Community Based Management of Severe Malnutrition in Tribal Area of Melghat- Cluster Randomized Control Field Trial

• Title of project: SAMMAN- Community based management of severe malnutrition in under 5 children in tribal area of Melghat region

• Name of Institution: MAHAN Trust, Address: Mahatma Gandhi Tribal Hospital, Karmagram . Utavali, tehsil- Dharni, Melghat (Amaravati)

• Objectives -

• To reduce the child mortality (in the age of group of 6 months to 5 years) due to severe malnutrition in tribal area of Melghat by 35% in usual residents population of 15000 (from 16 villages) over a period of 3 years.
• To reduce the prevalence of severe malnutrition (in the age of group of 6 months to 5 years) by at least 35% in usual residents population of 15000 from 16 villages in tribal area of Melghat over a period of 3 years.
• To achieve Case fatality rate of 2 % of treated severely malnourished children.
• Need and rational of the project :

Melghat is a hilly difficult to approach tribal forest terrain in Amaravati district of Maharashtra, India . Population is 2,80,000 & 75% of them are tribal. Most of the tribal (>90 %) are farmers or laborers, living below poverty line(>75%) & very hard life in huts without electricity (>90%) & illiterate (>50%). Medical facilities are worst in Melghat as compared to rest of Maharashtra. A detailed study conducted by MAHAN showed that more than 20% of tribal children are severely malnourished and the under 5 children mortality rate is more than 100 per 1000 live births due to lack of proper nutrition, medical facilities, superstitions & reluctance for hospitalization of severely malnourished children. There is an immediate need to fight severe malnutrition in children between the ages of 6 months to 5 years. This project is being implemented as a pilot project in 16 villages of Melghat which has potential for replication in all tribal and rural part of India.

• Methodology Study design: The study is a cluster randomized parallel group controlled field trial Study area: 35 tribal villages selected from 5 clusters of Melghat by lottery method divided into intervention and control area.

Sample size - 1500 severely malnourished children from intervention and control area each.

• Intervention:

Provision of community based health care to severely malnourished children (Age group: 6 months through 5 years) in 16 tribal villages by trained semi-literate village health workers.

• Treatment of severely malnourished children .
• Growth monitoring of all children below the age of 5 years.
• Treatment of associated diseases like Diarrhea, Pneumonia, Malaria, etc.
• Management of resistant or relapsed severely malnourished cases by pediatrician.
• Intensive behavior change communication of parents of children below the age of 5 years for proper nutrition.

• Duration: 5 years (May 2011 to September 2015)

• Monitoring indicators for the outcome objectives:

Primary outcomes

• Prevalence of severe malnutrition (Severe Acute Malnutrition; Severe Underweight and Indian Academy of Pediatrician (IAP) Grade III, IV)
• No. of child deaths due to severe malnutrition
• Case fatality rate of treated severely malnourished children

The secondary outcomes

• Child mortality rate between 6 to 60 months age group

The secondary outcomes

• Child mortality rate between 6 to 60 months age group

• Scope & end result expected of project

• Lives of 1500 severely malnourished children from Melghat will be saved.
• This model of community based management of severe malnourished children using RUTF prepared by local tribal females from local produce will have better socio-cultural acceptance by parents, and will be palatable for children, hence will be more effective.
• It will also be useful in long term for preventing recurrences and roll back cases as parents awareness will be improved with behavior change communication.
• Based on this study, national and international policies related to community based management of severely malnourished children may be framed.
• It will be a step towards fulfillment of fundamental rights of children guaranteed by constitution of India.

Inclusion criteria

• Children suffering from severe malnutrition as per weight for height criteria (WHO), weight for age criteria (WHO), MUAC (WHO), IAP grade III & IV. Defacto method.

Exclusion criteria

• Children who have failed in appetite test and cannot tolerate oral F75 food. Also,
• Parents, guardian refuse to give consent.