Effectiveness of Task Shifting in the Management of Malnourished Children in Northern Kenya: A Cluster-Randomized Controlled Trial
Authors:   African Population and Health Research Center, P.O. Box 10787-00100, APHRC Campus, Kitisuru, Nairobi, Kenya, Mwangi1 Bonventure , Pythagore Pierre Donfouet1,2 Hermann ,   African Population and Health Research Center, P.O. Box 10787-00100, APHRC Campus, Kitisuru, Nairobi, Kenya; The World Bank Health Nutrition and Population Global Practice, 1818 H Street, NW Washington, D.C. 20433 USA., Daniel3 Tewoldeberhan ,   UNICEF Eastern and Southern Africa Regional Office, Nairobi, Kenya, Wilunda1 Calistus ,   African Population and Health Research Center, P.O. Box 10787-00100, APHRC Campus, Kitisuru, Nairobi, Kenya, Mwaniki1 Elizabeth ,   African Population and Health Research Center, P.O. Box 10787-00100, APHRC Campus, Kitisuru, Nairobi, Kenya, Njiru4 James ,   Save the Children International, 3rd Floor ABC Place Waiyaki Way, Westlands Box 19423, 00202 KNH Nairobi, Kenya., Keane6 Emily ,   UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Schofield5 Lily ,   5Save the Children UK, St Vincent House 30 Orange Street London WC2H 7HH, United Kingdom, Maina6 Lucy ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Kutondo6 Edward ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Agutu6 Olivia ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Okoth6 Peter ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Raburu6 Judith ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Samburu6 Betty ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Alemu Zerfu1,7 Taddese ,   African Population and Health Research Center, P.O. Box 10787-00100, APHRC Campus, Kitisuru, Nairobi, Kenya; 7International Food Policy Research Institute, P.O. Box 5689, Addis Ababa, Ethiopia, Khamadi Wekhomba8 Jemimah ,   8Action Against Hunger-Kenya, Old Dagoretti Estate, House 26, Off Ngong Road 13-Amboleli Road P.O. Box: 39900-00623, Nairobi, Kenya, Charle Cuellar9 Pilar ,   9Action Against Hunger, 6 Mitre Passage, London SE10 0ER, United Kingdom, Matanda10 Charles ,   10Ministry of Health, P.O. Box 30016-00100, Nairobi, Kenya, Mutua10 Alex ,   10Ministry of Health, P.O. Box 30016-00100, Nairobi, Kenya, Gichohi10 Grace ,   10Ministry of Health, P.O. Box 30016-00100, Nairobi, Kenya, Chabi11 Martin ,   11World Health Organization, U-Block, Third floor, United Nations Office in Nairobi, Kenya, Codjia6 Patrick ,   6UNICEF Kenya Country Office, P.O. Box 44145-00100, Nairobi, Kenya, Guerrero Oteyza12 Saul ,   12UNICEF Headquarters, New York, USA., Kimani-Murage1 Elizabeth ,   African Population and Health Research Center, P.O. Box 10787-00100, APHRC Campus, Kitisuru, Nairobi, Kenya
Published: January 2025

Treating children with acute malnutrition can be challenging, particularly regarding access to healthcare
facilities during treatment. Task shifting, a strategy of transferring specific tasks to health workers with
shorter training and fewer qualifications, is being considered as an effective approach to enhancing health
outcomes in primary healthcare. This study aimed to assess the effectiveness of integrating the treatment
of acute malnutrition by community health volunteers (CHVs) into integrated community case management
(iCCM) in two sub-counties in northern Kenya (Loima and Isiolo). We conducted a two-arm non-inferiority
cluster-randomized controlled trial across 20 community health units. Participants were children aged 6-59
months with uncomplicated acute malnutrition. In the intervention group, CHVs used simplified tools and
protocols to identify and treat eligible children at home and provided the usual iCCM package. In the
control group, CHVs provided the usual iCCM package only (screening and referral of the malnourished
children to the health facilities). The primary outcome was recovery (MUAC ≥12.5 cm for two consecutive
weeks). Results show that children in the intervention group were more likely to recover than those in the
control group [73.3 vs. 50.3; risk difference (RD)=25.7% (95% CI 11.7 to 39.6) and risk ratio (RR)=1.53
(95% CI 1.18 to 1.97)]. The probability of defaulting was lower in the intervention group than in the control
group: RD=-20.8% (95% CI -31.3 to -10.2) and RR=0.29 (95% CI 0.17 to 0.49). The intervention reduced
the length of stay by about 13 days, although this was not statistically significant and varied substantially by
sub-county. Integrating the treatment of acute malnutrition by CHVs into the iCCM program led to better
malnutrition treatment outcomes. There is a need to integrate acute malnutrition treatment into iCCM and
review policies to allow CHVs to treat uncomplicated acute malnutrition.
Keywords: Task shifting, community health volunteers, non-inferiority cluster-randomized controlled trial,
child malnutrition