Dataset Information

Severe acute malnutrition treatment delivered by low-literate community health workers in South Sudan: A prospective cohort study.

ABSTRACT:

Background

Community health worker (CHW)-delivered acute malnutrition treatment programs have been tested previously, but not with low-literate/-numerate cadres who operate in areas with the highest malnutrition burden and under-five mortality rates. The International Rescue Committee developed low-literacy-adapted tools and treatment protocol to enable low-literate/-numerate community-based distributors (CBD, the CHW cadre in South Sudan) to treat children for severe acute malnutrition (SAM) in their communities.

Methods

We conducted a prospective cohort study in March-September 2017, with 44 CBDs enrolling a total of 308 SAM children into treatment in their communities. Child treatment outcomes and length of treatment were documented. Uncomplicated SAM cases, defined for our study as children with mid-upper arm circumference (MUAC) of 90 to <115 mm or bilateral pitting oedema, without any medical complications, were treated for up to 16 weeks, and were considered fully recovered when they reached MUAC?125 mm for two consecutive weeks.

Results

The recovery rate from the severe to the moderate acute malnutrition (MAM) cut-off of MUAC 115 mm was 91% (95% confidence interval (CI)?=?88%-95%). The median length of treatment was five weeks. The recovery rate of children from SAM to full recovery was 75% (95% CI?=?69%-81%). The median time to full recovery was eight weeks. The recovery rates reported here exclude children referred for care from the denominator, per standard reporting of acute malnutrition treatment recovery rates. When the data were compared against routine monitoring and evaluation data from nearby static clinics, children treated by CBDs appeared to have improved continuity of care and shorter time to recovery.

Conclusions

The recovery rate for SAM children enrolled in acute malnutrition treatment by low-literate CBDs shows promise that deploying CHWs to treat SAM in areas with high prevalence and low treatment access may lead to higher recovery, better continuity of care in the transition between SAM and MAM, and shorter treatment time. Proper adaptations of tools and protocols can empower CHW cadres with low literacy and numeracy to successfully complete treatment steps. Key questions of scalability and cost-effectiveness remain.

SUBMITTER: Kozuki N

PROVIDER: S-EPMC7295452 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Publications

Severe acute malnutrition treatment delivered by low-literate community health workers in South Sudan: A prospective cohort study.

Kozuki Naoko N Van Boetzelaer Elburg E Tesfai Casie C Zhou Annie A

Journal of global health 20200601 1

<h4>Background</h4>Community health worker (CHW)-delivered acute malnutrition treatment programs have been tested previously, but not with low-literate/-numerate cadres who operate in areas with the highest malnutrition burden and under-five mortality rates. The International Rescue Committee developed low-literacy-adapted tools and treatment protocol to enable low-literate/-numerate community-based distributors (CBD, the CHW cadre in South Sudan) to treat children for severe acute malnutrition ...[more]

PMID: 32566163

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Project description:BackgroundFunds for community-based management of acute malnutrition (CMAM) programs are short-term in nature. CMAM programs are implemented in countries with weak policies and health systems and are primarily funded by donors. Beyond operational expansion, their institutionalisation and alignment with governments' priorities are poorly documented. The study aimed to identify pathway opportunities and approaches for horizontal and vertical scaling up of CMAM programs in South Sudan.MethodsThe study was conducted in South Sudan between August and September 2021 using an online qualitative survey with 31 respondents from policy and implementing organisations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework guided the study's design. It was self-administered through the Qualtrics platform. We used Qualitative Content Analysis supported by the Nvivo coding process. A deductive a priori template of codes approach was complemented by a data-driven inductive approach to develop the second level of interpretive understanding.ResultsFindings from the study demonstrate that the emphasis of CMAM programs was horizontal scaling up, characterised by geographic distribution and coverage as well as operational expansion. Main challenges have included unsustainable funding models, the inadequacy of existing infrastructure, high operational costs, cultural beliefs, and access-related barriers. Factor impacting access to CMAM programs have been geographical terrains, safety, and security concerns. Vertical scaling up, which emphasises institutional and ownership strengthening through a sound policy, regulatory, and fiscal environment, received relatively little attention. Nutrition supplies are not part of the government's essential drug list and there is limited or no budgetary allocation for nutrition programs by the government in national budgets and fiscal strategies. Factors constraining vertical scalability have included weak government systems and capacity, a lack of advocacy and lobbying opportunities, and an apparent lack of exits strategies.ConclusionAddressing the scalability problems of CMAM programs in South Sudan demands a delicate balancing act that prioritises both horizontal and vertical scalability. Government and political leadership that harness multidisciplinary and multi-sectoral coordination are required. There is a need to increase policy commitment to malnutrition and associated budgetary allocation, emphasise local resource mobilisation, and ensure financial sustainability of integrating CMAM programs into the existing health and welfare system.

Project description:Severe acute malnutrition (SAM) affects over 16.6 million children worldwide. The integrated Community Case Management (iCCM) strategy seeks to improve essential health by means of nonmedical community health workers (CHWs) who treat the deadliest infectious diseases in remote rural areas where there is no nearby health center. The objective of this study was to assess whether SAM treatment delivered by CHWs close to families' locations may improve the early identification of cases compared to outpatient treatment at health facilities (HFs), with a decreased number complicated cases referred to stabilization centers, increased anthropometric measurements at admission (closer to the admission threshold) and similarity in clinical outcomes (cure, death, and default). The study included 930 children aged 6 to 59 months suffering from SAM in the Kita district of the Kayes Region in Mali; 552 children were treated by trained CHWs. Anthropometric measurements, the presence of edema, and other medical signs were recorded at admission, and the length of stay and clinical outcomes were recorded at discharge. The results showed fewer children with edema at admission in the CHW group than in the HF group (0.4% vs. 3.7%; OR = 10.585 [2.222-50.416], p = 0.003). Anthropometric measurements at admission were higher in the CHW group, with fewer children falling into the lowest quartiles of both weight-for-height z-scores (20.2% vs. 31.5%; p = 0.002) and mid-upper arm circumference (18.0% vs. 32.4%; p<0.001), than in the HF group. There was no difference in the length of stay. More children in the CHW group were cured (95.9% vs. 88.7%; RR = 3.311 [1.772-6.185]; p<0.001), and there were fewer defaulters (3.7% vs. 9.8%; RR = 3.345 [1.702-6.577]; p<0.001) than in the HF group. Regression analyses demonstrated that less severe anthropometric measurements at admission resulted in an increased probability of cure at discharge. The study results also showed that CHWs provided more integrated care, as they diagnosed and treated significantly more cases of infectious diseases than HFs (diarrhea: 36.0% vs. 18.3%, p<0.001; malaria: 41.7% vs. 19.8%, p<0.001; acute respiratory infection: 34.8% vs. 25.2%, p = 0.007). The addition of SAM treatment in the curative tasks that the CHWs provided to the families resulted in earlier admission and more integrated care for children than those associated with HFs. CHW treatment also achieved better discharge outcomes than standard community treatment.

Project description:BACKGROUND:Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country. METHODS:This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors. RESULTS:In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics. CONCLUSION:CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.

Project description:BackgroundThis study investigates the frequency of near-miss events and compares correlates in the world's newest nation.MethodsA cross-sectional study was carried out to audit near-miss events and their causes. A total of 1,041 mothers were sampled. Data were gathered using World Health Organization near-miss evaluation tools according to morbidity and organ failure-based criteria. Intensive care unit admission criteria were not used (as there is no functional intensive care unit in Juba Teaching Hospital). Descriptive statistics and bivariate and multivariable logistic regression were used to analyze the data. The study adhered to the Declaration of Helsinki.ResultsNearly half (49.7%) of the clients were young pregnant women (aged 15-24 years), with a mean age of 25.07±5.65 years. During the study period, there were 994 deliveries, 94 near-misses, and 10 maternal deaths. This resulted in maternal near-miss and mortality rates of 94.1 per 1,000 and 1,007 per 100,000 live births, respectively. Severe maternal outcome and maternal near-miss rates were 10.47 per 1,000 (morbidity-based criteria) and 41.3 per 1,000 (organ failure-based criteria), respectively. The likelihood of mortality was 25% (95% CI 10%-51%) for a ruptured uterus, 9% (95% CI 4%-17%) for severe postpartum hemorrhage, and 11% (95% CI 3%-30%) for eclampsia. Anemia, hemorrhage, and dystocia were the highest contributory factors in the occurrence of maternal near-misses.ConclusionThe near-miss rate was high. Contributing factors were lack of resources, low quality of primary health care, and delays in care. All near-misses should be regarded as opportunities to improve the quality of maternity care. Health institutes should address delays in conducting interventions, referral barriers, and personnel gaps. Fully functional intensive-care units must be created in all facilities, including Juba Teaching Hospital and other hospitals. Notification policies for all near-miss cases should be in place in all health care units, with a "no shame, no blame" approach.

Dataset Information

Severe acute malnutrition treatment delivered by low-literate community health workers in South Sudan: A prospective cohort study.

Background

Methods

Results

Conclusions

Publications

Severe acute malnutrition treatment delivered by low-literate community health workers in South Sudan: A prospective cohort study.

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