Impact Evaluation of a Package of Integrated and Multisectoral Services (PASIM) to Reduce Child Wasting in Chad
Phase: NA
Conditions: Acute Malnutrition in Childhood, Wasting
Sponsor: International Food Policy Research Institute

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Integrated Research on Acute Malnutrition (IRAM)  
 
Study of the impact of a package of integrated and multisectoral 
services (PASIM) to reduce child wasting in Chad  
 
IFPRI (promoter) 
UNICEF (sponsor) 
ASRADD (implementation) 
Moustagbal (data collection) 
DNTA (research partner) 
 
 
 
 
 
 
 
 
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Integrated Research on Acute Malnutrition (IRAM) 
SUMMARY SHEET 
Country :  
Chad 
Type of project :  
Research Project 
Randomized, unblinded, community-based, effectiveness study 
 
 
Project Title :  
Integrated Research on Wasting (IRAM): Study of the impact of 
an integrated and multisectoral service package (PASIM) to 
reduce early childhood wasting in Chad  
 
 
Version : 
Version 1, dated February 25, 2021 
 
 
Project Codes :  
IRAM-Tchad 
 
Clinic test. Gov: registration to be completed after approval from 
the ethics committee. 
 
Project summary 
(objective, intervention, 
participants, results) : 
The general objective of the integrated and multisectoral services 
package (PASIM) is to reduce the incidence and prevalence of 
wasting through integrated interventions, including, among other 
things, strengthening the activity of community care groups. The 
members of the care groups make home visits to children aged 6-
23 months (or up to 59 months when the children are under 
treatment for wasting or have been discharged in the previous 6 
months) to deliver messages for behavioral change related to 
complementary feeding, health and hygiene ; deliver nutritional 
supplement and water purification inputs; improve screening 
coverage (training and supervision of families to take the Mid-
Upper 
Arm 
Circumference 
measurements, 
referral 
of 
malnourished cases); and verify adherence to treatment of 
malnourished cases, in the health district of Mongo, Guéra 
province, Chad, Central Africa. 
 
The evaluation of the impact of PASIM will be based on a cluster 
randomized controlled trial, consisting of 100 villages or clusters 
of villages. The selected evaluation model will be that of a 
comparison of control groups (n=50; no implementation of the 
intervention) and intervention (n=50) through the follow-up of 3 
cohorts : 
1- Longitudinal in-home follow-up of a semi-open cohort of 
1,750 children aged 6 months at enrollment (included 
continuously for 7 months and all followed through to the 
end of the study, which will last 9 months in total).  
2- Longitudinal follow-up of all children aged 6-23 months 
enrolled for wasting treatment, based on health system 
records. 
3- Longitudinal follow-up at home for 6 months of a closed 

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cohort of 700 children aged 6-23 months at inclusion, 
discharged from a treatment for acute malnutrition.  
 
The primary impact results are as follows: 
- 
The longitudinal prevalence of wasting at the end of the 
study (Cohort 1).  
- 
The recovery rate (Cohort 2). 
- 
The incidence of relapse during the 9 months of the 
intervention (Cohort 3).  
Secondary impact results include, but are not limited to : 
- 
The incidence of wasting during the 9 months of the 
intervention (Cohort 1) ; 
- 
The screening coverage (cohorts 1 and 3); 
- 
The proportion of wasting cases enrolled in a treatment 
program (cohorts 1 and 3); 
 
- 
The adherence to treatment (cohort 2) during the 9 
months of the intervention. 
 
Study Tools : 
 
 
 
Consent Forms : 
 
Instruments : 
 
Duration of the project : 
Questionnaires, anthropometric measurements, and biological 
measurements on capillary blood by finger puncture (rapid 
malaria test, hemoglobin level) 
 
See Appendix 1 
 
See Appendix 2 
 
9 months (April 2021 - December 2021) 
 
 
Sponsor :  
 
Foreign, Commonwealth & Development Office (FCDO) via the 
United Nations Children's Fund (UNICEF) 
 
Agency of setting  
implementation :  
Sahelian Alliance for Applied Research for Sustainable 
Development (ASRADD) 
 
 
Partner institution : 
 
Developer :  
Ministry of Public Health (DNTA) 
 
International Food Policy Research Institute (IFPRI)  
 
 
Data collection :  
Moustagbal 
 
 
Project Contacts : 
Elodie Becquey (PI) - IFPRI Senegal - e.becquey@cgiar.org 
Lieven Huybregts (PI) - IFPRI USA - l.huybregts@cgiar.org 
Mariama Touré – IFPRI Senegal – m.toure@cgiar.org 
 
 

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Summary 
1 PROBLEM STATEMENT AND STUDY RATIONALE .................................................................. 7 
2 GENERAL OBJECTIVE ....................................................................................................................... 8 
3 RESEARCH METHODS ................................................................................................................... 10 
3.1 FRAMEWORK OF THE STUDY ........................................................................................................... 10 
3.1.1 STUDY AREA .................................................................................................................................................. 10 
3.1.2 PCIMA NATIONAL PROGRAM ................................................................................................................... 11 
3.2 THE INTERVENTION ......................................................................................................................... 13 
3.2.1 BENEFICIARIES OF PASIM ......................................................................................................................... 13 
3.2.2 DELIVERY PLATFORM: COMMUNITY CARE GROUPS .............................................................................. 13 
3.2.3 PASIM SERVICES ......................................................................................................................................... 13 
3.3 TARGET POPULATION AND STUDY POPULATION ........................................................................... 15 
3.4 RESEARCH QUESTIONS .................................................................................................................... 16 
3.5 IMPACT STUDY ................................................................................................................................. 16 
3.5.1 IMPACT STUDY MODEL ................................................................................................................................ 16 
3.5.2 STRATIFICATION AND RANDOMIZATION .................................................................................................. 17 
3.5.3 SAMPLE SIZE, SAMPLING, APPROACHES, AND INCLUSION CRITERIA .................................................. 18 
3.5.4 STUDY RESULTS ........................................................................................................................................... 22 
3.5.5 MEASURES AND PROCEDURES ................................................................................................................... 24 
3.5.6 DATA ANALYSIS ........................................................................................................................................... 26 
3.6 COST AND COST-EFFECTIVENESS STUDY ......................................................................................... 26 
3.7 DATA MANAGEMENT ....................................................................................................................... 27 
3.8 DISSEMINATION STRATEGY ............................................................................................................. 28 
4 ETHICAL CONSIDERATIONS ....................................................................................................... 28 
4.1 COMMUNITY INFORMATION ............................................................................................................ 28 
4.2 VOLUNTARY AND INFORMED PARTICIPATION ............................................................................... 28 
4.3 RISKS AND SERIOUS ADVERSE EFFECTS .......................................................................................... 29 
4.4 EMERGENCIES ................................................................................................................................... 29 
4.5 ANONYMITY ...................................................................................................................................... 30 
5 SPECIFIC PRECAUTIONS RELATED TO COVID-19 ............................................................... 30 
5.1 TRAINING OF INTERVIEWERS .......................................................................................................... 30 
5.2 FIELD STUDY .................................................................................................................................... 31 
6 PARTNERSHIP AND MANAGEMENT ......................................................................................... 31 
7 BUDGET ............................................................................................................................................. 33 

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8 TIMELINE .......................................................................................................................................... 34 
9 REFERENCES .................................................................................................................................... 35 
10 APPENDICES .................................................................................................................................. 36 
10.1 APPENDIX 1: CONSENT FORMS ....................................................................................................... 36 
10.2 APPENDIX 2: QUESTIONNAIRES ...................................................................................................... 36 
10.3 APPENDIX 3: RESUMES OF INVESTIGATORS .................................................................................. 36 
 
 
 

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List of Abbreviations 
 
ARI 
Acute respiratory infection 
ASRADD 
 Sahelian Alliance of Applied Research for Sustainable Development 
BCC 
Behavior Change Communication 
CHW 
Community Health Workers  
CSB ++ 
Corn-Soy Blend plus plus 
CTPNA 
Technical Permanent Committee of Nutrition and Food 
DMC II 
Developmental Milestones Checklist II 
DNTA 
Directorate of Nutrition and Food Technology 
FARNE 
Home for learning, nutritional rehabilitation and awakening 
FCDO 
Foreign, Commonwealth and Development Office 
GAM 
Globale Acute Malnutrition  
HAZ 
Height-for-age index in Z-score  
IFPRI 
International Food Policy Research Institute 
IYCF 
Infant and Young Child feeding 
MAM 
Moderate Acute Malnutrition 
MUAC 
Mid-Upper Arm Circumference 
NGO 
Non Governmental Organization 
PASIM 
Integrated and multisectoral services package 
PCIMA 
Integrated Management of Acute Malnutrition  
PCIMA-C 
Integrated Management of Acute Malnutrition at the Community Level  
PECIME 
Integrated Management of Childhood Illnesses  
PECMAS 
Management of Severe Acute Malnutrition 
RUSF 
Ready-to-Use Supplement Food 
RUTF 
Ready-to-Use Therapeutic Food 
SAM 
Severe Acute Malnutrition 
SBCC 
Social and Behavior Change Communication  
SIAN 
Week of Intensified Nutrition Activities 
SQ-LNS 
(Small Quantities of) Lipid-based Nutritional Supplements 
UNA 
Ambulatory Nutritional Unit  
UNICEF 
United Nations Children's Fund 
UNS 
Supplementary Nutritional Unit 
UNT 
Therapeutic Nutritional Unit 
VGS 
Care Group Volunteer 
WASH 
Water, Sanitation and Hygiene 
WAZ 
Weight-for-Age Index in Z-score 
WFP 
World Food Program 
WHA 
World Health Assembly 
WHO 
World Health Organization 
WHZ 
Weight-for-height index in Z-score 
 

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1 Problem Statement and Study Rationale  
 
Worldwide, 47 million children under the age of five suffer from wasting1 (1). Wasting 
significantly increases the risk of death: it kills 875,000 children under the age of five per 
year (2). All member states of the World Health Assembly (WHA) have agreed to reduce 
and maintain the prevalence of wasting to less than 5% by 2025 (3). However, the 
prevalence of wasting remains persistently high in many West and Central African 
countries such as Mali (14.8%), Mauritania (13.5%), Chad (12.9%) and Niger (10.1%). 
Wasting trends suggest that the WHA goal will not be achieved in these countries, 
despite their commitment to combat wasting as expressed in their nutrition policies (4). 
Progress in reducing the burden of wasting is hampered by a number of factors. First, 
programmatic evidence on how to prevent wasting is limited. There is a growing body of 
evidence on the effectiveness of dietary supplements in preventing wasting, but little is 
known about the effectiveness of other strategies such as social and behavior change 
communication (SBCC) (with or without supplements), cash transfers, or water, hygiene, 
and sanitation (WASH) interventions (5). Second, coverage of community-based 
management of wasting (CIMCI) treatment remains low in many settings (6). On the 
supply side, documented constraints include the complexity of current treatment 
procedures, which disproportionately affects resource-limited settings, and frequent 
shortages of treatment commodities. On the demand side, low participation in 
screening and low treatment uptake and adherence are key constraints to effective 
treatment. The recent PROMIS studies in Mali and Burkina Faso demonstrate that 
screening uptake can be more than doubled by providing small quantities of lipid-based 
nutrient supplements (SQ-LNS) combined with social and behavior change 
communication (SBCC) as incentives for participation (7,8). However, these studies 
showed that increased screening in these settings did not automatically lead to 
increased treatment coverage, which remained below 25%. 
There is an urgent need to test innovative solutions to prevent wasting and increase 
screening, treatment initiation and adherence. Options include integrating prevention 
into screening to increase coverage and prevent wasting; strengthening referral 
processes for wasted children and supporting and encouraging parents to enroll their 
children in treatment; establishing outreach screening and treatment units; transferring 
some responsibility for treatment to community health workers; and/or simplifying 
treatment procedures for both parents and service providers. 
In response to this urgent need, UNICEF and IFPRI started a multi-country partnership to 
generate evidence on wasting prevention and treatment interventions in four countries: 
Chad, Mali, Mauritania, and Niger.  
In Chad and Mali, impact evaluations will be conducted to generate solid evidence of 
the effectiveness of integrated interventions to reduce wasting. Impact evaluation in 
 
1 Defined in children 0-59 months of age as a weight-for-height score of less than -2 z-score according to WHO weight-
for-height references (13); depending on the context and the measurement tools used, wasting is also defined by a 
brachial perimeter of less than 125 mm in a child aged 6-59 months or by the presence of bilateral edema (0-59 
months). 

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these countries will be combined with a cost study and a documentation of the 
implementation process. In Mauritania and Niger, in-depth implementation research 
will be conducted to generate the necessary evidence on how integrated nutrition 
services are implemented in the field. The proposed studies will help fill important 
knowledge gaps by assessing the operational feasibility, impact and cost-effectiveness 
of community-based integrated interventions that use simple procedures to integrate all 
elements of the continuum of care from wasting prevention to treatment, into a single 
platform at the community level in four West African countries (Figure 1). The evidence 
generated through this partnership will inform national, regional and global policies on 
wasting and is consistent with the Global Plan of Action on Child2 Wasting (9), 3and the 
WFP-UNICEF regional partnership. 
 
 
Figure 1: Conceptual Framework of Continuum of Care for wasting 
 
2 General objective  
 
The overall objective of the intervention is to reduce the longitudinal prevalence of 
wasting in children aged 6 to 23 months inclusive (corresponding to a peak prevalence) 
by integrating several approaches along the continuum of care for wasting into an 
integrated, multisectoral package of services (PASIM). 
The main objective of the research is to provide strong evidence of the effectiveness of 
the integrated interventions of the PASIM to reduce wasting.  
 
The implementation of PASIM will be led by the Sahelian Association for Applied 
Research and Sustainable Development (ASRADD) in collaboration with the health 
 
2 In March 2020, the inter-agency Global Action Plan on child wasting (GAP) was published. UNICEF is partnering with 
WHO to produce evidence to inform both the GAP and the review of WHO normative guidelines. This project will help 
fill key knowledge gaps related to this collaboration with WHO. 
3 Evidence from this partnership between UNICEF and IFPRI will also include other key stakeholders, including WFP. 
Within the framework of the regional partnership between UNICEF and WFP, and in particular the associated learning 
agenda, this project will be conducted to help highlight current gaps in integrated approaches to reduce child wasting, 
from prevention to treatment. 

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services of the health district of Mongo, Guéra province, and other implementing 
partners in the zone. The activities will take place at the health center and community 
levels, and include i) a prevention component combining the strengthening of 
community care groups (who will conduct home visits to deliver behavior change 
messages) and the distribution of a nutritional supplement (CSB++) to [6-11] months old 
children diagnosed as non-wasted (as a result of the green MUAC) and water 
purification inputs to all [6-11] months old children unconditionally (regardless of 
wasting status); ii) a component related to strengthening screening and referral that will 
involve families (family MUAC approach), with [6-23] months old children, trained and 
supervised by community care groups (who will also conduct routine screening); 
children diagnosed as wasted will be referred and will receive treatment (including food 
supplements) at the FARNE or nutritional units; iii) a treatment component that includes 
strengthening the protocol for integrated management of acute malnutrition (PECIMA) 
currently in use in Chad, as well as support from community groups through follow-up 
home visits to wasting cases for counseling and verification of adherence and 
compliance to treatment; and iv) a final relapse prevention component combining a 6-
month home follow-up by community care groups for [6-23] months old children who 
recovered from wasting to provide nutritional counseling, a preventive nutritional 
supplement (CSB++), water purification inputs, and a supervision of testing by families. 
 
 
 

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3 Research Methods  
3.1 Framework of the study  
 
3.1.1 Study area  
Chad is a low-income country in Central Africa with a population4 of nearly 16 million in 
2019. In 2018, 42% of the population lived below the national poverty threshold5. The 
study will be conducted in the health district of Mongo located in the Guéra province, 
which includes 26 zones of responsibility (ZR) of the health centers (CS). The population 
statistics of Guéra province show a total of 31,7716 children aged 6-59 months in 2019 
with 12.9 (12.1-13.7) % of them suffering from a weight-for-height <-2 z-score (10).  
When considering data from 2016, and all criteria for defining wasting (defined as WHZ 
<-2 or MUAC <125 mm or bilateral edema for overall wasting; WHZ <-2 or MUAC <125 
mm or bilateral edema for severe wasting), it can be seen that the levels of GAM and 
SAM in the Guéra are globally slightly above the national average, which is relatively 
high : between 15 and slightly more than 20% for overall wasting, and around 5% for 
severe wasting, with no real trend towards improvement since 2016. Even if there is a 
significant reduction in overall wasting (from 21% to 16%) and severe wasting (from 
6.6% to 3.9%) between 2018 and 2019 in the Guera, it cannot be concluded at this stage 
that this is the result of an overall improving trend. 
 
A contextual analysis of wasting in the Health District of Mongo carried out in 2020 (11) 
identified the following main factors: 
• Suboptimal infant and young child feeding practices (IYCF) 
• Seasonal food insecurity  
• Insufficient adequate diet knowledge and habits 
• Inadequate primary care management 
• Cultural factors: use of traditional healers, removal of the uvula, giving the child 
water from the backwater, early marriages, etc.  
• Insufficient autonomy for women 
• Poor food hygiene practices  
• Suboptimal WASH infrastructures and practices: limited access to clean water, 
widespread open defecation, waste disposal problems. 
 
4 United Nations World Population Prospects, 2019 
5 Chad Presentation, https://www.banquemondiale.org/fr/country/chad/overview; Access on 2020-12-17 
6 Projections considering the average household size in Chad of 5.2 individuals according to the 2009 
census. 

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In 2015, the SLEAC survey conducted in Chad showed that the coverage of SAM care 
was 37% and was considered moderate (12). The barriers identified by the survey are a 
strong lack of knowledge about malnutrition and a poor understanding of treatment 
and the IMCI programs, the barrier of distance and the availability of means to get to 
health centers. 
Analysis of 2018 and 2019 admission data in the outpatient or therapeutic nutritional 
units of the Guéra shows a high rate of admission of children already known to PECMAS 
services, specifically children in relapse (after an episode successfully treated) and 
children readmitted after dropping out of the program (11). This rate decreased 
significantly between 2018 and 2019, but still exceeds 10% of children admitted in the 
age groups above 6 months. In addition, exit data show that successful treatment 
increased significantly between 2018 and 2019, with a significant decrease in the 
dropout rate from 7.5% to 2.6%. The death rate is quite low, around 0.5%. On the other 
hand, the occurrence of shortages of RUSF in UNA as reported in the monitoring files 
(zero stock at the end of the month) over a 2-year period reveals that all the health 
centers monitored suffered at least one shortage in 2 years. A third of the 18 facilities 
had shortages observed 5 times or more over the 24 months observed. 
 
3.1.2 PCIMA National Program  
Chad's current national protocol for the management of acute malnutrition has been 
implemented since 2014. It technically describes the organization of the continuum of 
care for wasting at the central (national), provincial, district, health center and 
community levels. It describes all aspects of the implementation of screening and 
treatment. Routine PCIMA services for the treatment of MAM and SAM are available in 
health centers throughout the country.  
The program for the management of severe or moderate acute malnutrition 
implemented by the Ministry of Health is currently operating in all health centers in 
Mongo for the ambulatory management of uncomplicated cases (UNS Supplementary 
Nutritional Units for MAM, UNA Ambulatory Nutritional Units for SAM). In the district 
hospital, the pediatric services ensure the management of SAM with medical 
complications (Therapeutic Nutritional Unit, UNT). In some communities, MAMs are also 
treated in FARNEs (Homes for learning, nutritional rehabilitation and awakening), which 
are run by the community and NGO actors in partnership with the health services. 
 
a) Screening platforms 
Passive screening is done during preventive child care and curative consultations or 
immunization sessions by qualified health workers, doctors, and nurses. Passive 
screening is included in the outreach strategy (health worker going to the village for 
consultation), but the health center does not organize active screening (in the form of 
campaigns, for example). Health staff use either tape measures (MUAC) or weight-for-
height measurements for diagnosis. However, following the COVID19 pandemic, 

12 
 
precautionary measures have been taken and screening of children has been limited to 
measuring MUAC, including in health centers. Routine screening is done in the 
community by CHWs, care groups and mothers using MUAC. 
b) Reference and treatment of MAM and SAM 
When community workers screen a child for acute malnutrition, the child is: i) either 
diagnosed as negative (code green, MUAC ≥125mm); ii) or diagnosed as MAM positive 
(115mm ≤MUAC <125mm, code yellow); iii) or diagnosed as SAM positive (MUAC 
<115mm or bilateral edema, code red). In the case of SAM, the mother-child couple is 
referred to the health center for confirmation of the diagnosis based on the MUAC and 
initiation of treatment. If the diagnosis is confirmed, the child is examined to verify the 
presence or absence of medical complications. Following the COVID19 pandemic, only 
the MUAC criterion is currently used to screen children. 
 
In the absence of signs of complication, the MAM child is admitted to an outpatient 
program (UNS or FARNE) with a scheduled follow-up every two weeks. The duration was 
extended following the COVID19 pandemic; follow-up is currently monthly. The mother 
receives a ration of food supplements to be given to the child every day (RUSF or 
CSB++). In the absence of complications, and after a successful appetite test, the SAM 
child is included in an outpatient treatment program (UNA) with follow-up scheduled 
every week. The duration was extended following the COVID19 pandemic; follow-up is 
currently every two weeks. The mother receives a ration of food supplements (RUSF) to 
be given to the child every day. Complicated cases of SAM or MAM or cases with edema 
are referred for inpatient treatment at the hospital which has a pediatric ward (UNT 
ward). 
 
Children are discharged from these treatment programs if they reach a weight-for-
height>-2 z-scores and a MUAC>=125mm and the absence of bilateral edema for two 
consecutive visits.  
c) Psycho-cognitive stimulation program at UNA/UNT 
 
During the rehabilitation of children under treatment at UNA/UNT, their psycho-
cognitive stimulation should begin, and continue after discharge, to reduce the risk of 
mental and physical sequels. Psychosocial stimulation should be done by the doctor and 
nurses. The social worker is in charge of organizing the sessions. 
This program includes activities such as :  
- 
Organizing sessions to teach mothers how to make toys themselves with cheap 
and salvageable materials;  
- 
Organizing training sessions to teach mothers the importance of games and 
discovery in providing the psycho-cognitive and physical stimulation the child 
needs (this is an integral part of the treatment);  

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- 
Keeping the mother with the child and encourage her to feed, carry, comfort, 
and play with him/her as much as possible. 
 
3.2 The intervention  
 
3.2.1 Beneficiaries of PASIM  
Children receiving PASIM are [6-59] months of age, with various variations in the 
package depending on the child's age. 
 
3.2.2 Delivery Platform: Community Care Groups  
This program is implemented by the NGO ASRADD with technical and financial support 
from UNICEF and in collaboration with local authorities and technical partners working 
in the Mongo Health District. It is a multisectoral approach at the community level. 
Fifteen people from the community, called Care Group Volunteers (VGS), form a 
community care group (also called care group or ialafé), with a coverage radius of 15 to 
20 households per VGS. Household eligibility for prevention activities is based on the 
1,000-day window: any household with a pregnant woman or a child under the age of 
two is eligible. Eligibility is extended to children up to 59 months of age for screening, 
follow-up of children undergoing emaciation treatment, and prevention of relapse 
within six months of discharge from treatment. The number of groups depends on the 
size of the village, so that all beneficiaries who wish to be covered can be covered. 
The care groups are facilitated and trained by the ASRADD instructor who regularly 
monitors each group. VGS are trained on key themes and refer women to health centers 
when needed. All stages of the continuum of care are reinforced by the activities of the 
care groups, i.e., prevention, screening, monitoring of adherence and compliance to 
treatment, and referral. 
 
3.2.3 PASIM Services  
PASIM's activities are part of the continuum of care for acute malnutrition and aim to fill 
the gaps identified in the context analysis conducted by IFPRI and UNICEF in 2020 in the 
health district of Mongo.  
The PASIM is delivered by the care groups. Each beneficiary is visited at home at least 
once a month (up to once a week if possible).  
The package of activities includes : 
• Prevention over the period of 1000 days (from pregnancy until the child is 2 
years old): 
o Behavior change communication (all children in care groups) :  
▪ Awareness of dietary diversification from 6 months of age and 
adequate complementary feeding. 
▪ Raising awareness of good water and hygiene practices. 

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o Monthly delivery of a nutritional supplement: enriched flour (CSB++), at a 
rate of 3 kg/month/beneficiary child. The nutritional supplement is 
limited to [6-11] months old children diagnosed as non-wasted (green 
MUAC). 
o Monthly 
delivery 
of 
a 
water 
purification 
input: 
bleach 
or 
flocculant/decontamination sachets for the potabilization of the water of 
the whole household. The water treatment input is limited to households 
with [6-11] months old children. 
o Delivery of micronutrient powders to [6-23] months old children (30 
sachets per month for 2 months, every 6 months, according to 
international recommendations). 
• Screening for [6-59] months old children: 
o Delivery of a MUAC measuring tape and training of families in its use, and 
actions to be taken based on the results. This will involve distributing 
Shakir bands to all households with [6-59] months old children and 
training mothers/guardians, or any other family members who express an 
interest, in screening for wasting using the MUAC criteria, and explaining 
the procedure to follow if the child tests positive in the family. 
o Formative supervision of MUAC measurement in families. The training 
will be carried out by the members of the care groups and at each home 
visit, they will be able to ensure that the MUAC measurement technique 
is well mastered by the mother (or another member) and correct the 
technique if necessary.  
o Monthly screening by the VGS of the children they follow, using the 
MUAC.  
• Referral to the health center of [6-59] months old children screened as 
malnourished (result of MUAC orange or red): The VGS refers children who are 
diagnosed as malnourished to the health center using a referral coupon and 
makes a note in the care group's follow-up logbook; the ASRADD promoter 
regularly retrieves this data and follows up with the health center. If the 
promoter notices that a certain number of children did not follow up on the 
referral, he returns to the care group, which returns to the families to identify 
the children who did not go to the health center, understand the reason, and 
seek solutions with the families.  
• Follow-up of [6-59] months old children under treatment and for 6 months after 
discharge from the national treatment and consolidation program (if eligible): 
VGS follows children under treatment until they recover (taking treatment until 
they are cured) and for the whole duration of their consolidation (for children 
cured of severe emaciation) through home visits. 

15 
 
o They monitor treatment adherence (i.e., families follow the planned 
schedule of visits and receive inputs for treatment or consolidation) and 
treatment compliance (i.e., the malnourished or consolidating child 
receives the planned dose of therapeutic or supplementary food each 
day).  
o They 
also 
deliver 
a 
water 
purification 
input: 
bleach 
or 
flocculant/decontamination sachets for the purification of the water for 
the entire household. 
• Upon recovery or discharge from consolidation program for a child aged [6-23] 
months, follow-up is extended for 6 months (or until the child is 59 months old) 
with the delivery of the complete prevention package : 
o Behavior change communication 
o Monthly delivery of a nutritional supplement: enriched flour (CSB++), at a 
rate of 3 kg/month/child beneficiary 
o Monthly delivery of a water potabilization input: bleach or 
flocculant/decontamination sachets for the potabilization of the water of 
the whole household.   
Other activities of the care group are carried out upstream of the peak of acute 
malnutrition (before the child's 6 months of age and during pregnancy) and essentially 
include activities promoting good practices for the prevention of all forms of 
malnutrition and illness during the 1,000-day period (which extends from the mother's 
pregnancy to the child's second birthday), integrating the promotion of good maternal 
diet and the promotion of exclusive breastfeeding in the first 6 months. 
 
3.3 Target population and study population  
 
Research will be limited to the age group most at risk of wasting. Thus, for this research, 
the target population is all [6-23] months old children, whether healthy, wasted, or in 
remission of wasting, living in one of the 100 most populated villages of the Health 
District of Mongo (representing 8 out of 10 children in the Health District). 
The study area includes 100 villages or groups of villages in the health district of Mongo 
located in the province of Guéra in south-central Chad.  
The study populations will be composed of : 
1- Children recruited at 6 months of age in the 100 most populated villages and 
followed throughout the study. Children will be enrolled every month during the 
first 7 months of the study. Including the month of inclusion, children will 
therefore be followed for 9 months (for children enrolled at the beginning of the 
study) and for a minimum of 3 months (for children enrolled during the 7th 
month). 

16 
 
2- [6-23] months old children living in the 100 most populated villages, discharged 
from treatment in the nutritional units and FARNE and followed for a period of 6 
months. 
3- [6-23] months old children living in the 100 most populated villages, enrolled in a 
wasting treatment program in the nutritional units (UNA, UNS) and the FARNE, 
and followed up until the end of the program. 
 
3.4 Research Questions  
 
Main Research Question : 
• What is the impact of PASIM on the prevalence of wasting in young children?  
• What is the impact of PASIM on the recovery rate of wasted children?  
• What is the impact of PASIM on the occurrence of relapses after treatment 
and recovery from wasting?  
 
Secondary Research Questions along the Continuum of Care : 
• What is the impact of PASIM on the incidence of wasting in young children?  
• What is the impact of PASIM on the wasting screening coverage in young 
children? 
• What is the impact of PASIM on enrollment in a program for treating cases 
that test positive in young children? 
• What is the impact of PASIM on nutritional status at enrollment in treatment 
in young children?  
• What is the impact of PASIM on the duration, coverage, and adherence of/to 
the treatment of emaciation in young children?  
• What is the impact of PASIM on the psycho-cognitive development of young 
children? 
• What is the unit cost of PASIM per beneficiary child?  
• If there is an impact of the intervention, how cost-effective is PASIM? 
• Is the intervention well implemented, in terms of coverage, effectiveness, 
uptake, fidelity/rationality of implementation, and potential for 
sustainability? 
3.5 Impact study  
 
A rigorous impact evaluation of the PASIM implemented by ASRADD in collaboration 
with the health services of Mongo will be conducted by IFPRI in partnership with the 
national NGO Moustagbal for data collection.  
 
3.5.1 Impact study model  
 

17 
 
The study design includes a two-group, stratified, randomized, unblinded, community-
based efficacy trial. The unit of randomization will be the village or, in some cases, the 
cluster of small villages (grouped prior to the draw).  
 
The evaluation of the program model in the Mongo district will compare two groups:  
1) The control group receiving the standards of care and the usual activities of 
the partners without additional support from the IRAM project for the 
implementation of the PASIM. This includes the usual PCIMA program. This 
group will also continue to benefit from the BCC and screening services 
already existing in their areas.  
2) The intervention group will receive the PASIM through the care groups, in 
addition to the standard of care (the usual PCIMA program) and the BCC and 
screening services already existing in their areas.  
 
The impact evaluation includes three sub-studies to study the impacts of PASIM along 
the continuum of care in order to answer the research questions : 
1. A longitudinal cohort (Cohort 1) to study the impact of the intervention on the 
prevalence of wasting (impact of prevention and treatment), incidence of 
wasting (impact of prevention), knowledge and practices of WASH, nutrition and 
child health. This will be a semi-open cohort in which children who reach 6 
months of age will be recruited and followed through to the end of the study.  
2. A longitudinal cohort (cohort 2) of children aged [6-23] months at enrollment in 
UNS and UNA (at the health center and at the FARNE site) to study the impact on 
treatment outcome (drop-out, death, recovery, deterioration), adherence to 
treatment, and duration of the episode under treatment.  
3. A longitudinal cohort (cohort 3) of children aged [6-23] months discharged from 
UNS/UNA/FARNE treatment to study the impact of the intervention on the 
relapse rate six months after discharge.  
 
 
3.5.2 Stratification and randomization  
For accessibility issues (dispersion of the population in small hamlets) and required 
number of children for the study (probability of finding the necessary number of 
children each month), only the 100 most populated villages (or relevant groupings of 
neighboring villages) in Mongo will be included in the study and randomized between an 
intervention and a control group, after stratification to balance village size between 
groups, and area of residence (urban/rural).  
A first level of stratification will be based on the criterion of the total population of the 
village or group of villages to ensure comparability between intervention and control 
groups. The 50 most populated villages will be randomized separately from the 50 least 
populated villages. 
A second level of stratification will be done in each subgroup according to the type of 
health center (urban/rural). In fact, a principal component analysis (PCA) showed a 
profile of villages according to these two criteria (size of village, urban/rural health 

18 
 
center) which summarizes the difference between villages. This a priori stratification 
(before randomization) ensures a more balanced distribution of covariates between the 
study groups. The balance in the pre-existence of certain relevant PASIM services in 
certain villages will be verified.  
These 100 villages or clusters of villages will be randomly assigned to the intervention 
and control groups using Stata software by an investigator based in Dakar and outside 
the study area. Stata's "sample7" command was used to perform a simple random draw 
of half of the villages on the list of 100 villages. The villages randomly selected by the 
software were assigned to the intervention group and the others to the control group. 
To ensure the randomness and replicability of this draw, a random seed (the number 
used to initiate the draw) was obtained from the random number generator on 
random.org. 
PASIM will be implemented by the executing partners in the villages of the intervention 
group only (50 villages, including 25 large villages and 25 medium villages). 
 
Table 2: Stratification Criteria 
 Criteria 
- Total population of the village 
- Urban Health Centre vs. Rural Health Centre 
 
 
 
3.5.3 Sample Size, Sampling, Approaches, and Inclusion Criteria  
The three cohorts of children needed to longitudinally assess the effects of PASIM along 
the continuum of care will be as follows: 
• Main cohort (#1): includes 1,750 children in the community aged 6 to 6.9 
months, included for a period of 7 months and followed up monthly until the 
end of the study (the total duration of the study is 9 months from April 2021 to 
December 2021). 
• Treatment Cohort (#2): includes all 6-23 months old children living in the 100 
study villages, or included in the main or relapse cohort, and registered for 
treatment, based on health system records. 
• Relapse Prevention Cohort (#3): includes 700 children aged 6 to 23 months 
inclusive who were discharged from treatment and followed up monthly for 6 
months. 
 
The main cohort (#1) will include children aged 6-6.9 months. Given the small size of 
most villages and the sample size needed to detect a significant, plausible and 
meaningful difference in longitudinal wasting prevalence (primary outcome) between 
groups, we have calculated that we need to include an average of 3 children per month 
for 7 months in the 50 largest villages (25 villages in the control group and 25 in the 
 
7 Gould, W. W. 2012a. Using Stata’s random-number generators, part 2: Drawing without replacement. The Stata Blog: 
Not Elsewhere Classified. http://blog.stata.com/2012/08/03/using-statas-random-number-generators-part-2-drawing-without-
replacement/. 

19 
 
intervention group) and an average of 2 children per month for 7 months in the 50 
smallest villages in the study area (i.e., the medium-sized villages in the Mongo Health 
District: equally 25 in the control group and 25 in the intervention group). The children 
will all leave the cohort in the same month: counting the month of inclusion, the 
children will be seen for a maximum of 9 months (for children included at the start of 
the study) and a minimum of 3 months (for children included during the 7th month). 
This will result in a total sample of 1,750 children (10,500 visits in total of which 1,750 
inclusions and 8,750 follow-ups, see Table 1). With 15% dropout, the size of this study 
would provide sufficient power to detect a relative decrease of about 35% in the 
longitudinal prevalence of wasting and a relative decrease of about 28% in the incidence 
of wasting, with a power of 80% and a statistical significance of 5%, taking into account 
the cluster effect at the village level and the imbalance in cluster size.  
In each of the 100 villages, these children will be randomly selected from a randomly 
ordered list from a census of children aged 0-6 months (conducted by the survey team 
in the first month of the survey). Their parents will be offered the opportunity to 
participate in the study during a home visit (see Voluntary and Informed Participation 
Process and Consent Documentation described in Section 4). Children whose parents 
refuse or who are not located will be replaced until a maximum of three new children 
have been included in a given month, or until the list of eligible children is exhausted. 
Inclusion will end when 21 children have been included in each of the 50 largest villages 
and at least 14 children have been included in each of the other 50 villages. Inclusion in 
the cohort will begin in April and continue until October 31, 2021. 
  
The criteria for inclusion of children in the main cohort are:  
- 
6-6.9 months of age  
- 
Child singleton 
- 
The mother must live in the study area from the time of inclusion.  
- 
The agreement of the mother or guardian 
 
The exclusion criteria are :  
- 
Congenital malformations that make anthropometric measurements impossible.  
- 
Mother intends to leave the study area by December 2021. 
  
The Relapse Prevention Cohort (#3) will include [6-23] months old children discharged 
from the program and living in the 100 villages in the study area. Given the small size of 
most villages and the required sample size, we have calculated that we need to enroll 8 
children in the 50 largest villages and 6 children in the 50 average villages and follow 
them every month for 6 months each. This will result in a total sample size of 700 
children (4,900 visits in total, including 700 inclusions and 4,200 follow-ups). Such a 
sample size would provide sufficient power to detect a decrease of about 33% in the 
incidence of relapse. 
All available children in each village who are discharged from PCIMA treatment 
(identified based on nutrition unit registers) will be invited to participate in the study 

20 
 
until the required sample size is reached for each village. During the discharge visit, 
parents will be asked if they agree to have their contact (first name, last name, village, 
and if possible, telephone or location) forwarded to the survey team for an 
explanatory home visit. If they agree, participation in the study will be offered during 
a follow-up home visit (see process for voluntary and informed participation and 
documentation of consent described in Section 4). In villages with more children than 
necessary, the study team will select children from a randomly selected list. Inclusion 
must be completed by June 30, 2021, to allow 6 months of observation before 
December 31, 2021. 
The inclusion criteria for the relapse study are: 
- 
Child has been successfully treated for wasting (moderate or severe) and has 
been discharged from the national treatment program within the last 30 days.     
- 
The child is between 6 and 23 months of age at inclusion.         
- 
The child is singleton.        
- 
The mother must live in the study area from the time of inclusion.  
- 
The agreement of the mother or guardian 
 
The exclusion criteria are :  
- 
Congenital malformations that make anthropometric measurements impossible.  
- 
Mother intends to leave the study area by December 2021. 
  
 

21 
 
Table 1: Chronology of Inclusion in the Main and Relapse Cohorts and the Number of Children Followed Monthly  
  
April 
May 
June 
July 
August 
September October 
November December 
Primary Cohort 
  
  
  
  
  
  
  
  
  
Month of inclusion 1 (n = 
250) 
n = 250 
  
    
  
  
  
  
  
Month of inclusion 2 (n = 
250) 
  
n = 500 
  
    
  
  
  
  
Month of inclusion 3 (n = 
250) 
  
  
n = 750 
  
    
  
  
  
Month of inclusion 4 (n = 
250) 
  
  
  
n = 1 
000 
  
    
  
  
Month of inclusion 5 (n = 
250) 
  
  
  
  
n = 1250 
  
    
  
Month of inclusion 6 (n = 
250) 
  
  
  
  
  
n = 1500 
  
    
Month of inclusion 7 (n = 
250) 
  
  
  
  
  
  
n = 1750 
n = 1750 
n = 1750 
 
Relapse Prevention 
Cohort 
  
  
  
  
  
  
  
  
  
Month of inclusion 2 (n = 
350) 
  
n = 350 
  
    
  
  
  
  
Month of inclusion 3 (n = 
350) 
  
  
n = 7 00 
n = 700 
n = 700 
n = 700 
n = 700 
n = 700 
n = 350 
    
  
  
  
  
  
  
  
  
Total number of children 
in the two cohorts 
250 
850 
1450 
1700 
1950 
2200 
2450 
2450 
2100 
  

22 
 
The treatment cohort (#2) will include all records of children (aged [6-23] months) living 
in the 100 villages in the study area and enrolled between April 2021 and December 
2021 in a treatment program by the national PCIMA program (UNA, UNS, FARNE, UNT). 
Treatment data are collected by the health centers as part of their routine.  
Each nutritional unit and FARNE will be visited by an enumerator twice a month.  
The enumerator will be responsible for monitoring data quality and copying data from 
the registers to electronic forms. 
The copied data will not personally identify the children, except for the children 
followed in cohorts 1 and 3 whose parents will give their consent as part of the 
informed consent process to link the treatment data to their cohort data. For other 
registry data for children outside of cohorts 1 and 3, there is no provision for seeking 
parental consent as we will treat these data as secondary data. No follow-up visits will 
be made by the interviewers, so they will not attempt to locate the children. Thus, the 
data copied will not include names, phone numbers, or dates of birth. However, it will 
include other variables such as anthropometric measures and inputs given and services 
received, as well as sex, age group, and village code, solely for the purpose of 
accounting for these primary adjustment factors and the cluster effect when analyzing 
the data. 
The criteria for inclusion in the treatment cohort are : 
- 
The child is included in a national treatment program.  
- 
The child is between 6 and 23 months of age at inclusion         
- 
Child lives in one of the 100 villages in the study area 
 
3.5.4 Study Results  
 
For this study, wasting is defined by WHZ <-2 (relative to the WHO reference of 2006) or 
MUAC <125 mm or bilateral edema. Moderate Acute Malnutrition (MAM) is defined by -
3≤ WHZ <-2 (relative to WHO reference of 2006) or 115mm≤MUAC <125 mm. Severe 
Acute Malnutrition is defined by WHZ <-3 (relative to WHO 2006 reference) or MUAC 
<115 mm or bilateral edema.  
 
The main results of the study are: 
1. Longitudinal prevalence of wasting among children enrolled at 6 months of age 
followed monthly until the end of the study (Cohort 1). This indicator is defined 
for each child as the number of visits during which wasting is observed divided 
by the total number of monthly visits made (by interviewers). 
2. The recovery rate in children enrolled at [6-23] months of age for up to 3 months 
of treatment in a UNS, UNA or FARNE and followed through to discharge (Cohort 
2). This indicator is defined as the number of discharges considered cured 
according to national program criteria (WHZ>-2 and MUAC>=125mm and 
absence of bilateral edema for two consecutive visits, within 12 weeks of 
enrollment in the program) divided by the total number of discharges recorded. 

23 
 
3. The incidence of wasting in children enrolled at [6-23] months of age at 
discharge and followed for 6 months (Cohort 3). This indicator is defined as the 
number of new cases of wasting recorded during monthly visits.  
 
 
Secondary outcomes of the study include:  
 
For Cohorts 1 and 3 : 
- 
The longitudinal prevalence of : 
o MAM, defined by the number of MAM diagnoses divided by the total number of 
monthly visits made  
o SAM, defined by the number of SAM diagnoses divided by the total number of 
monthly visits made 
- 
The impact of : 
o Wasting, defined by the number of new cases of wasting recorded during 
monthly visits.  
o MAM, defined by the number of new MAM cases recorded during monthly visits  
o SAM, defined by the number of new SAM cases recorded during monthly visits  
- 
The prevalence of anemia defined as the proportion of children with a hemoglobin 
level below 11g/dl at the end of the study. 
- 
Mean hemoglobin concentration at the end of the study 
- 
Prevalence of stunting defined as the proportion of children with HAZ <-2 (relative to 
the 2006 WHO reference) at the end of the study. 
- 
The average z-scores HAZ at the end of the study  
- 
Wasting screening coverage defined as the proportion of children screened (using 
MUAC, weight-for-height or bilateral edema) in the month prior to the monthly visit. 
Two sub-outcomes will also be concerned:  
o Screening coverage by care groups.  
o Coverage of the family MUAC component, which is the screening performed by a 
family member in the past month. 
- 
The referral rate of positive screenings defined as the proportion of children who 
tested positive during the month (according to the mother) who were referred to 
the health center or FARNE site.  
- 
Enrollment of wasting, MAM, and SAM cases defined as the proportion of cases who 
tested positive in the month prior to the monthly visit who were enrolled in a UNA 
or UNS treatment program. 
- 
Children's psycho-cognitive development, as assessed by the DMC-II score at the 
end of the study 
- 
Linear growth rate (change in height-for-age index per month)  
- 
Speed of weight growth (change in weight-for-height index per month)  
- 
Weight gain (weight change per month)  
- 
MUAC gain (change in MUAC per month)  

24 
 
- 
The longitudinal prevalence of childhood morbidity, i.e. acute respiratory infections, 
fever, diarrhea and malaria, defined by the number of diagnoses of signs of these 
morbidities divided by the total number of monthly visits made.  
- 
Mother/guardian’s knowledge of nutrition, WASH, and health expressed as 
cumulative total and domain scores in a subsample of children who reached 9 
months of age 
- 
Infant and young child feeding practices (IYCF) 
o Introduction of (semi) solid and soft complementary foods  
o Minimum dietary diversity in children, defined as the proportion of children who 
consumed at least 5 of the 8 food groups (including breast milk) the day before 
the survey. 
o Minimum meal frequency for children, defined as the proportion of children 
who had eaten the day before the survey: 2 meals for breastfed children 6-8 
months, 3 meals for breastfed children 9-23 months, or 4 meals for non-
breastfed children 6-23 months.  
o Minimum acceptable child feeding, defined as the proportion of children with 
both minimal dietary diversity and minimal meal frequency on the day before 
the survey. 
o Consumption of iron-rich or iron-fortified foods in children.  
- 
Practices related to water, hygiene and sanitation 
- 
Vaccination coverage.  
 
For Cohort 2 : 
- 
Nutritional status (measured by weight-for-height in z-score and MUAC) at 
enrollment in UNS and UNA in children 6-23 months of age. 
- 
The duration of UNS and UNA treatment defined as the number of days spent on 
treatment (enrollment and discharge) in children 6-23 months of age at enrollment. 
- 
Treatment adherence defined as the proportion of cases enrolled for treatment who 
received timely treatment from dedicated services until recovery. 
- 
The treatment outcome (drop-out, death, transfer, non-response rates) 
- 
The longitudinal prevalence of childhood morbidity, i.e. diarrhea, vomiting, fever, 
respiratory infections and malaria, defined by the number of days for which signs of 
these morbidities were reported divided by the total number of days in the recall 
periods. 
 
Finally, the cost-effectiveness of the intervention package will also be evaluated by a 
sub-study. 
 
3.5.5 Measures and Procedures  
For this survey work, interviewers will use Android tablets with specialized software for 
computer interviews (Survey Solutions software).  
In the primary (#1) and relapse (#3) cohorts, children's anthropometric measures will be 
recorded during monthly home visits, and several modules of questions will be 

25 
 
administered to provide essential insight into relevant parental and household 
practices. For the treatment cohort, each nutritional unit (26) and each FARNE (about 
19) will be visited by an enumerator twice a month. The enumerator will be responsible 
for monitoring data quality and copying data from the registers to electronic forms. 
 
Questionnaires  
• Village/CHW/care group questionnaire: A module of questions will be 
administered to the village representative at the beginning of the study. 
Questions about the village's infrastructure and organization and past and 
current health and nutrition interventions will be asked. In addition, specific 
questions will be asked to the community health worker and a representative of 
the existing care group volunteers to understand their roles, activities, 
motivations and knowledge of nutrition and health at the beginning of the 
project. 
 
• Health center questionnaire: A module of questions will be administered to a 
manager of each health center (26) to draw up a profile of the organization of 
care and available inputs. 
 
• At the household level: Questions on household composition, socio-economic 
status, household expenditures, household food security, livestock/land/asset 
holdings, and concession construction materials will be administered. There will 
be a module of questions on food hygiene, hygiene and sanitation practices. 
Household participation in social or NGO/government-related programs will also 
be assessed. 
 
• At the level of mothers/caregivers and children: Questions on the level of 
education of the mother and father, primary occupation, decision-making 
power, stress, postpartum depression, and health and nutrition of the eligible 
child will be administered. Specific questions on nutritional, water, sanitation, 
hygiene knowledge and practices, and uvula removal practice will be asked to 
the mother/guardian in charge of the child's care. Other modules will include the 
use of health care services and contact times with different platforms involved in 
the prevention, screening, or treatment of wasting. The child's age will be 
obtained from a birth certificate or using a local events calendar in the event 
that objective proof of the date of birth cannot be presented.  
 
Anthropometry  
Anthropometric measurements will be taken during the initial and final surveys and 
during the monthly longitudinal follow-up visits. The child's weight will be taken using 
an electronic scale to the nearest 100g. The length will be measured with a measuring 
rod to the nearest 1 mm. The Mid-Upper Arm Circumference (MUAC) will be measured 
using a non-stretch tape with 0.1 cm accuracy. All measurements will be taken in 

26 
 
duplicate by an anthropometer and an assistant. All measurements will be standardized 
prior to the study. Standardization exercises using repeated measurements on 10 
children aged 6-15 months will be repeated every two months. From these 
standardization sessions, inter- and intra-measurement variations will be documented. 
The weight-for-height and height-for-age z-scores will be calculated using the WHO 
2006 growth standards. 
The MUAC, weight and height of the mother will also be measured using a non-stretch 
tape, a scale, and a tape measure, respectively.  
 
Morbidity and Mortality  
During longitudinal follow-up, the assessment team investigators will conduct monthly 
home visits to provide a daily reminder of child morbidity (acute respiratory infections, 
diarrhea, fever, and malaria) over the previous 3 days. A diarrheal episode is defined as 
at least three loose stools in the last 24 hours, or stools with blood. Fever will be 
measured by a thermometer and the history of fever in the previous days will also be 
asked. The presence of an acute respiratory infection (ARI) in the previous week will be 
assessed by recalling the specific symptoms associated with ARI (cough, difficulty 
breathing, rapid breathing, runny nose). The presence of malaria parasites will be 
checked for the presence of malaria parasites with a rapid diagnostic test for malaria by 
capillary finger or heel swab, if body temperature is above 37.5 °C or if the mother 
reports a fever episode in the child within the last 72 hours.  
 
Hemoglobin measurement on capillary blood  
The hemoglobin concentration will be measured at the beginning and end of the 
program. For this purpose, a drop of capillary blood will be taken from the child's finger. 
The hemoglobin concentration will be measured by spectrophotometry using a 
HemoCue 301 (HemoCue Ltd, Dronfield, UK).  
Anemia in children and severe anemia are defined by hemoglobin concentrations of less 
than 11 g.dL-1 and less than 7 g.dL-1 respectively. 
 
3.5.6 Data Analysis  
A detailed statistical analysis plan will be developed and made available online before 
the data analysis begins. 
 
3.6 
Cost and cost-effectiveness study  
Costs will be estimated from a societal perspective, including all costs incurred by 
institutions and communities 10. Costs will be calculated using a combination of 
accounting records and "ingredient" estimates using unit costs and input quantities 11. 
An Activity-Based Costing (ABC) methodology will be used, allowing for the 
categorization and allocation of all program costs to their core activities. Financial costs 
as well as economic costs (in-kind donations, household expenditures, etc.) will be 
collected. 

27 
 
To obtain these data, program documentation and expenditure information will be 
reviewed, and key informant interviews and focus groups will be conducted with staff 
involved in program implementation. Another outcome of these interviews and focus 
groups will be an estimate of time allocation; staff time allocation will be used using the 
ABC method to allocate staff costs among activities. Focus groups will be conducted 
with households to gain an understanding of the direct and indirect costs they incur in 
participating in the program. The effect of plausible variation in household cost 
estimates from the focus groups will be assessed through sensitivity analysis. 
The analysis will include both the total costs of the program and the incremental costs 
of additional activities in the intervention area. Cost-effectiveness ratios will be 
calculated based on program costs and outcomes. Incremental cost-effectiveness ratios 
will be calculated by dividing the incremental costs in the intervention area by the 
number of cases of acute malnutrition prevented in the intervention area compared to 
the control area. This ratio represents the incremental cost of achieving an additional 
positive outcome in the intervention zone compared to the control zone. Comparison 
with other similar published work will be considered where appropriate. 
 
3.7 Data Management  
As mentioned above, for survey work, interviewers will use Android tablets with 
specialized software for computer interviewing (Survey Solutions software). 
Immediately after validation of the questionnaire by the interviewer, each questionnaire 
is synchronized via an internet connection on a secure server, and the questionnaire is 
automatically deleted from the interviewer's tablet. The server is accessible only to IFPRI 
investigators. After checking the quality of the data collected, the questionnaire can be 
returned to the interviewer's tablet for field corrections. Once these corrections have 
been made, the same synchronization process allows the data to be stored on the 
secure server. 
 
Management of all research data will follow IFPRI's institutional protocol for research 
data management, overseen by the IFPRI Data Governance Committee, as well as 
UNICEF data governance standards. Data will be stored on a secure server accessible 
only to principal investigators. All data will then be carefully anonymized and de-
identified so that the privacy of participants and research subjects is fully protected. 
Databases will be anonymized using identification codes. No names, GPS coordinates, 
dates of birth or other identifying data will be stored in the databases. 
 
IFPRI will have exclusive use of the data for primary impact analysis. In accordance with 
IFPRI's policy on research data management and open access, at the time of publication 
of scientific articles presenting primary results, the fully anonymized databases will 
become a public good and will be made available to the scientific community, 
government, and partners. 
 

28 
 
3.8 Dissemination strategy  
The results will be widely disseminated through restitution workshops (including at 
least one restitution workshop in Mongo), seminars, conferences and/or webinars. 
Scientific results will be transcribed into non-technical blogs, briefing notes, and social 
network products that will be accessible to program planners, implementers, and 
funders.  
 
IFPRI will bring its expertise in the dissemination of all research results. This includes 
free access to the scientific articles published based on this work and the availability of 
the collected data (which will thus become a public good), after being duly de-identified 
and anonymized to ensure full protection of the participants' private data. 
 
UNICEF will also provide technical expertise in disseminating findings and conclusions to 
national and international decision-makers to inform relevant policies and programs for 
the reduction of wasting. 
 
4 Ethical considerations  
 
The study protocol will be submitted for review to the Institutional Review Board (IRB) 
of IFPRI (Washington DC, USA) and the National Bioethics Committee of Chad 
(N'Djamena, Chad). The intervention study will be registered with clinicaltrials.gov or a 
similar public repository. The data analysis plan will also be recorded.  
In accordance with IFPRI requirements, all IFPRI staff participating in the study will have 
completed the Collaborative Institutional Training Initiative (CITI Program) basic training 
"Social and Behavioral Research", which addresses research ethics issues in data 
collection, analysis, and management.  
The entire data collection team will be trained in, and bound by, the basic ethical 
principles outlined below. 
 
4.1 Community Information  
The data collection team will inform local and regional health authorities and 
community representatives. In each village in the study area, representatives of the data 
collection team will present the objectives and procedures of the study to the village 
authorities. 
 
4.2 Voluntary and informed participation  
The purpose and procedures of the study will be explained to all mothers and heads of 
households of eligible children in their local language through an information sheet. All 
respondents reserve the right to refuse to participate in the study. Each interviewer will 

29 
 
be asked to read the consent statement in its entirety, slowly and in the participant's 
local language so that they can understand it. They will then ask if the consent 
statement has been understood and if there are any questions. 
Consent for children will be given by a parent or legal guardian. An informed consent 
form will be signed by the child's primary caregiver and, if present, by the head of the 
household. 
 
4.3 Risks and serious adverse effects  
There are no known risks related to the evaluation methods (questionnaires, 
anthropometry). Good clinical practice will be respected by taking capillary blood 
samples to determine the hemoglobin level and performing the malaria test during 
longitudinal follow-up. Conducting field studies during the COVID-19 pandemic requires 
the implementation of strong mitigation strategies to prevent transmission of the virus. 
Special precautions will therefore be taken and clearly explained to participants when 
consent is sought. These precautions are detailed in section 5 below (Specific 
precautions related to COVID-19). 
 
4.4 Emergencies  
In the event of a medical emergency that occurs or is identified during the assessment 
visits, all study participants in both the control and intervention groups will receive 
medical care. Medical emergencies will be defined by any severe anemia (hemoglobin 
level <7g/dL), or danger signs (lack of response to voice and/or pain; unconsciousness; 
inability to eat or drink; vomiting everything; seizure). These emergencies will be 
referred by the data collection team to the health center and the program will bear 
any medical costs related to these emergencies (consultation, prescription, 
hospitalization, and medical evacuation decided by the medical corps within the 
framework of the national protocol, if they are not already covered by the national free 
healthcare program), until the medical emergency is lifted (e.g., discharge from 
hospital). If a chronic disease has caused these emergencies, the care related to the 
emergency will be covered, but not the chronic pathology. Drugs prescribed following a 
referral for a positive malaria test will also be covered. We do not plan to cover 
medical care for children identified with emaciation as treatment is currently free of 
charge for parents. As the indicators related to acute malnutrition are the primary and 
secondary outcomes of the study, any additional treatment would risk influencing the 
results and their generalizability. Nevertheless, severe wasting is a medical emergency. 
Therefore, all cases of severe wasting according to current national criteria (currently 
brachial perimeter <115 mm or bilateral edema) that will be identified by the data 
collection teams and that have not yet been included in a treatment program will also 
be referred to the nutritional units. 
 

30 
 
4.5 Anonymity  
Every precaution will be taken to ensure the anonymity of participants during data 
collection, data management, data analysis and dissemination of results. As described 
above, completed questionnaires will be automatically deleted from the interviewer's 
tablet after synchronization on the secure server. The server is accessible only to IFPRI 
investigators. All databases will be made anonymous using identification codes. 
Personal data will be used only by the investigation team for the purposes of 
longitudinal follow-up, in order to trace the children followed in the cohorts on a 
monthly basis. No personal data will be shared outside the survey team or kept in the 
de-identified databases.  
 
 
5 Specific precautions related to COVID-19  
 
Conducting field studies during the COVID-19 pandemic requires the implementation of 
strong mitigation strategies to prevent transmission of the virus. The following 
measures will be introduced to reduce the risk of transmission. 
5.1 Training of Interviewers  
1. Prior to each day of training, all interviewers and support staff will be examined 
by research staff for possible symptoms (e.g., cough, difficult breathing, fever, 
fatigue). Suspected cases will be required to stay at home and remain in 
quarantine for at least 7 days or as per national recommendations if longer. 
Fever will be measured with a flash thermometer. 
2. Interviewer training will be organized in 1 or 2 large auditoriums allowing an 
interpersonal distance of 2 meters at all times. The auditoriums will be ventilated 
at each break. During breaks, interviewers will be asked to leave the auditorium 
in small groups to avoid contact. Meals, coffee breaks and practical exercises will 
be organized outside. 
3. The training and standardization exercises in anthropometry will take place 
outdoors. 
4. During training, all personnel will wear a face mask without exception. 
5. After each day of training, the benches, tables and shelves will be disinfected 
with an alcoholic solution (>70% v/v alcohol). 
6. Before transferring the interviewer teams to the Mongo health district, each 
interviewer will perform a COVID-19 PCR test. Positive cases will be quarantined 
according to national recommendations. 
7. We are training 10% more interviewers than the number needed for the study in 
order to maintain the possibility of replacing interviewers who present 
symptoms of VIDOC-19 and who will have to be quarantined. 
 

31 
 
5.2 Field Study  
1. The informed consent form contains a paragraph explaining to the head of the 
family and to the interviewees the risk associated with COVID-19 and how the 
interviews will be conducted to limit the risk of transmission.  
2. All interviews will take place outdoors in the open air. 
3. Interviewers and anthropometrists will wear a face mask during the 
administration of the questionnaire and all measurements. 
4. The survey team will provide two reusable masks to each household enrolled. At 
each monthly visit, respondents will wear a face mask. A new mask will be 
provided by the survey team if the masks distributed at enrollment are not 
available. 
5. The interviewer will stand at a distance of two meters during the interview. 
6. Other members of the household will be asked to respect the two-meter 
distance at all times. 
7. Anthropometric agents will wear a face shield in addition to their face mask. 
They will record the height and weight of the standing adult positioned behind 
the participant to avoid face-to-face contact. For measurements of children, the 
child's mother/guardian will be asked to maintain a distance of two meters from 
the anthropometrics officers. 
8. After each measurement, the MUAC tapes, scales and height rods will be 
disinfected with a 70% alcoholic solution as recommended by the WHO. 
9. Before starting the interview, the interviewer will assess the interviewee's 
temperature and probe for symptoms related to COVID-19. In case of suspected 
case of COVID-19, the interview will be cancelled. 
10. Prior to each workday, team supervisors will measure each interviewer's body 
temperature and assess the symptoms of COVID-19 (e.g. cough, difficult 
breathing, fever, fatigue). When a suspected case is encountered, the 
interviewer will be asked to observe a quarantine according to national 
recommendations. 
6 Partnership and management  
 
This study is the result of a partnership between UNICEF and IFPRI, commissioned to 
IFPRI by UNICEF. The principal investigators of the study are Dr. Elodie Becquey and Dr. 
Lieven Huybregts (IFPRI).  
The funder of this study is the United Kingdom Foreign, Commonwealth and 
Development Office (FCDO). The NGO ASRADD implements the IRAM program under 
the responsibility of UNICEF Chad in collaboration with the relevant local authorities. 
IFPRI is in charge of evaluating the study and will be responsible for ensuring compliance 
with the study protocol. The role of designing, conducting and deciding to disseminate 
the results of the study is reserved to IFPRI, in order to guarantee the study's 
impartiality. Table 3 provides an overview of all parties involved.  
The Directorate of Nutrition and Food Technology (DNTA) at the Ministry of Public 
Health and National Solidarity as well as the multisectoral platform Permanent Technical 

32 
 
Committee of Nutrition and Food (CTPNA) and the Provincial Health Delegation will be 
privileged partners who will support the project in obtaining administrative documents 
(ethical approval, research authorization) and also in advising and facilitating field work. 
 
Table 3: Overview of actors and roles 
Stakeholder 
Name 
Role 
Research Sponsor 
UNICEF West and Central Africa 
Address 
Dakar Almadies Senegal 
Telephone: +221 33 831 02 00 
Email : 
- Dolores Rio 
 drio@unicef.org 
UNICEF Chad 
Address 
Road to the Airport N'Djaména 
BP 1146 N'Djamena, Republic of Chad 
Telephone: +235 2251 89 89 
Email:  
- Djibril Cissé  
  dcisse@unicef.org 
- Saidou KABORE 
 Ksaidou@unicef.org  
 
- Financing of the study 
- Coordination 
of 
program 
implementation 
 
Promoter 
IFPRI Dakar 
Title 3396, Lot #2 
BP 24063 Dakar Almadies Senegal 
Phone: +221.33.869.9800 
Email: 
- Elodie Becquey (PI) 
 E.Becquey@cgiar.org 
- Mariama Touré 
M.toure@cgiar.org 
IFPRI  
2033 K St, NW 
Washington, DC 20006-1002 USA 
Phone: +1 202-862-5600 
Fax: +1 202-467-4439 
Email:  
- Lieven Huybregts (PI)  
 L.Huybregts@cgiar.org 
- Jef Leroy  
J.leroy@cgiar.org 
- Principal Investigator 
 
- Study design  
 
- 
Quality control of data collection 
 
- Dissemination of results 
 
- Guarantor of the research 
protocol 
 
Implementing 
Agency 
ASRADD 
Youssouf Boye Avenue 
BP 2449, N'Djamena, Republic of Chad 
Phone: + 235 99 95 60 68 / 00235 66 28 13 
77 
 Email:  
- Dr. Moussa Abderamane 
Mellah03@yahoo.fr  
- 
Program Implementation 
 
- 
Project Management 
 
- 
Training and formative 
supervision of health staff and 
care groups for the 
implementation of the PASIM 

33 
 
as described in the protocol 
 
Data 
collection 
Agency 
Moustagbal 
BP 10 - Mongo, Guera, Tchad  
(+235) 66 75 44 00 / 99 29 52 80  
Email:  
- Abdoulaye Baine 
moustagbal.dg@gmail.com 
- Seid Ahmat Djarma 
djarmaseidahmat@yahoo.fr 
 
- 
Data collection 
Research Partner 
Ministry of Public Health  
Directorate of Nutrition and Food Technology 
(DNTA) 
 
- 
Support in obtaining 
administrative documents 
(ethics approval, research 
authorization) 
- 
Advices  
- 
Facilitation of field work 
7 Budget  
 
The IRAM project is funded by the CFODF through UNICEF. Table 4 shows the 
distribution of the main budget lines for data collection. 
 
Table 4: IRAM Data Collection Budget 
 
DESCRIPTION 
 TOTAL (XAF)  
STAFF  
               97,591,500  
LONGITUDINAL STUDY 
               95,164,033  
Preparatory Phase for Data Collection 
 1,285,000  
Data Collection Supplies 
 1,771,000  
Covid-19 Protections 
                   4,588,800  
Biomedical consumables 
                   6,907,650  
Training of field agents 
 12,351,250  
Pilot Study (Pre-Test) 
                   1,542,000  
Data Collection 
                 66,718,333  
Administrative management fees (7%) 
                     13,492,887   
 TOTAL 
                  206,248,421   
 

34 
 
8 Timeline  
Table 5 provides a chronology of the different components of the IRAM program. The 
implementation of the study will be finalized at the end of 2020. 
Data analysis and dissemination of results in scientific journals and as technical reports 
on partner websites will take place in 2022. 
 
 
 
 
 
 
 
 
 
 
Table 5: Chronology of the IRAM study 
 
Activities 
2021 
2022 
  
Mar 
Apr 
May 
Jul 
July 
Aug 
Sept 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jul 
Obtaining ethical 
approval 
x 
 
 
 
 
 
 
 
  
  
  
Interviewers Training 
x 
x 
 
 
 
  
  
  
Cohort 1 
  
x 
x  
x 
x 
 x 
x  
x  
x  
x  
  
  
Cohort 2 
  
x 
x  
x 
x 
 x 
x  
x 
x 
x  
  
  
Cohort 3 
  
x 
x 
x 
x 
x 
x 
x 
x 
  
  
Data Analysis 
  
 
 
 
 
 
 
 
x  
x 
x 
x 
  
Report writing 
  
 
 
 
 
 
 
 
  
  
x 
x 
x 
Dissemination of 
results 
  
  
  
  
  
  
  
  
  
  
  
  
x 
x 
 
 
 

35 
 
9 References  
 
1.  
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malnutrition: key findings of the 2020 edition [Internet]. [cited 2020 Oct 3]. Available from: 
https://www.who.int/publications/i/item/jme-2020-edition 
2.  
Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, Ezzati M, Grantham-Mcgregor 
S, Katz J, Martorell R, et al. Maternal and child undernutrition and overweight in low-income and 
middle-income countries. Lancet. 2013;382:427–51.  
3.  
Resolution WHA65.6. Comprehensive implementation plan on maternal, infant and young child 
nutrition. Sixty-fifth World Health Assembly, Geneva, 21-26 May 2012 [Internet]. Geneva; 2012 
[cited 2020 Jan 6]. Available from: 
https://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1 
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World Health Organization. Global Database on the Implementation of Nutrition Action [Internet]. 
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MQSUN +. 2018;72. Available from: https://www.ennonline.net/attachments/3045/MQSUN-
_State-of-Evidence-and-Thinking-on-Wasting.pdf 
6.  
IFPRI. Taking Action: Progress and Challenges in Implementing Nutrition Policies and Programs. 
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DC;  
7.  
Huybregts L, Le Port A, Becquey E, Zongrone A, Barba FM, Rawat R, Leroy JL, Ruel MT. Impact on 
child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into 
community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali. 
PLOS Med. Public Library of Science (PLoS); 2019;16:e1002892.  
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Becquey E, Huybregts L, Zongrone A, Le Port A, Leroy JL, Rawat R, Touré M, Ruel MT. Impact on 
child acute malnutrition of integrating a preventive nutrition package into facility-based screening 
for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in 
Burkina Faso. PLOS Med. Public Library of Science (PLoS); 2019;16:e1002877.  
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FAO, WHO, UNHCR, UNICEF, WFP, UN OCHA. Global action plan on child wasting: a framework for 
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the Sustainable Development Goals [Internet]. 2020. Available from: 
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action 
10.  
Kabore S. National Nutrition Survey 2019 Final Report. 2019 Oct.  
11.  
Becquey E, Huybregts L, Touré M, Diop L, Zagré R, Diatta AD. Inception report of the Integrated 
Wasting Research Project (IRAM) at Tchad : Context analysis and considerations for intervention 
formulation. Washington, DC; 2020.  
12.  
Wight J. Simplified Batch Survey Technique Applied to Quality Assurance to Assess Access and 
Coverage - Nutrition Survey of the Sahelian Band, Chad, September 2015 [Internet]. 2015. 
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https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/
files/sleac_tchad_rapport_finale_2015.pdf 
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WHO Multicentre Growth Reference Study Group. WHO child growth standards: Length/height-
for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: 
methods and development. Geneva; 2006.  

36 
 
 
10 Appendices  
10.1 Appendix 1: Consent Forms  
10.2 Appendix 2: Questionnaires  
10.3 Appendix 3: Resumes of Investigators