Performance of low-literate community health workers treating severe acute malnutrition in South Sudan.

Previous studies have described barriers to access of childhood severe acute malnutrition (SAM) treatment, including long travel distances and high opportunity costs. To increase access in remote communities, the International Rescue Committee developed a simplified SAM treatment protocol and low-literacy-adapted tools for community-based distributors (CBD, the community health worker cadre in South Sudan) to deliver treatment in the community. A mixed-methods pilot study was conducted to assess whether low-literate CBDs can adhere to a simplified SAM treatment protocol and to examine the community acceptability of CBDs providing treatment. Fifty-seven CBDs were randomly selected to receive training. CBD performance was assessed immediately after training, and 44 CBDs whose performance score met a predetermined standard were deployed to test the delivery of SAM treatment in their communities. CBDs were observed and scored on their performance on a biweekly basis through the study. Immediately after training, 91% of the CBDs passed the predetermined 80% performance score cut-off, and 49% of the CBDs had perfect scores. During the study, 141 case management observations by supervisory staff were conducted, resulting in a mean score of 89.9% (95% CI: 86.4%-96.0%). For each performance supervision completed, the final performance score of the CBD rose by 2.0% (95% CI: 0.3%-3.7%), but no other CBD characteristic was associated with the final performance score. This study shows that low-literate CBDs in South Sudan were able to follow a simplified treatment protocol for uncomplicated SAM with high accuracy using low-literacy-adapted tools, showing promise for increasing access to acute malnutrition treatment in remote communities.