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Ready-to-use Therapeutic Food (RUTF) therapy is a standard protocol for treating children with severe acute malnutrition (SAM) admitted in Out-Patient Therapeutic Programmes (OTP). The amount of RUTF to be consumed by a child is based on weight (200 kcal/kg body weight/day) as stipulated in the Kenya Integrated Management of Acute Malnutrition (IMAM) protocol for timely weight gain. There is limited information on the determinants of consumption of the correct amount of RUTF. This study sought to fill this gap by establishing the associations between the caregivers’ and the child’s characteristics and the amount of RUTF the child ate within a 24-h recall period. We used a cross-sectional study design and interviewed 200 caregivers of children 6–23 months of age admitted in four OTP centers in Nairobi Kenya. We used a researcher-administered questionnaire to collect information from the caregivers. Seventy-three percent of the children ate the recommended amount of RUTF. A smaller proportion (54.4%) of younger children (6–11 months of age) ate the recommended amount of RUTF compared to older children (12–17 months old and 18–23 months old at 89.1% and 82.8%, respectively). The predictors of consumption of the correct amount of RUTF were child’s birth order—firstborn (AOR 29.92; 95% CI: 5.67–157.93) and children’s age; 12–17 months old (AOR 5.19; 95% CI: 2.18–12.36) and 18–23 months (AOR 6.19 95% CI: 2.62), indicating that firstborn and older children were more likely to consume the correct amounts of RUTF. Caregivers’ knowledge and correct practices in feeding a child with RUTF also predicted the consumption of the correct amount of RUTF. In conclusion, maternal and child characteristics are determinants of the consumption of the correct amount of RUTF by children in OTP.
We used a cross‐sectional analytical design with quantitative approaches to data collection, analysis, and presentation. This design enabled the studying of multiple outcome and exposure variables in a representative sample, at one point in time (Sedgwick, 2014). The dependent variable was adequate intake of RUTF. The independent variables were caregivers’ socioeconomic characteristics, such as occupation and education level and demographic characteristics, such as caregiver’s marital status, age, and parity, demographic characteristics of the child (age, sex, and birth order), and caregivers’ knowledge and practices for feeding a child with SAM. The study was conducted in four Out‐Patient Therapeutic Programme sites in Kamukunji Sub‐County, Nairobi City County: Bahati, Majengo, Eastleigh, and Biafra health centers. Each of these centers had nutritionists, nurses, and other cadres of health workers. The health facilities had operational OTP centers, integrated with the child welfare clinics within the same facility. Nutrition services offered in the OTP are integrated within the mother and child health program with strong linkage with the outpatient pediatric treatment unit, in keeping with the Kenya Integrated Management of Acute Malnutrition (IMAM) guidelines (Ministry of Medical Services & Ministry of Public Health and Sanitation, 2009; Wambani, 2012). The selected health facilities where this study was conducted are all public health facilities that get technical support from Concern Worldwide, an International Non‐Governmental Organization working in partnership with the Ministry of Health. The NGO provided support in the form of capacity building, commodity supply for the RUTF, whereas the government provided support in the form of supply of essential drugs and support supervision. The support provided by the government and the NGO ensures that the capacity of OTP staff and the community health volunteers are built and that essential nutrition commodities and treatment drugs are consistently available to provide effective and timely service delivery in the management of children with severe acute malnutrition. The caregivers do not pay for this service. In this study, we targeted caregivers with children aged 6–23 months admitted into the OTP centers in Kamukunji sub‐county, for the treatment of severe acute malnutrition. The four study locations have one thing in common, in that the majority of beneficiaries to which they provide essential health services are communities residing in Nairobi’s informal settlements. These include: Kiambiu, Biafra, City Carton, Bahati, and Pumwani‐Majengo informal settlements. Lack of access to safe, adequate and running water, inadequate sanitation facilities, inconsistent electricity supply, use of unsafe cooking fuel (paraffin, charcoal, and firewood), insufficient education support, access challenges to appropriate health and nutrition services, lack of enough space for shelter, and insufficient finances are the most common challenges in these settlements (Kimani‐Murage et al., 2011; Otieno, 2014). Most of the caregivers are involved in casual labor, petty trading, small‐scale manufacturing (Jua Kali), and illicit activities, for example, brewing unhygienic liquor. About half (51%) of residents in these informal settlements live in overcrowded conditions (Otieno, 2014). There is a widespread inappropriate infant and young child feeding (IYCF) and high rates of food security in the informal settlements (Ireri et al., 2020; Kimani‐Murage et al., 2011; Macharia et al., 2018; Simiyu et al., 2019), thus children are more likely to be exposed to suboptimal breastfeeding and complementary feeding practices which are major determinants of acute malnutrition. We purposively sampled the four OTP centers (Biafra, Majengo, Eastleigh, and Bahati) because it was necessary to target specifically the caregivers with children admitted to OTP with severe acute malnutrition, and it is these centers that have OTP services. We also considered homogeneity in living conditions (urban informal settlements) for the purposive sampling as all the four health facilities are situated in a strategic location where they serve the majority of families residing in the urban informal settlements. We recruited all the 200 caregivers and their children 6–23 months of age in the four OTP centers who were enrolled into the program at the time of the study and who met the inclusion criteria, upon obtaining their voluntary, informed consent (Martinez‐Mesa et al., 2016). Caregivers with children 6–23 months of age admitted to outpatient therapeutic program in the four specified health facilities in Kamukunji Sub‐county, presenting with severe acute malnutrition (SAM) without complications, having passed the appetite test. Children with edema grade 1 (+) without any medical complications were included in the study. In all cases, voluntary informed consent was obtained from the caregiver. We had planned that should any child sampled for the study develop medical complications (heart disease, Spina Bifida, vomiting, and presence of grade 2 or grade 3 nutritional edema [++, +++]) during the time of the study and be referred to the stabilization/inpatient center before the caregiver was interviewed, the same would be excluded from the sample. However, there were no such cases and therefore we retained the 200 sample of caregivers and their children aged 6–23 months old. Data collection was conducted by three research assistants with a Diploma level of qualification in Nutrition under the supervision of the researchers. The research assistants were trained by the researchers before data collection. The caregivers were interviewed face to face, using a researcher‐administered questionnaire. The questionnaire was content‐validated and pre‐tested with about 10 mothers who were not included in the main study. During this pre‐test, the test–retest method was used to ensure reliability, by conducting two interviews 7 days apart (Batterham, 2011; Kothari & Garg, 2014). The questionnaire yielded a correlation coefficient of 0.7 using the Cronbach’s Correlation formula, which is acceptable (Kothari & Garg, 2014). Some adjustments were made to the questionnaire after pre‐test. The questionnaire had questions on caregiver’s knowledge and practices, such as breastfeeding and the amount of RUTF the child ate in the last 24 h, giving water to the child to drink, safe storage of RUTF, washing hands before feeding the child, and not giving any other complementary food when the child was on RUTF therapy. The interviews were conducted at the OTPs on the days the caregivers and their children had scheduled weekly clinic appointments at the health facilities. The questions assessing the feeding practices among the caregivers were based on the Kenya Ministry of Health Integrated Management of Acute Malnutrition (IMAM) protocols (Ministry of Medical Services & Ministry of Public Health and Sanitation, 2009) for feeding a child with severe acute malnutrition, which are based on the WHO guidelines. These guidelines stipulate that children admitted to OTP should be on RUTF therapy and are only permitted to breastfeed, according to IMAM protocols (Ministry of Medical Services & Ministry of Public Health and Sanitation, 2009). Adequate intake of RUTF for children with SAM was determined by calculating the proportion of children 6–23 months of age, who consumed 200 kcal of RUTF per kilogram of body weight the day before the survey. The assessment considered the content of the RUTF given to the children with SAM as an exclusive meal because it contains all the required energy and micronutrients to meet the nutritional needs of children with severe acute malnutrition. Each sachet of RUTF supplies 500 kcal (Ministry of Medical Services & Ministry of Public Health and Sanitation, 2009); hence, the daily rations based on the weight of the child are further calculated in terms of the number of sachets, for the sake of easy understanding and administration by the caregiver. Adequate dietary intake, therefore, refers to the consumption of an adequate amount of RUTF by the child with SAM, according to IMAM protocol. During the interview, the weight of the child was taken from what was recorded in the OTP ration card during the last appointment and recorded by the researcher, and the mother was asked to state the amount of RUTF (in form of sachets) the child ate on the day prior to the survey. The information on the weight and the number of RUFT sachets consumed was recorded in the researcher‐administered questionnaire, and from this an appropriate response was recorded as to whether the child consumed adequate amount of RUTF or not. Data analysis was conducted using the SPSS software (version 22). Descriptive statistics (frequencies, means, medians, standard deviations, and percentages) were used to describe the caregivers and child demographic characteristics and maternal knowledge and practices on feeding a child with SAM. The Caregivers’ knowledge on feeding a child with SAM was based on eight knowledge items out of which the mean knowledge score was calculated. One point was awarded for each correct answers resulting in a total score of 8, whereas zero was awarded for incorrect answers, and thus the least score was zero. Chi‐square test was used to establish associations between categorical variables. Multiple logistic regression was performed to establish the determinants of consumption of the correct amount of RUTF in the last 24 h among the children with SAM. A p‐value of <.05 was used as a criterion for statistical significance.
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