533 children were screened and 10,344 children were identi ed and enrolled for treatment. (24,26) This research study is aimed to evaluate the effectiveness of IMAM POSHAN-II with respect to the percentage of cured, non-recovered and defaulted children and rate of weight gain. We have also attempted to examine the factors associated with cured, non-recovered and defaulted SAM children.

IMAM POSHAN-II
Under IMAM POSHAN-II, treatment services were provided through Subcenters[3] at block level through frontline health workers such Auxiliary Nurse Midwife (ANM) [4], Accredited Social Health Activist (ASHA) [5] and Anganwadi Workers (AWW). (27) Before implementation, ASHAs, AWWs and ANMs were trained intensively for anthropometric measurements at the district level to ensure quality delivery of health services. During this intervention, Subcenters were designated as POSHAN centres and ASHA's were called POSHAN Prahari. (27) Process of diagnosing Severe Acute Malnutrition (SAM) under IMAM POSHAN-II The process to diagnose Severe Acute Malnutrition included screening, identi cation and enrollment. The process ow is illustrated in gure 1. During identi cation, the shortlisted children with MUAC<12.5cm were brought to nearest sub-centre by POSHAN Prahari where ANM measured for weight, height or length and MUAC. Children were also checked for bilateral pedal oedema and any medical complications. Later, ANM along with mother or caregiver conducted appetite test for the screened children using EDNS [6]. (27) If the child was diagnosed with bilateral pedal oedema and or identi ed with any medical complication and or failed in appetite test, then he or she was referred to the nearest Malnutrition Treatment Center (MTC) irrespective of the anthropometric measurements. (27) If WHZ<-3SD and or MUAC<11.5cm, then the child was identi ed as SAM. Identi ed SAM children without any medical complications with adequate appetite were enrolled in the program for treatment. (27) The children with MUAC between 11.5 to 12.4 cm and WHZ -3SD to <-2SD were categorized under Moderate Acute Malnutrition (MAM). They were referred to Anganwadi Center (AWC) for treatment through Integrated Child Development Services (ICDS) Supplementary Nutrition Program (SNP). (27)  Caregivers were also educated about the method of feeding EDNS inadequate portions. Children with ≤ 24 months were encouraged for continued breastfeeding. They were also counselled on minimum meal frequency, handwashing practices and immunization. They were advised to seek medical care or reach out to ASHA (POSHAN Prahari) immediately if the child became unwell during EDNS consumption. Throughout the treatment phase, POSHAN Prahari's visited the households of the enrolled children every day. During home visits, POSHAN Prahari's monitored for regular consumption of EDNS by the SAM children and counselled the mother for adequate dietary intake and hygiene practices. (27) As the anthropometric measurements of the child improved (table1) they were further observed for one more week for consistent improved nutritional status. In the following week, if the nutritional status of the child did not deteriorate, the child was categorized as cured and discharged from POSHAN program. (27) The cured children were followed up for four months, and the non-recovered children were referred to MTC. In the follow-up phase, POSHAN Prahari' s made home visits of cured children to track their nutritional status and dietary intake. (27) The detailed process ow of the treatment phase is shown in gure 2.
[1] Ready to Use-Therapeutic Food (RUTF): It is a high energy forti ed ready to eat food suitable for treatment of severely malnourished children. This food should be soft or crushable, palatable and easy for children to eat without any preparation. At least half of the proteins contained in the product should come from milk products. (33) [2] Medical Nutrition Therapy (MNT) kit consist of Energy dense Nutritional Supplement (EDNS), antibiotics and albendazole which is used for the treatment of SAM children in POSHAN-II. (24) [3] In Indian rural health system, a subcenter is the peripheral and rst point of contact between the community and primary health center system serving 5000 population in plains and 3000 population in hilly region. (44) [4] ANM is key eld level health functionary who are posted in Subcentre for maternal and child health besides treatment of common illnesses and are viewed as replacement of professional cadre of midwives in Primary Health Center (PHC). (44) [5] ASHA is a community level health activist whose primary task is to create awareness, counsel,

Data Collection
The primary respondent of the survey were mothers and enrolled SAM children. If the mother was not available, the primary caregiver of the child was interviewed. During the Baseline study, all the target children were covered at the sub-centre, whereas, for the mid-line and end-line survey, most of the children were covered at the household level. Ethical approval for the study was received from IIHMR Institutional Review Board (IRB). In the eld, before initiating the interview, informed consent was received from all the study respondents. Variables used for data analysis WHZ and or MUAC measurement were used to derive the outcome or dependent variable. The dependent variable used for the analysis was the nutritional status of the child at 8 and 12 weeks of the program. The independent variables used for the analysis were maternal education, annual family income, gender and age of the child, number of weeks of EDNS consumption. The percentage of cured, non-recovered, defaulted children were calculated using anthropometric data based on the enrollment and discharge criteria of the program (Table). After eight weeks of EDNS treatment, if the nutritional status of the child had not improved, they were continued in the program from 9 to 12 weeks. (27)  Around 55 percent of women have no school education followed by 23.3 percent of women with primary education and 21.4 percent of women with secondary and higher education (table 2).  Overall nutritional outcomes of enrolled SAM children The study covered 1,105 children, out of which 753 and 1,091 children were covered for midline and endline study. As shown in Table 3, the program yields the following nutritional outcomes at 8 weeks: Cured -42.4 percent (N=319), defaulter -4.1 percent (N=31), continued in the program from 9 to 12 weeks (non-recovered) -53.5 percent (N=403). After 12 weeks: cured -66.9 percent (N= 730), defaulter -8.1 percent (N=88) and non-recovered -25 percent (N=273). The rate of weight gain among all cured children was 3.2 gm/kg/day. Overall female children showed higher cure rate at 8 weeks (44.5 percent) and 12 weeks (68.9 percent) when compared to male children ( gure 4 and 5). At 12 weeks, SAM children enrolled with MUAC has shown higher cure rate (72.2 percent) when compared to children enrolled with WHZ (68.8 percent) followed by children enrolled with MUAC and WHZ (54.2 percent).

Socio-demographic variables with nutritional outcomes of SAM children
Pearson Chi-square test was applied to analyze the association of socio-demographic variables and compliance with EDNS consumption with nutritional outcomes. As shown in Table 5 Factors associated with nutritional outcomes of SAM children using binary logistic regression model The binary logistic regression model was used to analyze the sociodemographic factors associated affecting the nutritional outcomes of SAM children. From the analysis (table 6), it was observed that annual family income, maternal education and compliance towards EDNS consumption is statistically signi cant. It was found that with increasing annual family income the odds of a child getting cured 25 percent of non-recovered cases. The non-recovered cases (25 percent) were referred to MTC or health facility for treatment. The mean rate of weight gain among cured cases at 8 weeks was 3.2 g/kg/day.
There was no mortality observed during the study. The IMAM POSHAN-II program being rst of its kind to be implemented on large scale (10,344 SAM children in 20 districts) demonstrate a piece of evidence that SAM children without medical complications can be treated successfully using EDNS at community and household level. The proportion of defaulter (5.4 percent) at 8 weeks is lower than the international standards (< 15 percent). (29) Survival outcomes (100 percent survival rate) can be favourably compared with international standards (< 10 percent). (29) Overall cure rate at 8 weeks was 42.4 percent which is comparatively low with international standards (< 10 percent). (29) The comparison of program outcomes with national and international standards is shown in Table 7.
In  global evidence also shows that children identi ed using WHZ and MUAC are not the same. (40) Researches also prove that using MUAC as single admission criteria leads to a low estimation of the actual burden of SAM. (41) With this background and WHO guidelines as a backbone, IMAM POSHAN-II has used both WHZ < -3SD and MUAC < 11.5 cm independently or combined to identify SAM children. (27) It was observed that majority of children were enrolled as SAM with WHZ< -3SD (69.1 percent) followed by MUAC < 11.5 cm (16.2 percent) and both MUAC < 11.5cm and WHZ < -3SD (14.7 percent). After 12 weeks of treatment, it was found that children enrolled with MUAC show higher cure rate (72.2 percent) followed by WHZ (68.8 percent) and WHZ and MUAC (54.2 percent. Also, the overall cure rate was high among female children (68.9 percent) when compared to male children (64.6 percent).
Binary logistic regression model indicates that after 8 and 12 weeks of treatment, the odds of SAM children getting cured increases with increasing family income. Children of educated mothers were 6.3 times more likely to recover than children of mothers with no education. Compliance towards EDNS is signi cantly associated with recovery of children at 8 and 12 weeks. Children who consumed EDNS for ve to eight weeks are 3.1 times more likely to recover than children who consumed EDNS for less than four weeks. Over a treatment period of 8-12 weeks, it is observed that consumption of appropriate EDNS (as per recommended WHO guidelines) is the key for successful recovery of SAM children. EDNS tested for international and national quality standards could be manufactured as per the needs. (19) To reduce the increasing burden of SAM, IMAM POSHAN-II proves to be a promising alternative to treat uncomplicated SAM children.
The experience in Rajasthan demonstrates that community-based management of SAM can detect malnourished children at an early stage and can bring rapid improvement in nutritional status through EDNS. Further government and other partners should strengthen the existing health systems. ANM, ASHA and Anganwadi Worker (AWW) should be trained and empowered to deliver quality healthcare services. (12,22) A follow up research study at 12 months may help us to understand the full impact and sustainability of the program. (42) Cost-effective analysis of IMAM POSHAN-II will provide further insights on long term policy implementation and management. (43) Declarations Ethical approval and consent to participate Ethical approval was granted by Instituitional Review Board (IRB) for the Protectionof Human Subjects (IORG0007355) of The Indian Institute of Health management research (IIHMR) of Jaipur, Rajasthan. Informed consent was obtained and witnessed from each participant before conducting the interview. An consent form (in Hindi) was given read out and given to the particpnats by the eld data collection team.
Informed written (or thumb print if illiterate) consent was received from caregivers. It was made clear that the participation was voluntary. The research performed was part of the nutrition internevtion program implemented by Government of Rajasthan. The research study followed the norms as in accordance with the declaration of Helsinki.

Consent for publication
Participants gave written consent for publishing the study ndings without identifying an individual or any personal details.

Availablity of data and materials
The datasets used and or analysed during the current study are avaible from the corresponding author on reasonable request.

Competing interest
The authors declare that they have no competing interests

Funding
The study was funded by Global Alliance for Imporved Nutrition (GAIN), New Delhi. The funders had no role in the design of the study, implementation, data collection, analysis, interpretation and writing of the report.

Authors contributions
Original  Nutritional status of SAM children at 12 weeks by gender

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