4. Discussion
weight gain, malnutrition
MALNUTRITION
The results of the present study show that in a humanitarian setting, the treatment of SAM with a simplified protocol does not result in worse recovery and results in fewer discharge errors compared to the standard protocol. The socioeconomic survey showed that the intervention group households were worse off, with the highest proportion of families paying for housing, having less land available for cultivation, and being more exposed to food insecurity and food shortages in the weeks prior to the study. Even so, the proportion of children cured within the intervention group, respecting the Sphere standards for humanitarian interventions [Our results regarding SAM treatment performance when using a simplified protocol are consistent with previous evidence. One of the first experiences of using a simplified protocol with a reduced dose of RUTF was in an Action Against Hunger program in Myanmar in 2009, which was conducted to deal with a stockout of nutritional intrants. In this case, the protocol used on children with SAM involved reducing the dose according to the national protocol recommendation for stockout situations until the child reached a WHZ of >−3 or MUAC of >110 mm. Thereafter, all children received a fixed dose of 1 sachet of RUTF a day (500 kcal/day). James et al. evidenced that the cured proportion of children was 90.2% and the defaulted proportion of children was 2%, which reached the Sphere standard and were obtained with even lower doses than were used in our study [Our analysis found no differences between the study groups for the LoS, although the children in the intervention group had a lower average weight gain per day, which was 7.04 g/kg/day in the control group versus 5.95 g/kg/day in the intervention group. Regarding the LoS, Ogobara et al. in the Mayahi district, Niger—with a non-randomized controlled trial comparing the effectiveness and coverage of decentralized SAM treatment, with the CHWs applying the standard CMAM protocol—evidenced a LoS of 36 days, which is similar to the 35 days in the present study [In relation to RUTF consumption, the intervention group of our study consumed fewer sachets per SAM-cured child (70 vs. 95 in the standard protocol group). The lower WHZ in the control group could have contributed to this difference in the number of sachets of RUTF. The quantity of RUTF in our intervention group was lower than that in the ComPAS study conducted in Mali, where children with SAM used 96 sachets per child cured, which is consistent with the higher LoS in the study [In terms of coverage assessment, we have shown an increase in SAM treatment access in both groups with the standard CMAM protocol and the simplified protocol with no significant difference between both. The previous study with the ComPAS in South Sudan and Kenya did not show an effect on treatment coverage in either the control or intervention groups. This is explained by the fact that, in our study, in both groups, there was a decentralization of treatment with respect to the level of the HPs, which increased service delivery sites and brought them closer to families. This result is consistent with those of previous non-randomized controlled studies that were conducted with CHW-led treatment. In the groups where CHWs treated SAM outside health facilities, there was an increase in coverage at the end of the intervention of up to 86.7% in Mali, 68.8% in Niger, 78% in Mauritania, and 80.9% in Tanzania [Along with the performance of the protocol, from an implementation point of view, it is important to highlight the quality with which the management of acute malnutrition protocols are applied. This study analyzed errors in children who were discharged due to being considered cured, i.e., those who were discharged without having reached the WHZ and/or MUAC criteria. The intervention group with a simplified protocol had a significantly lower error proportion than the control group: 3.2% vs. 10.9%. Even within the group of children who were admitted with more severe anthropometric conditions, this difference remained significant (6.8% vs. 15.9%). This is an element, along with the effectiveness and coverage results, which is important to take into consideration, so that the simplified protocol can be used under exceptional circumstances [The main limitation of this study was that it was not a randomized controlled trial, so the results cannot be extrapolated to other contexts and the probability of residual confounding is increased. Although there was no difference between the groups, the proportion of cured cases was high, so these results should be taken with caution in other contexts where the proportion of cured cases is not as high as this one. Another possible limitation is the difference in sample sizes between groups, whereby there was a higher incidence of cases in the intervention area. However, this did reflect the reality of the field, where the worst socioeconomic conditions are recorded, with a higher population of 47,198 habitants vs. a population of 26,176 habitants in the intervention and control groups, respectively. Nevertheless, the statistical tests used are robust with regard to this type of sample imbalance and the results show that the simplification of the protocol is effective even with worse baseline conditions. The coverage surveys were carried out in different time periods, just 8 months later after the start of the project. The SQUEAC methodology suggests that this kind of survey can be implemented in periods of a minimum of 4 months after the new intervention is launched for monitoring the effect [