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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.
This study was conducted in a zone in Southern Ethiopia, which is densely populated and known for fragmentation of farm land ownership and limited income generating opportunities (Teklu 2003; Hailu and Regassa 2007). The zone has been facing recurrent droughts that resulted in crop failures and subsequent nutritional emergencies. Further, even in seasons of optimal food availability a significant number of households are food insecure and dependent on food aid for their subsistence (SNNPR 2000; Hailu and Regassa 2007). CMAM programmes were implemented by externally funded non-governmental organizations (NGOs) (Deconinck et al. 2008; ENN and FANTA 2008) intially 2000–04. In 2004, the CMAM programme were scaled up and integrated into the existing government health care system (Chamois 2009). The scaling up and integration took place in partnership with NGOs for RUTF supply and technical assistance (Deconinck et al. 2008; Chamois 2009). After development of a simplified SAM management protocol cadres of CHWs were trained in its application. Currently, treatment for uncomplicated SAM cases should be available at all health posts (lowest level of primary health care system) in the zone. The most commonly used brand of RUTF in the area is ‘Plumpy nut’. Two types of CHWs are engaged in the programme; health extension workers (HEWs) screen, manage and follow-up SAM cases aided by Community Volunteers (CVols) (Wakabi 2008). HEWs are women, who have been trained for 10 months through the national Health Extension Programme, and provide basic curative and preventive health services to rural communities for which they are given a salary (Egger and Swinburn 1997; Wakabi 2008; Wilder 2008). The CVols are members of the communities and they are selected based on willingness to assist HEWs after getting basic training. In this article, we will use the concept of CHW when referring to the HEWs and CVols collectively. This qualitative study was an initial part of a larger research project that aims to assess the effectiveness of CMAM programme focusing on role of household food security, maternal caring capacity and health systems characteristics. The conceptual framework of this study was Bronfenbrenner’s socio-ecological model that conceptualizes the relation between the diverse environments surrounding children, including the physical, mental and social context to health and health interventions (Bronfenbrenner and Ceci 1994). The concepts and components of the model formed basis for development of guidelines and data collection. The topic areas in the guideline were causes of malnutrition, care of SAM children, use of RUTF and challenges in the implementation CMAM programme. Caregivers of SAM children as well as CHWs were purposively recruited to get varying perspectives on the topic of the study. The selection criteria for caregivers were caring for one or more children, who were treated in the CMAM programme for at least 1 month, and for CHWs it was to have at least 1 year of experience in the CMAM programme. All those invited (n = 112) agreed to participate (Table 1). Profile of participants (n = 112) Methods for data collection were focus group discussions (FGDs) with caregivers and CVols as well as individual interviews with HEWs. FGDs and individual interviews took place from June to July 2010. FGD were chosen for their documented ability to grasp perceptions in a credible way (Dahlgren et al. 2007). A total of 15 FGDs were conducted; 7 with caregivers and 8 with CVols. Each group consisted of 6–8 participants and the duration of the discussion varied from 24 to 66 min with an average of 43 min. The shorter discussions were held with smaller groups. The interviewer made sure all participants were given the opportunity to share their perceptions. HEWs (n = 9) were interviewed, because it was logistically difficult for them to gather in groups for data collection. The duration of the interview varied from 25 to 76 min with the average duration of 40 min. Additional field notes were taken during the subsequent quantitative survey from August to December 2011 based on observations during visits to health posts, markets and shops as well as informal discussions with stakeholders at the community level and district health office staff. Qualitative data were collected using a pretested guideline whereby the broad topic areas were introduced by the interviewer, discussed among the participants with a minimum of input from the interviewer to allow the perceptions and priorities of the participants to come forward. Further probing was done when more information was deemed possible to elicit, resulting in detailed accounts of the perceptions. FGDs and interviews were conducted in privacy at the local health posts and audio-recorded with permission from the participants. The data collection were conducted in the local language by the first author who is an Ethiopian Ph.D. student with experience as a nurse and a nutrition officer. In the FGDs a research assistant, who also is a native and speaking the local language, took notes on the overall flow of the data collection, non-verbal communication and when necessary asked participants to clarify some responses. All recordings of FGDs, interviews and field notes were transcribed in the local language and translated into English to enable other co-researchers to partake in the analysis. Qualitative content analysis was used to identify both the manifest and latent content of the text (Graneheim and Lundman 2004). It was initiated with repeated readings of the transcripts to gain a global understanding of the content. This was followed by an inductive analysis where meaning units, i.e. statements that indicate perceptions related to the aim of the study were identified and summarized to shorter condensed meaning units. The condensed meaning units were shortened into codes, and sub-categories and categories were developed based on similarities and differences in content. Differences and similarities of perceptions of participants were identified. Representative quotes were taken from the text and agreement between co-authors was sought to ensure trustworthiness of the findings. An example of the process of analysis is found in Table 2. The first author conducted the analysis and the co-authors read the transcripts and all authors discussed alternative interpretations until consensus was reached. Examples from the process of analysis of excerpts of transcripts from FGD CG-FGD, FGD with caregivers; CVol-FGD, FGD with community volunteers
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