Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals

Exploring current barriers and enablers of severe acute malnutrition management among children (6-59 months): perspectives from health professionals in northern Ghana

INTRODUCTION

Malnutrition is a common global health problem that affects children under five years of age. This study aimed to explore current barriers and facilitators from the perspective of health personnel at Tamale Teaching Hospital and Kings Medical Centre in the clinical management of severe acute malnutrition (SAM) among children (6-59 months).

METHODS

This study used a qualitative research approach and employed a semi-structured interview guide, interviews (key informants), in-depth interviews, and focus group discussions. A total of 30 staff from both facilities, who were directly involved in SAM management, were purposively sampled. The research explored areas of SAM management, including workload, training, referrals, staff collaboration, therapeutic formula availability and vital infrastructure. Findings The findings revealed a lack of standardised training, emphasising the critical role of capacity development for effective case management. The absence of ready-to-use therapeutic food in both facilities, worsened by global economic crises, has led to reliance on locally formulated alternatives. Late referrals, high workloads and limited staff collaboration were highlighted as notable obstacles, impacting the overall quality of care. The enablers of SAM management included integration between nutrition and healthcare services, the availability of locally prepared therapeutic formulae, albeit limited, supportive infrastructure, and successful collaboration with hospital administration.

CONCLUSION

This study revealed critical obstacles and facilitators in the management of SAM among children (6-59 months). Recommendations are geared towards providing training protocols for health professionals, enhancing supply chain mechanisms to ensure the availability of therapeutic foods, and fostering a culture of collaboration within healthcare teams. Thus, when these challenges are addressed while at the same time leveraging existing enablers, health systems can significantly improve treatment outcomes of SAM cases. The findings will inform policy decisions by governmental bodies, health systems, and non-governmental organisations, guiding resource allocation, effective interventions, and overall improvement in care for malnourished children.

Barriers and facilitators of severe acute malnutrition management at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, North West Ethiopia, descriptive phenomenological study

BACKGROUND

Malnutrition is a clinical condition that affects all age groups, and it remains a major public health threat in Sub-Saharan Africa. As a result, this research aimed to investigate the barriers and facilitators of treating severe acute malnutrition at Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar City, North West Ethiopia.

METHODS

A descriptive phenomenological study was conducted from February to April 2021. The final sample size taken was fifteen based on data saturation. In-depth and key informant interviews were conducted with nine caregivers, three healthcare workers, and three healthcare managers supported by observation. A criterion-based, heterogeneous purposive sampling technique was used to select the study participants. Each interview was audio-taped to ensure data quality. Thematic analysis was done to analyze the data using Atlas. ti version 7 software.

RESULTS

Two major themes and six sub-themes emerged. Barriers related to severe acute malnutrition management include subthemes on socio-economic and socio-cultural conditions, perceived causes of severe acute malnutrition and its management, and the healthcare context. Facilitators of severe acute malnutrition management include severe acute malnutrition identification, service delivery, and being a member of community-based health insurance.

CONCLUSIONS

Effective management of severe acute malnutrition was affected by a multiplicity of factors. The results reaffirm how socioeconomic and sociocultural conditions, perceived causes of severe acute malnutrition (SAM) and its management and the health care context were the major barriers, while able to identifying severe acute malnutrition, service delivery, and is a member of community-based health insurance were the major facilitators for SAM management. Therefore, special attention shall be given to SAM management.

Factors influencing the implementation of severe acute malnutrition guidelines within the healthcare referral systems of rural subdistricts in North West Province, South Africa

Severe acute malnutrition (SAM) is associated with 30.9% of South Africa's audited under-five children deaths regardless of available guidelines to reduce SAM at each level of a three tyre referral system. Existing research has explored and offered solutions for SAM guidelines implementation at each referral system level, but their connectedness in continuation of care is under-explored. Therefore, I examined implementation of SAM guidelines and factors influencing implementation within subdistrict referral systems. An explanatory qualitative case study design was used. The study was conducted in two subdistricts involving two district hospitals; three community health centres, four clinics, and two emergency service stations. Between February to July 2016 and 2018, data were collected using 39 in-depth interviews with clinical, emergency service and administrative personnel; 40 reviews of records of children younger than five years; appraisals of nine facilities involved in referrals and observations. Thematic content analysis was used to analyse all data except records which were aggregated to elicit whether required SAM guidelines' steps were administered per case reviewed. Record reviews revealed SAM diagnosis discrepancies demonstrated by incomplete anthropometric assessments; non-compliance to SAM management guidelines was noted through skipping some critical steps including therapeutic feeding at clinic level. Record reviews further revealed variations of referral mechanisms across subdistricts, contradictory documentation within records, and restricted continuation of care. Interviews, observations and facility appraisals revealed that factors influencing these practices included inadequate clinical skills; inconsistent supervision and monitoring; unavailability of subdistrict specific referral policies and operational structures; and suboptimal national policies on therapeutic food. SAM diagnosis, management, and referrals within subdistrict health systems need to be strengthened to curb preventable child deaths. Implementation of SAM guidelines needs to be accompanied by job aids and supervision with standardised tools; subdistrict-specific referral policies and suboptimal national policies to ensure availability and accessibility of therapeutic foods.

Perceptions of healthcare providers and mothers on management and care of severely wasted children: a qualitative study in Karnataka, India

OBJECTIVES

To explore perceptions of healthcare providers and mothers of children with severe wasting on the perceived reasons for severe wasting, constraints on the management and barriers to caregiving and care-seeking practices.

DESIGN

In-depth qualitative interviews conducted with healthcare providers and mothers of children with severe wasting.

SETTING

Urban and rural locations in Karnataka state, India.

PARTICIPANTS

Healthcare providers (anganwadi workers, accredited social health activists, auxiliary nurse midwives, junior health assistant, medical officers, nutrition counsellors) from public healthcare centres and mothers of children with severe wasting.

RESULTS

Forty-seven participants (27 healthcare providers, 20 mothers) were interviewed. Poverty of households emerged as the underlying systemic factor across all themes that interfered with sustained uptake of any intervention to address severe wasting. Confusion of 'thinness' and shortness of stature as hereditary factors appeared to normalise the condition of wasting. Management of this severe condition emerged as an interdependent phenomenon starting at the home level coupled with sociocultural factors to community intervention services with its supplemental nutrition programme and clinical monitoring with therapeutic interventions through an institutional stay at specialist referral centres. A single-pronged malnutrition alleviation strategy fails due to the complexity of the ground-level problems, as made apparent through respondents' lived experiences. Social stigma, trust issues between caregivers and care-seekers and varying needs and priorities as well as overburdened frontline workers create challenges in communication and effectiveness of services resulting in perpetuation of severe wasting.

CONCLUSIONS

To ensure a continuum of care in children with severe wasting, economic and household constraints, coordinated policies across the multidimensional determinants of severe wasting need to be addressed. Context-specific interventions are necessary to bridge communication gaps between healthcare providers and caregivers.

Perceived quality of care for severe acute malnutrition management among caregivers of under-five children with severe acute malnutrition in Addis Ababa, Ethiopia, 2022: a mixed-method study

Introduction

All the factors at the institutional, provider, and client levels have an impact on the quality of care. In low- and middle-income countries, poor quality of severe acute malnutrition (SAM) management at health institutions is a major contributor to child morbidity and mortality. This study aimed to determine the perceived quality of care for SAM management among caregivers of under-five children.

Methods

This study was conducted in public health facilities that provide inpatient SAM management in Addis Ababa, Ethiopia. An institution-based convergent mixed-method study design was implemented. Quantitative data were analyzed by using a logistic regression model, while thematic analysis was used to analyze the qualitative data.

Results

A total of 181 caregivers and 15 healthcare providers were recruited. The overall perceived quality of care for SAM management was 55.80% (CI: 48.5-63.10). Urban residence (AOR = 0.32, 95% CI: 0.16-0.66), college and above level education (AOR = 4.42, 95% CI: 1.41-13.86), working as a government employee (AOR = 2.72, 95% CI: 1.05-7.05), readmitted to the hospital (AOR = 0.47, 95% CI: 0.23-0.94), and length of hospital stays >7 days (AOR = 2.1, 95% CI: 1.01-4.27) were found to be significantly associated factors with perceived low-quality care for SAM management. Additionally, lack of support and attention from higher levels of management, and lack of supplements, separate units, and laboratory facilities were among the factors that impede the provision of quality care.

Discussion

Perceived quality of SAM management services was low against the national goal of quality improvement to meet the expectations of both internal and external clients. Rural residents, those with more educational qualifications, government employees, newly admitted patients, and patients who stayed longer in hospitals were the most unsatisfied groups. Improving support and logistic supply to health facilities, providing client-centered care, and responding to caregivers' demands may help to improve quality and satisfaction.

Malnutrition in children under the age of 5 years in a primary health care setting

In this study, we outlined the types of malnutrition amongst children, the causes of malnutrition intervention at the primary health care level and some recommendations to alleviate childhood malnutrition in South Africa.

Predictors of in-hospital mortality among under-five children with severe acute malnutrition in South-Western Uganda

BACKGROUND

Severe acute malnutrition (SAM) affects about 13 million under-five children (U5), with an estimated one million dying every year. In this study we aimed at determining the in hospital mortality and its associated factors among U5s admitted with SAM.

METHODS

This was a prospective cohort study of children 6 months to 5 years with SAM admitted at Mbarara Regional Referral Hospital (MRRH) between June and August 2015. Care-takers were interviewed to collect socio-demographic and clinical information. Children under-went physical examination and had blood drawn for HIV, serum glucose, malaria, full blood count, culture and serum electrolytes investigation. Children were managed according to WHO treatment guidelines for SAM. All participants were followed up for a maximum period of 30 days. The proportion of U5 deaths within the first 48 hours and during the entire admission period was calculated. Using Poisson regression analysis, predictors of in-hospital mortality were analyzed with STATA/IC 11.0.

RESULTS

We enrolled 122 children, median age of 15 months [IQR:11-24], 58.2% males, 90% immunized, 81% ill for more than 2 weeks before admission, 71% from lower health facilities and majority with unknown HIV status(76%). Overall, 13 (10.7%) children died in hospital. Seven (5.7%) died within the first 48 hours. Intravenous (IV) fluid administration significantly predicted in-hospital mortality (adjusted IRR: 7.2, 95%CI: 2.14-24.08, p = 0.001).

CONCLUSION

The in-hospital mortality in U5s with SAM was lower than that previously reported in central Uganda. Intravenous fluid administration significantly predicted overall in-hospital mortality. While Administration of intravenous fluids is still the main stay of managing severely malnourished children with shock, more research needs to be conducted in order to review the parameters presently used to assess children for shock with a view of diagnosing and managing shock in these children when it is still early. Adequate guidance on use of IV fluids in management of severely malnourished children should be prioritized during continuous medical education for healthcare workers and in the treatment guidelines.

Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study

Background

In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa.

Methods

We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality.

Findings

We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9–19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4–3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4–5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9–4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2–2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1–5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1–21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6–3.3, p<0.001).

Interpretation

Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.