Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation

Under the NGO–government partnership, wasting among children under age 3 decreased by 28% in intervention areas and by only 5% in comparison areas. Success factors included persuading and engaging with communities including delivery of tailored information, close presence and supervision of field staff, and holistic management of other issues beyond acute malnutrition. This intensive approach may be challenging for the government to adapt effectively at large scale. Under the NGO–government partnership, wasting among children under age 3 decreased by 28% in intervention areas and by only 5% in comparison areas. Success factors included persuading and engaging with communities including delivery of tailored information, close presence and supervision of field staff, and holistic management of other issues beyond acute malnutrition. This intensive approach may be challenging for the government to adapt effectively at large scale. Background: We evaluated an adaptation of a large-scale community-based management of acute malnutrition program run by an NGO with government partnerships, in informal settlements of Mumbai, India. The program aimed to reduce the prevalence of wasting among children under age 3 and covered a population of approximately 300,000. Methods: This study used a mixed-methods approach including a quasi-experimental design to compare prevalence estimates of wasting in intervention areas with neighboring informal settlements. Cross-sectional data were collected from March through November 2014 for the baseline and October through December 2015 for the endline. Endline data were analyzed using mixed-effects logistic regression models, adjusting for child, maternal, and household characteristics. In addition, we conducted in-depth interviews with 37 stakeholders (13 staff and 24 mothers) who reported on salient features that contributed to successful implementation of the program. Results: We interviewed 2,578 caregivers at baseline and 3,455 at endline in intervention areas. In comparison areas, we interviewed 2,082 caregivers at baseline and 2,122 at endline. At endline, the prevalence of wasting decreased by 28% (18% to 13%) in intervention areas and by 5% (16.9% to 16%) in comparison areas. Analysis of the endline data indicated that children in intervention areas were significantly less likely to be malnourished (adjusted odds ratio, 0.81; confidence interval, 0.67 to 0.99). Stakeholders identified 4 main features as contributing to the success of the program: (1) tailoring and reinforcement of information provided to caregivers in informal settings, (2) constant field presence of staff, (3) holistic case management of issues beyond immediate malnourishment, and (4) persistence of field staff in persuading reluctant families. Staff capabilities were enhanced through training, stringent monitoring mechanisms, and support from senior staff in tackling difficult cases. Conclusion: NGO–government partnerships can revitalize existing community-based programs in urban India. Critical to success are processes that include reinforced knowledge-building of caregivers, a high level of field support and encouragement to the community, and constant monitoring and follow-up of cases by all staff levels.