The Impact of Community Health Workers on Child Malnutrition in the Philippines - A Cluster Randomized Controlled Trial

This study will focus on a new community health worker (CHW) program called 'Flourish', which is implemented by Philippine NGO International Care Ministries (ICM). ICM's core program is 'Transform', which is a 15-week poverty alleviation program that focuses on households living in ultra-poverty (less than 0.50 United States dollars (USD) per person per day). ICM runs 'Transform' in approximately 1,000 communities every year. Transform leverages local community networks to identify 30 participants from the most marginalized households in the community. ICM then provides these participants with 15 weeks of health and livelihood education, as well as with health interventions, including childhood malnutrition treatment. During the program, participants are given the opportunity to form a community savings group with the support of ICM. On average, twenty participants per community join these savings groups.

Participants receive a continuation of services from ICM after the Transform program ends. ICM promotes continued economic benefits by supporting the newly formed savings group. ICM also promotes continued health benefits through the 'Flourish' program. In the Flourish program, the savings group elects one person from their membership to serve as a community health worker. This community health worker is trained to screen for illness, provide health counseling, link to primary care, and deliver health commodities to: 1) the savings group's households and 2) the wider community. ICM equips each community health worker with a mobile phone and health commodities. The mobile phone assists the community health worker with screening and follow-up procedures and is also used to collect data on the household members.

A cluster randomized controlled trial will be run to assess the impact of the Flourish program on reducing malnutrition in children between 6 months and 12 years of age. A total of 170 communities will be randomized into two even groups: one arm will receive both the Transform and Flourish programs (Treatment) and one arm will receive the Transform program only (Control).

The maximum number of clusters that ICM can support during the study period is 170, therefore sample size calculations were focused on detectable effect size based on the number of children enrolled per cluster. With significance at 5% and power at 80%, given a background malnutrition rate of 8.5% (based on rates observed in similar settings by ICM) the investigators estimate the ability to detect a reduction of 3% points (35% decrease in malnutrition/ achieving 65% cure rate) if 40 children are enrolled per cluster. To account for potential attrition of ~10%, the study will target 45 children per cluster, which will be a cumulative target of 7,650 (45 x 170) for the whole study. The R package "clusterPower" was used for calculations.

In both arms, each member of the savings group will be asked to nominate up to three households to potentially be approached by ICM community health workers. The nominators will be asked to identify households that are of similar economic status and will be given criteria to help their assessment. Additionally, the households should have at least one child between the ages of 6 months and 12 years who has not previously received an ICM intervention. An ICM staff member will also approach the closest local primary health unit (Barangay Health Station or Rural Health Unit) and request nominations of any households with currently malnourished children.