A cluster randomized controlled trial was conducted in Chad to evaluate the effectiveness and cost-effectiveness of ready-to-use supplementary food (RUSF) for preventing child wasting. The trial involved over 1,000 young children across 14 clusters in Abeche town. The primary outcome was the cumulative incidence of wasting, with secondary outcomes including anemia prevalence, growth, and morbidity. Results found no effect on wasting incidence but marginal benefits for growth, hemoglobin levels, and reducing diarrhea/fever episodes. A cost-effectiveness analysis found the cost per case averted for secondary outcomes was over 100 times more than common prevention programs, questioning the contexts where RUSF is most effective and cost-effective. Lessons

1. 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
ALNAP conference Evidence & Knowledge in Humanitarian Action
March 6, 2013 - Washington, USA
Nutrition Research Advisor, Cécile Salpéteur
Research Officer, Chloe Puett
14 mars 2013

2. 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
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3. 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
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4. 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
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5. ©ACF, F.Houngbe 2010
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6. ©ACF, F.Houngbe 2010
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7. 45 neighborhoods
STUDY DESIGN
Abéché town
(N=110,000)
Inclusion based on
participatory approach
(ACF-France, 2010)
7 most vulnerable
neighborhoods
Listing of vulnerable
HH (n=3,000)
Listing checks
Division in 14 clusters and
localisation of HH in each cluster
Randomization of clusters
7 Clusters 7 clusters
Control Group Intervention Group
Food Assistance FA + RUSF
N=458 N=613
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8. ©ACF, F.Houngbe 2010
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9. Global timeframe
+ 1 year for scientific publication
2010 2011
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
Phase 1: Preparation 4.5 mo
8 mo
Phase 2 : Implementation
Acceptability Test RUSF
Inclusions + 5 distributions
Food intake Survey
KAP survey Mums’ knowledge
Follow up +1 mo & + 3 mo
Phase 3: data cleaning
and analyses >12 mo
Phase 4 : Dissemination
of results 6 mo
SMART surveys
SteerCo meetings
External Evaluation
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10. 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
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11. ©ACF, F.Houngbe 2010
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12. ©ACF, F.Houngbe 2010 Footer.ppt 12

13. ©ACF, F.Houngbe 2010
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14. ©ACF, F.Houngbe 2010
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15. ©ACF, F.Houngbe 2010
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16. ©ACF, F.Houngbe 2010
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17. ©ACF, F.Houngbe 2010
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18. ©ACF, F.Houngbe 2010
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19. Footer.ppt
©ACF, F.Houngbe 2010 19

20. 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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21. 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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22. Program costs
Cost outcome €
Total program costs (FA+RUSF) 1,009,106 €
Incremental cost of RUSF Component 229,017 € (23%)
Incremental cost per child 374 €
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23. Cost components
Community, 5%
Local office, 2%
Personnel, 27%
Logistics, 8%
Program
activities, 58%
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24. 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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25. 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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26. 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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27. 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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28. 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 -
csalpeteur@actioncontrelafaim.org
- Chloe Puett, Cost Effectiveness Expert, NY – cpuett@actionagainsthunger.org
- Lieven Huybregts, Principal Investigator, Gent - lieven.huybregts@ugent.be
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