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Background: Treatment of acute malnutrition in infants under 6 months is a relevant topic regarding the global problem of maternal and child malnutrition. While treatment for older age groups has shifted more towards an outpatient, community based approach, young infants are mostly treated in hospital. This study aims to describe barriers and facilitators for outpatient and inpatient treatment of malnourished infants under 6 months in Senegal. Methods: This qualitative descriptive study uses in-depth interviews with health workers and focus group discussions with mothers of malnourished infants, conducted from June to September 2015 in two case clinics. In data analysis, Collins’ 3 key factors for a successful nutrition program were used as a theoretical framework: access, quality of care and community engagement. Results: Within Collins’ 3 key factors, 9 facilitators and barriers have emerged from the data. Key factor access: Outpatient care was perceived as more accessible than inpatient concerning distance and cost, given that there is a milk supplement available. Trust could be more easily generated in an outpatient setting. Key factor quality of care: The cup and spoon re-lactation technique was efficiently used in outpatient setting, but needed close supervision. Basic medical care could be offered to outpatients provided that referral of complicated cases was adequate. Health education was more intensive with inpatients, but could be done with outpatients. Key factor community engagement: The community appeared to play a key role in treating malnourished young infants because of its influence on health seeking behaviour, peer support and breastfeeding practices. Conclusions: Outpatient care does facilitate access, provided that an affordable milk supplement is available. Quality of care can be guaranteed using an appropriate re-lactation technique and a referral system for complications. The community has the potential to be much engaged, though more attention is required for breastfeeding education. In view of the magnitude of the health problem of young infant malnutrition and its strong relationship with breastfeeding practices, an outpatient community-based treatment approach needs to be considered.
This is a descriptive qualitative study with elements of the content analysis design [21]. Collins et al.’s 3 key issues of community-based management of SAM were used as a theoretical framework [22]. Collins and colleagues describe 3 essential factors contributing to the effectiveness of outpatient care in malnourished children. First, care must be accessible and affordable. Secondly, good quality medical care with simple sustainable protocols is necessary. Third, community engagement is needed to help people understand the health problem and accept the services provided [22]. These 3 factors, known for treatment of SAM in children older than 6 months, were used to gain insight about the age group under 6 months. Data were collected using semi-structured individual in-depth interviews (IDI) with health workers as well as focus group discussions (FGD) of mothers visiting nutrition programs, conducted in each clinic from June to September 2015. Both IDIs and FGDs were done for triangulation purposes. Ethical clearance was obtained from the national ethics committee of Senegal (Comité National d’Ethique pour la Recherche en Santé, code: SEN15/30) and at the Royal Tropical Institute in The Netherlands. This report follows QCORECQ reporting guidelines [21]. The study took place in two private, non-profit clinics in the capital of Senegal. Both clinics have a long history of treating malnourished children, including infants <6 months with SAM. Each have a large catchment area, serving a mainly urban population. One clinic, called St Martin, has an inpatient approach, and uses diluted F-100 as a milk supplement. The other, Keru Yakaar (House of Hope in the local language), treats infants in an outpatient setting using infant formula offered at a reduced price. Cup and spoon feeding is the refeeding technique in both clinics. Medical treatment, including a broad-spectrum antibiotic, is also administered along with some basic laboratory analyses. Teaching sessions and individual supervision of mothers of malnourished young infants are part of the rehabilitative approach. IDIs and FGDs were conducted by the first author, a female Dutch medical doctor who had worked at Keru Yakaar for 3 years. She interviewed the health workers, some of whom were her colleagues. The IDIs were conducted in French. She was not involved fulltime in the nutrition program, so she did not know all the women participating in the FGD. She knew the basics of the local language (Wolof), sufficiently to follow and moderate the conversation during FGD. To gain the maximum amount of information from the mothers, a Senegalese nurse involved in the nutrition program at Keru Yakaar served as a research assistant and translated all information and conversation into the local language during each FGD. A male Senegalese medical student was present at each IDI and FGD to audio record the data. He did not take part in the conversations. Similar open-ended interview questions were used for the IDIs and FGDs. They focused on the 3 key aspects of treatment of acute malnutrition among infants under 6 months of age (access, quality of care and community involvement). For example an IDI question about access: “What do you think will make care for mothers with an infant with AM accessible and what could be barriers?” Additional questions were added to further clarify the answer. The interview guide was pilot tested with one health worker and adapted accordingly. IDIs and FGDs were audio recorded using a phone and later transcribed by the medical student. For IDIs, all the health workers on staff in both clinics and involved in the two nutrition programs (nurses, nurse assistants, midwives, and doctors) were approached and invited to participate in the study (convenience sampling); 4 declined (Fig. (Fig.1).1). All participating health workers signed a consent form before the IDI was conducted. Participants were interviewed in French, at their work place, at a time agreed upon by the interviewer and the participant. Each IDI took about 20-30 minutes. Data saturation was recognized with 12 interviews. Health workers were not identified by profession or role in the results section in order to give each one an equal voice and status towards the reader. Sampling flow chart IDIs and FGDs Two FGDs were conducted with mothers at the inpatient clinic and two FGDs with mothers at the outpatient clinic. 48 mothers were recruited on site for a FGD after a regular teaching session that is part of the nutrition program. The health worker in charge on the day of the FGD identified mothers who had young infants (under 6 months) being treated for acute malnutrition or whose child had started treatment in that age group (purposive sampling), and asked them individually to participate (Fig. (Fig.1).1). The researchers aimed for a group size of 8 to 12 mothers. This group size was chosen because a larger group would have made discussion less dynamic and a smaller size may have limited the number of perspectives. Purpose and general information about the study were explained to the entire group. Those who agreed to take part signed a consent form and were directed by the research assistant to the court yard of the clinic, to start the FGD. Demographic data of the participants was not obtained. This added a level of confidentiality particularly because of the small sample size. The FGDs were conducted in French, with simultaneous translation into Wolof by the research assistant. Each FGD took about 30 minutes to complete. Questions were similar to the ones in IDIs but put in a story. For example: “Your cousin has a baby that is not growing well, he is very small. What would you recommend her to do? Where to go? Why?”. Mothers were also invited to tell their own stories on the topic until no new aspects were mentioned (saturation). IDI and FGD transcriptions were analysed by giving codes to quotes. To code a deductive coding was first performed manually, using only the 3 key factors: access, quality of care and community engagement. Then, each quote was given a sub-code, that emerged from the transcripts. For coding Microsoft Word was used. Coded quotes were copied into an excel sheet, organising them in groups of similar codes. This was an iterative process and some codes could be grouped and merged. For example quality of care- illness and quality of care- protocols merged into quality of care- medical care. Quoted phrases were translated into English.
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