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Background: In Ethiopia uncomplicated severe acute malnutrition (SAM) is managed at health posts level through the outpatient therapeutic program (OTP). Yet, evidence on the treatment success rate of the program is scarce. This study determines the treatment outcomes and predictors of time-to-recovery among children 6-59 months of age with SAM managed at the health posts level in Shebedino district, Southern Ethiopia. Methods: This was a prospective cohort study that enrolled 216 children with SAM identified through a campaign conducted in May 2015 and treated over eight weeks at 25 health posts of the district. The average time-to-recovery was estimated using Kaplan-Meier survival curve and the independent predictors of the recovery were determined using multivariable Cox-proportional hazard model. The outputs of the analyses are presented via adjusted hazard ratio with 95% confidence intervals (AHR, CI). Results: At the end of the eight weeks of treatment 79.6% (95% CI: 74.2-85.0%) of cases recovered from SAM with a weight gain rate of 5.4 g/kg/day. The median time-to-recover was 36 days. The analysis indicated, maternal illiteracy (0.54, 0.38-0.78), severe household food insecurity (0.47, 0.28-0.79), walking for more than 1 h to receive the treatment (0.69, 0.50-0.96), diarrhoea co-morbidity (0.63, 0.42-0.91) and practicing sharing of ready to use therapeutic food (RUTF) (0.53, 0.32-0.88) were associated with slower propensity of recovery from SAM. Children who were enrolled with marasmus diagnosis showed lower recovery than children with kwashiorkor (0.30, 0.18-0.51). Conclusion: The median time-to-recover was 36 days. Discouraging sharing of RUTF, appropriate management of diarrhoea in SAM cases and improving access to OTP sites can help to improve the treatment outcome for SAM.
The study was conducted from June to August 2015 in Shebedino district of Sidama zone, Southern Ethiopia. The district is located in the Great Rift Valley area, about 300 kms South of Addis Ababa, the capital of Ethiopia. Shebedino is administratively subdivided into 35 kebeles (32 rural and 3 urban). A kebele is the smallest administrative unit in Ethiopia comprising approximately 1000 households. In 2015, Shebedino had an estimated population of 294,214; of these 14% were infants and children 6–59 months of age. Shebedino is affected by recurrent and chronic food insecurity. In the district, the average farmland ownership by a household is around 0.5 ha. Crop cultivation and livestock rearing are the major livelihood activities in the rural areas. Maize and Enset (false banana) are the major staple foods. The district has one primary hospital, nine health centers and thirty two health posts, making the potential health service coverage 98%. According to the health care system of Ethiopia, every kebele is expected to have a health post whereby at least two health extension workers (HEWs) are deployed to provide a package of preventive and essential curative services including the management of uncomplicated SAM in children. HEWs identify SAM cases from their catchment area through multiple modalities including periodical growth monitoring and promotion, enhanced outreach strategy (EOS)/community health day (CHD) campaigns, and static service provided at the health post. A prospective cohort study was conducted among children aged 6–59 months with uncomplicated SAM enrolled at the OTP sites of the district following a CHD campaign conducted in late May 2015. The cases were followed for the maximum eight weeks through weekly visits starting from June 01, 2015. However, children who recovered earlier were only followed until recovery. Screening of the children and administration of the treatment were made by the frontline health workers according to the national protocol without any direct involvement of the research team. All children 6–59 months of age who were newly diagnosed with uncomplicated SAM during the CHD campaign and got enrolled in the OTP program were eligible for the study. According to the national protocol, uncomplicated SAM cases are diagnosed as children with good appetite and no major medical complication having MUAC of less than 110 mm and/or first or second degree bilateral pitting oedema [4]. According to the national protocol patients fulfilling the admission criteria are enrolled and given a weekly Plumpy’Nut ration – trade name of a peanut-based ready-to-use therapeutic food (RUTF). Each week, their weight is taken until they achieve a target weight stated in the protocol. On each visit the children are expected to receive a medical assessment and caregivers should be given nutrition education [4]. As the study employed an observational design, the research team was not involved in any aspect of the treatment of the children. An optimal sample size of 219 children with SAM was determined using Stata 11.0 program based on formula designed for survival analysis. The inputs for the computation were: 95% confidence level, 80% power, 1.5 adjusted hazard ratio to be detected as significant (equivalence of medium effect size) for time-to-recovery outcome variable and 15% compensation for possible non-response. Further, based on the sample size calculation formula for estimating a population average, the sample size (n = 219) was considered adequate for determining the median time-to-recovery. From the total 32 rural health posts found in the district, 25 were selected purposively based on the availability of new SAM cases recruited for OTP during the CHD screening. The total sample size 219 was distributed to health posts proportionally to their newly recruited SAM cases and ultimately the study subjects were selected using quota sampling technique (Fig. 1). Flowchart of the study At the end of the CHD camping 219 malnourished children were recruited for the study. Nevertheless, at the first follow-up 3 children were excluded as they were receiving the treatment from health posts found outside Shebedino district. The remaining 216 children were followed for a maximum duration of eight weeks and hence included in the analysis. Data were gathered by eleven trained enumerators and supervisors using a structured and pretested questionnaire. Baseline data were collected at enrolment and follow-up measurements were made on weekly bases for a maximum of eight weeks. Socio-demographic and economic variables were gathered at baseline using standard questions extracted from the DHS questionnaire [17]. Dietary Diversity (DD) of the children was assessed at baseline and consecutive weekly follow-up visits by asking the caregivers whether the child had taken from the standard seven food groups recommended by the WHO in the preceding day of the study without setting a minimum intake restriction [18]. The seven food groups were: (i) grains, roots and tubers; (ii) legumes and nuts; (iii) milk and milk products excluding breast milk; (iv) flesh foods; (v) eggs; (vi) vitamin A-rich fruits and vegetables; and (vii) others fruits and vegetables [18]. Household food security was measured at baseline using the Household Food Insecurity Access Scale (HFIAS) by asking about the occurrence and frequency of occurrence of nine food insecurity related events in the preceding four weeks of the survey. Ultimately the food security situation was classified into four ordinal categories: secure, and mild, moderate and severe insecurity [19]. Recent illness history of the child was assessed by asking the caregiver whether the child had fever, cough and diarrhoea in the preceding two weeks of the interview. The questionnaire used for collecting the data is provided as a supporting file with this manuscript (Additional file 1). Anthropometric measurements – height, weight and MUAC – of the children were taken at baseline and on successive weekly visits using calibrated equipments following standardized procedures. Height and weight were measured without shoes and wearing light clothes using portable stadiometer and Salter spring scales. Height and weight were measured to the nearest 0.1 cm and 100 g, respectively. MUAC was measured at the middle point of the left arm to the nearest 0.1 cm using MUAC tape. Bilateral pitting oedema was assessed by applying normal thumb pressure for 3 s to the both feet. The dependent variable of the study is time-to-recover from SAM (i.e. the event of interest is recovery and that the response variable is rate of recovery). The independent variables considered are: age and sex of the child, maternal and paternal educational status, level of household food insecurity, household wealth index, distance from the OTP sites, perceived severity of SAM by the caregivers, perceived benefit of SAM treatment, type of malnutrition (Marasmus or Kwashiorkor), dietary diversity and clinical symptoms (diarrhoea, cough and fever). As described in the following conceptual framework, the independent variables were grouped into distal and proximal factors (Fig. 2). Conceptual framework of the study describing the distal and proximal determinants of time-to-recovery from SAM Data were entered, cleaned, and analyzed using SPSS for windows, version 20. Data were described using frequencies, percentages and proper measure of central tendency and dispersion. During enrollment and follow-ups, dietary diversity scores (DDSs) were determined weekly by summing up the number of unique food groups the child received in the preceding day of the assessment. Ultimately a grand DDS was computed by averaging all the available weekly scores by the number of observations. A grand score of 4 or more was considered as optimal DDS [18]. The treatment outcomes were classified as recovered, non-responder and defaulter in line with the national protocol for the management of SAM [4] and the effectiveness of the program is judged by the Global SPHERE standards [20]. Recovery was defined based on the criteria used to diagnose SAM upon enrollment. For children admitted to OTP based on low MUAC, MUAC greater than 110 mm at two consecutive weeks and/or achieving target weight gain within the maximum stay of 8 weeks in the OTP were used to define recovery. For children admitted based on edema, recovery was resolution of edema at two consecutive weeks. Conversely, children who fail to achieve the aforementioned recovery criteria within the maximum eight weeks treatment were considered as non-responders. Children who missed appointments for two consecutive weeks while being confirmed that they are alive were considered as defaulters. The time-to-recover from SAM was determined by calculating the differences (in day) from the start of treatment until the child were declared recovered. The average time-to-recover in days was estimated using Kaplan-Meier survival analysis. Predictors of time-to-recovery were identified using bivariable and multivariable Cox-proportional hazard models (CPHM). All independent variables that had p-value less than 0.25 in bivariable model were considered as candidate variables for the multivariable model. In order to avoid over adjustment bias, proximal and distal variables were fitted in separate models in accordance with the conceptual framework of the study. The output of the multivariable CPHM is presented using adjusted hazard ratios (AHR) with the respective 95% confidence intervals (CI). The proportional hazard assumption of the model was assessed on the basis of Schoenfeld residuals. Multicolinearity was checked using variance inflation factor. For the distal CPHM model a total of eight variables were considered. These were: sex and age of the index child, maternal and paternal educational status, agro-ecology of the kebele, household food insecurity status, household wealth index, two-way travelling distance to the health post, and home visit by HEWs during the follow-up period. In the bivariable analyses, five variables (age of the child, maternal literacy, agro-ecological zone, food insecurity and distance to health post) had p-values less than 0.25 and hence considered for the multivariable model. For the proximal CPHM a total of nine variables were considered. The variables were DDS, type of nutritional diagnosis at baseline, occurrence of diarrhoea, fever and cough, RUTF sharing and selling practices, breastfeeding status and maternal perception on severity of SAM. After the bivariable analyses, all of the variables except breastfeeding status were found eligible (p-value < 0.25) for the multivariable analysis. Household wealth index was computed using Principal Component Analysis (PCA) as an indicator of household wealth status. A total of fifteen variables related to ownership of selected household assets, size of agricultural land, quantity of livestock, materials used for housing construction, and ownership of improved water and sanitation facilities were considered. Ultimately the generated score was divided into quintiles: poorest, poorer, middle, richer, and richest. The research protocol was reviewed and approved by the institutional review board (IRB) of College of Medicine and Health Science, Hawassa University. Data were collected after securing informed verbal consent from the caregivers of the children. Verbal consent, instead of written consent, was preferred because most of the study respondents were not literate. The same was approved by the IRB that reviewed the protocol of the study. Confidentiality was maintained while handling participants’ information. Nutrition education was given to the entire caregivers.
