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Integrated community-based management of severe acute child malnutrition: Studies from rural Southern Ethiopia
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The World Health Organization (WHO) recommends the community-based Outpatient Therapeutic Program (OTP) as a standard treatment protocol for the management of uncomplicated Severe Acute Malnutrition (SAM) at the community level. OTP has been scaled up and integrated into the existing grassroots level government health systems in several developing countries. The aim of this thesis was to assess the implementation and outcome of a scaled-up and integrated OTP service provided at community level.

Methods: One qualitative study and three quantitative studies were conducted in southern Ethiopia. Children admitted to 94 integrated OTPs, their caregivers and health extension workers providing primary health care services in the nearby health posts were included in this study. The quantitative studies were based on data generated from observation of a cohort of 1,048 children admitted to the integrated OTPs.

Result: On admission 78.8% of the children had SAM. The majority of these children 60.2% exited the program neither achieving program recovery criteria nor being transferred to inpatient care. Fourteen weeks after admission to OTP, 34.6% were severely malnourished and 34.4% were moderately malnourished, thus 69.0% were still acutely malnourished. Ready-to-use Therapeutic Foods (RUTFs) provided for SAM children were commonly shared with other children in the household and sold as a commodity for the collective benefit of the family thus admitted children received only a portion of the provided amount. Further, the program suffered a severe shortage of RUTFs, where only  46.6% of admitted children were given the recommended amount of RUTFs by providers on admission and only 34.9% of these had uninterrupted provision during the follow-up.

Conclusion: The integrated OTPs we studied provide a constrained service and the use of RUTFs by families is not as intended by the program. The majority of admitted children remained acutely malnourished after participating in the program for the recommended duration. For integrated OTPs to be effective in chronically food-insecure contexts, interventions that also address the economic and food needs of the entire household are essential. This may require a shift to view SAM as a symptom of broader problems affecting a family rather than as a disease of an individual child. In addition, further research is needed to understand the health system context regarding RUTFs and medication supply and service utilization of integrated OTPs.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. , 62 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1232
Keyword [en]
Severe acute malnutrition, integrated outpatient therapeutic programme, programme outcome, recovery, Ethiopia
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-292781ISBN: 978-91-554-9601-2 (print)OAI: oai:DiVA.org:uu-292781DiVA: diva2:926637
Public defence
2016-08-26, Betty Petterssonsalen, Blåsenhus, von Kraemers allé 1, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2016-06-02 Created: 2016-05-09 Last updated: 2016-06-22
List of papers
1. Perceptions of usage and unintended consequences of provision of ready-to-use therapeutic food for management of severe acute child malnutrition: A qualitative study in Southern Ethiopia
Open this publication in new window or tab >>Perceptions of usage and unintended consequences of provision of ready-to-use therapeutic food for management of severe acute child malnutrition: A qualitative study in Southern Ethiopia
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2015 (English)In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 30, no 10, 1334-1341 p.Article in journal (Refereed) Published
Abstract [en]

Background:

Severe acute child malnutrition (SAM) is associated with high risk of mortality. To increase programme effectiveness in management of SAM, community-based management of acute malnutrition (CMAM) programme that treats SAM using ready-to-use-therapeutic foods (RUTF) has been scaled-up and integrated into existing government health systems. The study aimed to examine caregivers’ and health workers perceptions of usages of RUTF in a chronically food insecure area in South Ethiopia.

Methods:

This qualitative study recorded, transcribed and translated focus group discussions and individual interviews with caregivers of SAM children and community health workers (CHWs). Data were complemented with field notes before qualitative content analysis was applied.

Results:

RUTF was perceived and used as an effective treatment of SAM; however, caregivers also see it as food to be shared and when necessary a commodity to be sold for collective benefits for the household. Caregivers expected prolonged provision of RUTF to contribute to household resources, while the programme guidelines prescribed RUTF as a short-term treatment to an acute condition in a child. To get prolonged access to RUTF caregivers altered the identities of SAM children and sought multiple admissions to CMAM programme at different health posts that lead to various control measures by the CHWs.

Conclusion:

Even though health workers provide RUTF as a treatment for SAM children, their caregivers use it also for meeting broader food and economic needs of the household endangering the effectiveness of CMAM programme. In chronically food insecure contexts, interventions that also address economic and food needs of entire household are essential to ensure successful treatment of SAM children. This may need a shift to view SAM as a symptom of broader problems affecting a family rather than a disease in an individual child.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-246617 (URN)10.1093/heapol/czv003 (DOI)000366493200010 ()
Available from: 2015-03-09 Created: 2015-03-09 Last updated: 2017-05-11Bibliographically approved
2. Predicted implications of using percentage weight gain as single discharge criterion in management of acute malnutrition in rural southern Ethiopia
Open this publication in new window or tab >>Predicted implications of using percentage weight gain as single discharge criterion in management of acute malnutrition in rural southern Ethiopia
2015 (English)In: Maternal and Child Nutrition, ISSN 1740-8695, E-ISSN 1740-8709, Vol. 11, no 4, 962-972 p.Article in journal (Refereed) Published
Abstract [en]

Mid-upper arm circumference (MUAC) is increasingly used in identifying and admitting children with acute malnutrition for treatment. It is easy to use because it does not involve height assessment, but its use calls for alternative discharge criteria. This study examined how use of percentage weight gain as discharge criterion would affect the nutritional status of children admitted into a community-based management programme for acute malnutrition in rural southern Ethiopia. Non-oedematous children (n = 631) aged 6-59 months and having a MUAC of <125 mm were studied. By simulation, 10%, 15% and 20% weight was added to admission weight and their nutritional status by weight-for-height z-score (WHZ) was determined at each target. Moderate and severe wasting according to World Health Organization WHZ definitions was used as outcome. Applying the most commonly recommended target of 15% weight gain resulted in 9% of children with admission MUAC <115 mm still being moderately or severely wasted at theoretical discharge. In children with admission MUAC 115-124 mm, 10% of weight gain was sufficient to generate a similar result. Children failing to recover were the ones with the poorest nutritional status at admission. Increasing the percentage weight gain targets in the two groups to 20% and 15%, respectively, would largely resolve wasting but likely lead to increased programme costs by keeping already recovered children in the programme. Further research is needed on appropriate discharge procedures in programmes using MUAC for screening and admission.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-208312 (URN)10.1111/mcn.12076 (DOI)000362197100042 ()23941395 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency, SWE-2010-179
Available from: 2013-09-27 Created: 2013-09-27 Last updated: 2017-12-06Bibliographically approved
3. Community based outpatient therapeutic programme for severe acute malnutrition in rural southern Ethiopia; Recovery, fatality and nutritional status after discharge
Open this publication in new window or tab >>Community based outpatient therapeutic programme for severe acute malnutrition in rural southern Ethiopia; Recovery, fatality and nutritional status after discharge
(English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203Article in journal, News item (Refereed) Submitted
Abstract [en]

Background: A scaled up and integrated outpatient therapeutic program (OTP) brings the treatment of severely malnourished children closer to the community. However, studies documenting program outcome and nutritional status beyond discharge from OTP are scarce. This study evaluated recovery from severe acute malnutrition (SAM), fatality and nutritional status up to 14 weeks after admission to the programme.

Methods: In this cohort study, 1048 children admitted to 94 OTPs in southern Ethiopia were followed for 14 weeks. Independent anthropometric measurements and information on treatment outcome were collected at four home visits.

Results: On admission 78.8% (826/1048) of the children had severe acute malnutrition. The mean length of admission to the programme was 7.1 weeks [95% CI 6.9 -7.3]. Only 37.8% (216/571) of children with SAM on admission fulfilled the programme recovery criteria (gained 15% in weight or oedema resolved, if present on admission) at discharge. However, of the children who achieved programme recovery criteria at discharge, 57.6% (121/210) were still acutely malnourished. Of all children admitted to the programme for whom nutritional assessment was done 14 weeks later, 34.6% (321/928) were severely and 34.4% (348/928) were moderately malnourished, thus 69.0% were acutely malnourished. A total of 27/982 (2.7%) of the children had died by 14 weeks, of whom all but one had SAM on admission. Children with severe oedema on admission had the highest fatality rate (12.0%, 9/75).

Conclusion: Despite children participating for the recommended duration of the programme, many were discharged without reaching programme criteria for recovery and acute malnutrition remained prevalent beyond discharge. Further research is needed to understand the factors constraining community management of acute malnutrition. 

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-291455 (URN)
Available from: 2016-05-02 Created: 2016-05-02 Last updated: 2017-11-30Bibliographically approved
4. Challenges in Implementing the Integrated Community-Based Outpatient Therapeutic Program for Severely Malnourished Children in Rural Southern Ethiopia
Open this publication in new window or tab >>Challenges in Implementing the Integrated Community-Based Outpatient Therapeutic Program for Severely Malnourished Children in Rural Southern Ethiopia
2016 (English)In: Nutrients, ISSN 2072-6643, E-ISSN 2072-6643, Vol. 8, no 5, 251Article in journal (Refereed) Published
Abstract [en]

Currently, treatment of uncomplicated severe acute malnutrition is managed inthe integrated Community based Outpatient Therapeutic Program (C-OTP) using ready-to-usetherapeutic foods (RUTFs). The aim of this study was to determine challenges in implementingthe critical steps in C-OTP and caregivers’ perceptions of service provision in southern Ethiopia.A total of 1048 caregivers of children admitted to the OTP and 175 Health Extension Workers (HEWs)from 94 selected health posts were included in the study. Program admission, follow-up and exitinformation was collected from caregivers during home visits. HEWs were interviewed at theirrespective health posts. Only 46.6% (481/1032) were given the recommended amount of RUTF and19.3% (196/1015) were given antibiotics on admission. During C-OTP participation 34.9% (316/905)had uninterrupted provision of the recommended amount of RUTF. Of the children who left theprogram, 220/554 (39.7%) exited the program in line with the national recommendation. Caregivers(42.9% (394/918) and HEWs (37.1%, 62/167) perceive that RUTFs were being sold as a commodity.Inadequate provision and unintended usage of RUTFs, lack of antibiotics and inappropriate exitfrom the program were major constraints. For successful saving of lives, adequate resources must beallocated, and providers must be trained regularly, and supervised properly.

Keyword
severe acute malnutrition; ready to use therapeutic foods; outpatient therapeutic program; integrated; Ethiopia
National Category
Medical and Health Sciences Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-291458 (URN)10.3390/nu8050251 (DOI)000378780900012 ()
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2016-05-02 Created: 2016-05-02 Last updated: 2017-11-30Bibliographically approved

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