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Melaku B, Gebremichael B, Negash B, Kitessa M, Kassa O, Dereje J, Kefelegn R, Firdisa D. Time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda, East Hararghe Zone, Eastern Ethiopia. Front Nutr 2024; 11:1369419. [PMID: 39171105 PMCID: PMC11335514 DOI: 10.3389/fnut.2024.1369419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/29/2024] [Indexed: 08/23/2024] Open
Abstract
Background Acute malnutrition is a major global public health problem, particularly in low-and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food-insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda East Hararghe Zone, Eastern Ethiopia, from January 1 to December 31, 2022. Methods A facility-based retrospective cohort study was conducted on 567 children with moderate acute malnutrition in Fedis Woreda, East Hararghe Zone, eastern Ethiopia. A multi-stage sampling technique was employed, and data was collected using a structured checklist. Data were extracted from randomly selected records after obtaining ethical clearance. Data were cleaned, coded, entered into EpiData 4.6, and analyzed using STATA/SE version 14. Descriptive statistics and analytic analysis schemes, including bivariable and multivariable Cox proportional hazards models, were conducted, and finally, statistical significance was considered at p < 0.05. Results The overall median time to recovery was 16 weeks. The major predicting factors for time to recovery among children aged 6-59 months were admission with a mid-upper arm circumference of 12.1-12.4 centimeters (AHR = 1.02, 95% CI: 1.01-1.19), access to transportation to facilities (AHR = 0.62, 95% CI: 0.36-0.81), children using specialized nutritious foods (RUSF; AHR = 1.96, 95% CI: 1.36-3.11), and children who had diarrhea (AHR = 0.4, 95% CI: 0.31-0.71). Conclusion The study found a median recovery time of 16 weeks for children with targeted supplementary feeding. Significant predictors included admission with a MUAC of 12.1-12.4 centimeters, transportation access, RUSF use, and the presence of diarrhea. These findings highlighted the importance of these factors in determining and improving recovery from moderate-acute malnutrition.
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Affiliation(s)
- Berhanu Melaku
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Berhe Gebremichael
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Belay Negash
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Monas Kitessa
- School of pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Obsan Kassa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Jerman Dereje
- Department of psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Reta Kefelegn
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Dawit Firdisa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Cichon B, López-Ejeda N, Mampindu MB, Bagayoko A, Samake M, Cuellar PC. Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation. GLOBAL HEALTH, SCIENCE AND PRACTICE 2024; 12:e2300431. [PMID: 38901972 PMCID: PMC11216703 DOI: 10.9745/ghsp-d-23-00431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 05/14/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Enabling community health workers (CHWs) to treat acute malnutrition improves treatment access and coverage. However, data on the cost and cost-effectiveness of this approach is limited. We aimed to cost the treatment at scale and determine the cost-effectiveness of different levels of supervision and technical support. METHODS This economic evaluation was part of a prospective nonrandomized community intervention study in 3 districts in Mali examining the impact of different levels of CHW and health center supervision and support on treatment outcomes for children with severe acute malnutrition. Treatment admission and outcome data were extracted from the records of 120 participating health centers and 169 CHW sites. Cost data were collected from accountancy records and through key informant interviews. Results were presented as cost per child treated and cured. Modeled scenario sensitivity analyses were conducted to determine how cost-efficiency and cost-effectiveness estimates change in an equal scale scenario and/or if the supervision had been done by government staff. RESULTS In the observed scenario, with an unequal number of children, the average cost per child treated was US$203.40 in Bafoulabé where a basic level of supervision and support was provided, US$279.90 in Kayes with a medium level of supervision, and US$253.9 in Kita with the highest level of supervision. Costs per child cured were US$303.90 in Bafoulabé, US$324.90 in Kayes, and US$311.80 in Kita, with overlapping uncertainty ranges. CONCLUSION Additional supervision has the potential to be a cost-effective strategy if supervision costs are reduced without compromising the quality of supervision. Further research should aim to better adapt the supervision model and associated tools to the context and investigate where efficiencies can be made in its delivery.
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Affiliation(s)
| | - Noemí López-Ejeda
- EPINUT Research Group, Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | - Aliou Bagayoko
- Nutrition Direction of the Ministry of Hygiene and Public Health, Bamako, Mali
| | - Mahamadou Samake
- Nutrition Direction of the Ministry of Hygiene and Public Health, Bamako, Mali
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Molanes-López EM, Ferrer JM, Dougnon AO, Gado AA, Sanoussi A, Ousmane N, Lazoumar RH, Charle-Cuéllar P. Cost-effectiveness of severe acute malnutrition treatment delivered by community health workers in the district of Mayahi, Niger. HUMAN RESOURCES FOR HEALTH 2024; 22:22. [PMID: 38553707 PMCID: PMC10979590 DOI: 10.1186/s12960-024-00904-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/29/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND A non-randomized controlled trial, conducted from June 2018 to March 2019 in two rural communes in the health district of Mayahi in Niger, showed that including community health workers (CHWs) in the treatment of severe acute malnutrition (SAM) resulted in a better recovery rate (77.2% vs. 72.1%) compared with the standard treatment provided solely at the health centers. The present study aims to assess the cost and cost-effectiveness of the CHWs led treatment of uncomplicated SAM in children 6-59 months compared to the standard national protocol. METHODS To account for all relevant costs, the cost analysis included activity-based costing and bottom-up approaches from a societal perspective and on a within-trial time horizon. The cost-effectiveness analysis was conducted through a decision analysis network built with OpenMarkov and evaluated under two approaches: (1) with recovery rate and cost per child admitted for treatment as measures of effectiveness and cost, respectively; and (2) assessing the total number of children recovered and the total cost incurred. In addition, a multivariate probabilistic sensitivity analysis was carried out to evaluate the effect of uncertainty around the base case input data. RESULTS For the base case data, the average cost per child recovered was 116.52 USD in the standard treatment and 107.22 USD in the CHWs-led treatment. Based on the first approach, the CHWs-led treatment was more cost-effective than the standard treatment with an average cost per child admitted for treatment of 82.81 USD vs. 84.01 USD. Based on the second approach, the incremental cost-effectiveness ratio of the transition from the standard to the CHWs-led treatment amounted to 98.01 USD per additional SAM case recovered. CONCLUSIONS In the district of Mayahi in Niger, the CHWs-led SAM treatment was found to be cost-effective when compared to the standard protocol and provided additional advantages such as the reduction of costs for households. TRIAL REGISTRATION ISRCTN with ID 31143316. https://doi.org/10.1186/ISRCTN31143316.
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Affiliation(s)
- Elisa M Molanes-López
- Department of Statistics and Operational Research, Faculty of Medicine, Universidad Complutense de Madrid (UCM), 28040, Madrid, Spain
| | - José M Ferrer
- Department of Statistics and Operational Research, Faculty of Medicine, Interdisciplinary Mathematics Institute, Universidad Complutense de Madrid (UCM), HUMLOG Research Group, 28040, Madrid, Spain
| | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, 623, Niamey, Niger
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Alier KK, Tappis H, Ismail S, Doocy S. Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan. Public Health Nutr 2023; 27:e15. [PMID: 38095095 PMCID: PMC10830371 DOI: 10.1017/s1368980023002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. DESIGN Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). SETTING Study was conducted as part of a bigger evaluation study in South Sudan. PARTICIPANTS International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. RESULTS The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. CONCLUSIONS Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.
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Affiliation(s)
- Kemish Kenneth Alier
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Sule Ismail
- US Centers for Disease Control and Prevention, Juba, South Sudan
- Integral Global Consulting, Atlanta, GA
| | - Shannon Doocy
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
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Akinmoladun OF, Bamidele OP, Jideani VA, Nesamvuni CN. Severe Acute Malnutrition: The Potential of Non-Peanut, Non-Milk Ready-to-Use Therapeutic Foods. Curr Nutr Rep 2023; 12:603-616. [PMID: 37897619 PMCID: PMC10766793 DOI: 10.1007/s13668-023-00505-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW This review provides information on the prospect and effectiveness of ready-to-use therapeutic foods (RUTFs) produced locally without the addition of milk and peanut. RECENT FINDINGS The foods used in fighting malnutrition in the past decades contributed little to the success of the alleviation program due to their non-effectiveness. Hence, RUTFs are introduced to fight malnutrition. The peanut allergies, the high cost of milk, and the high production cost of peanut RUTF have made its distribution, treatment spread, and accessibility very slow, especially in areas where it is highly needed. There is a need, therefore, for a low-cost RUTF that is acceptable and effective in treating severe acute malnutrition among under-5 children. This review shows both the success and failure of reported studies on the use of non-peanut and non-milk RUTF, including their cost of production as compared to the standard milk and peanut-based RUTF. It was hypothesised that replacing the milk ingredient component with legumes like soybeans can reduce the cost of production of RUTFs while also delivering an effective product in managing and treating severe acute malnutrition (SAM). Consumers generally accept them better because of their familiarity with the raw materials.
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Affiliation(s)
- Oluwaseun F Akinmoladun
- Department of Nutrition, Faculty of Health Sciences, University of Venda, Private Bag X5050, Thohoyandou, 0950, South Africa.
- Department of Nutrition and Dietetics, College of Agriculture, Food Science and Technology, Wesley University, PMB 507 Ondo, Ondo State, Nigeria.
- Department of Health Science, University of the People, Pasadena, CA 91101, USA.
| | - Oluwaseun P Bamidele
- Department of Food Science and Technology, University of Venda, Private Bag X5050, Thohoyandou, 09590, South Africa
| | - Victoria A Jideani
- Department of Food Technology, Cape Peninsula University of Technology, P.O. Box 652, Cape Town, 8000, South Africa
| | - Cebisa N Nesamvuni
- Department of Nutrition, Faculty of Health Sciences, University of Venda, Private Bag X5050, Thohoyandou, 0950, South Africa
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Mdege ND, Masuku SD, Musakwa N, Chisala M, Tingum EN, Boachie MK, Shokraneh F. Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002551. [PMID: 37939029 PMCID: PMC10631642 DOI: 10.1371/journal.pgph.0002551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023]
Abstract
This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.
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Affiliation(s)
- Noreen Dadirai Mdege
- Department of Health Sciences, University of York, York, United Kingdom
- Centre for Research in Health and Development, York, United Kingdom
| | - Sithabiso D. Masuku
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nozipho Musakwa
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mphatso Chisala
- Department of Population, Policy and Practice, Great Ormond Street Hospital, Institute of Child Health, University College London, London, United Kingdom
| | | | - Micheal Kofi Boachie
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Farhad Shokraneh
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Nottingham, United Kingdom
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Gizaw G, Bahwere P, Argaw A, Wells JCK, Friis H, Olsen MF, Abdissa A, Wibaek R, Abera M, Sadler K, Boyd E, Collins S, Girma T. Growth and Body Composition 5 y After Treatment for Severe Acute Malnutrition: A 5-y Prospective Matched Cohort Study in Ethiopian Children. Am J Clin Nutr 2023; 118:1029-1041. [PMID: 37923494 DOI: 10.1016/j.ajcnut.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Short-term anthropometric outcomes are well documented for children treated for severe acute malnutrition (SAM). However, anthropometric recovery may not indicate restoration of healthy body composition. OBJECTIVES This study aimed to evaluate long-term associations of SAM with growth and body composition of children 5 y after discharge from community-based management of acute malnutrition (CMAM). METHODS We conducted a 5-y prospective cohort study, enrolling children aged 6 to 59 mo discharged from CMAM (post-SAM) (n = 203) and nonmalnourished matched controls (n = 202) from Jimma Zone, Ethiopia in 2013. Anthropometry and body composition (bioelectrical impedance) were assessed. Multiple linear regression models tested differences in height-for-age (HAZ), weight-for-age (WAZ), and body mass index-for-age (BAZ) z-scores; height-adjusted fat-free mass index (FFMI); and FM index (FMI) between groups. RESULTS Post-SAM children had higher stunting prevalence than controls at discharge (82.2% compared with 36.0%; P < 0.001), 1 y (80.2% compared with 53.7%; P < 0.001), and 5 y postdischarge (74.2% compared with 40.8%; P < 0.001). Post-SAM children remained 5 cm shorter throughout follow-up, indicating no HAZ catch-up. No catch-up in WAZ or BAZ was observed. Post-SAM children had lower hip (-2.05 cm; 95% CI: -2.73, -1.36), waist (-0.92 cm; CI: -1.59, -0.23) and mid-upper arm (-0.64 cm; CI: -0.90, -0.42) circumferences and lower-limb length (-1.57 cm; 95% CI: -2.21, -0.94) at 5 y postdischarge. They had larger waist-hip (0.02 cm; 95% CI: 0.008, 0.033) and waist-height (0.013 cm; 95% CI: 0.004, 0.021) ratios, and persistent deficits in FFMI at discharge and 6 mo and 5 y postdischarge (P < 0.001 for all). No difference was detected in head circumference, sitting height, or FMI. CONCLUSIONS Five y after SAM treatment, children maintained deficits in HAZ, WAZ, BAZ, and FFMI, with preservation of FMI, sitting height, and head circumference at the expense of lower-limb length, indicating a "thrifty growth" pattern. Research is urgently needed to identify effective clinical and public health interventions to mitigate these consequences of malnutrition.
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Affiliation(s)
- Getu Gizaw
- Department of Human Nutrition and Dietetics, Jimma University, Jimma, Ethiopia; Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.
| | - Paluku Bahwere
- Valid International, Oxford, United Kingdom; Center for Epidemiology, Biostatistics, and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| | - Alemayehu Argaw
- Department of Human Nutrition and Dietetics, Jimma University, Jimma, Ethiopia; Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Mette Frahm Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Alemseged Abdissa
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Laboratory Sciences, Jimma University, Jimma, Ethiopia; Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Rasmus Wibaek
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Mubarek Abera
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Psychiatry, Jimma University, Jimma, Ethiopia
| | | | - Erin Boyd
- United States Agency for International Development, Washington DC, USA
| | | | - Tsinuel Girma
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
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Cichon B, Lopez Ejeda N, Charle Cuellar P, Hamissou IA, Karim AAA, Aton C, Sanoussi A, Ousmane N, Lazoumar RH, Gado AAO, Harouna ZY, Oteyza SG. Cost of Acute Malnutrition Treatment Using a Simplified or Standard Protocol in Diffa, Niger. Nutrients 2023; 15:3833. [PMID: 37686865 PMCID: PMC10490076 DOI: 10.3390/nu15173833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
Evidence on the cost of acute malnutrition treatment, particularly with regards to simplified approaches, is limited. The objective of this study was to determine the cost of acute malnutrition treatment and how it is influenced by treatment protocol and programme size. We conducted a costing study in Kabléwa and N'Guigmi, Diffa region, where children with acute malnutrition aged 6-59 months were treated either with a standard or simplified protocol, respectively. Cost data were collected from accountancy records and through key informant interviews. Programme data were extracted from health centre records. In Kabléwa, where 355 children were treated, the cost per child treated was USD 187.3 (95% CI: USD 171.4; USD 203.2). In N'Guigmi, where 889 children were treated, the cost per child treated was USD 110.2 (95% CI: USD 100.0; USD 120.3). Treatment of moderate acute malnutrition was cheaper than treatment of severe acute malnutrition. In a modelled scenario sensitivity analysis with an equal number of children in both areas, the difference in costs between the two locations was reduced from USD 77 to USD 11. Our study highlighted the significant impact of programme size and coverage on treatment costs, that cost can differ significantly between neighbouring locations, and that it can be reduced by using a simplified protocol.
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Affiliation(s)
| | - Noemi Lopez Ejeda
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, 28040 Madrid, Spain;
| | | | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger; (A.S.)
| | - Nassirou Ousmane
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger; (A.S.)
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Abebe A, Simachew Y, Delbiso TD. Effect of ready-to-use therapeutic foods on time to recovery among children with severe acute malnutrition in Ethiopia: a prospective cohort study. BMC Pediatr 2023; 23:340. [PMID: 37407934 DOI: 10.1186/s12887-023-04168-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND The therapeutic feeding unit (TFU) provides comprehensive inpatient clinical care for children suffering from severe acute malnutrition (SAM) in three stages: stabilization, transition, and rehabilitation. During the transitional and rehabilitation phases, children receive either F-100 or ready-to-use therapeutic food (RUTF). Although both promote weight gain, RUTF is more energy dense than F-100. There is limited and contrasting evidence regarding their effect on recovery time. Therefore, this study aimed to assess the effect of RUTF on time to recovery among SAM children aged 6-59 months admitted to the TFU in Ethiopia. METHODS Health Facility-based prospective cohort study was conducted among 476 children treated in three hospitals and four health centers in the Sidama region from September 2021 to January 2022. A structured questionnaire adopted from the Ethiopian national protocol for the management of SAM was used for data collection. Data were entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. The Kaplan-Meir curve and log-rank test were used to compare time to recovery between children who received RUTF and F-100. Multivariable Cox proportional hazard analysis was conducted to assess the association between time to recovery and the type of therapeutic food, controlling for the confounding variables. RESULTS The median recovery time was significantly shorter in children receiving RUTF (7 days; 95% CI: 6.62-7.38) compared to F-100 (10 days; 95% CI: 8.94-11.06). Children below 24 months (AHR = 0.54, 95% CI: 0.42-0.69), dehydrated (AHR = 1.34, 95% CI: 1.07-1.75), edematous malnutrition (AHR = 1.29, 95% CI: 1.03-1.61), and anemic (AHR = 2.57, 95% CI: 1.90-3.48) during admission were associated with time to recovery. CONCLUSIONS Children who received RUTF recovered faster than children who received F-100. Administering RUTF to children below 24 months, who present with anemia and dehydration can improve their recovery rate and shorten their stay in the health facility.
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Affiliation(s)
- Arsema Abebe
- Department of Public Health Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Yilkal Simachew
- School of Public Health, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Tefera Darge Delbiso
- Department of Public Health Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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Joseph FI, Falade A, Earland J. Time to recovery and its predictors among children 6-59 months with acute malnutrition admitted to community inpatient therapeutic feeding centers in Katsina State, Northwest Nigeria: a retrospective review of health records (2010-2016). JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:10. [PMID: 36800992 PMCID: PMC9936680 DOI: 10.1186/s41043-023-00352-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 02/07/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Severe acute malnutrition (SAM) among children under five years of age remains a huge public health and economic burden in Sub-Saharan Africa. We investigated time to recovery and its predictors among children aged 6 to 59 months admitted into Community-based Management of Acute Malnutrition (CMAM) stabilisation centres for complicated severe acute malnutrition and whether the outcomes met the minimum Sphere standards. METHODS The study was a retrospective cross sectional quantitative review of data recorded in six CMAM stabilization centres registers in four Local Government Areas, Katsina state, Nigeria from September 2010 to November 2016. Records of 6925 children, aged 6-59 months with complicated SAM were reviewed. Descriptive analysis was used to compare performance indicators with Sphere project reference standards. Cox proportional hazard regression analysis was used to estimate the predictors of recovery rate at p < 0.05 and Kaplan-Meier curve to predict the probability of surviving different forms of SAM. RESULTS Marasmus was the most common form of severe acute malnutrition (86%). Overall, the outcomes met the minimum sphere standards for inpatient management of SAM. Children with oedematous SAM (13.9%) had the lowest survival rate on Kaplan-Meier graph. The mortality rate was significantly higher during the 'lean season'-May to August (Adjusted Hazard Ratio (AHR) = 0.491, 95% CI = 0.288-0.838). MUAC at Exit (AHR = 0.521, 95% CI = 0.306-0.890), marasmus (AHR = 2.144, 95% CI = 1.079-4.260), transfers from OTP (AHR = 1.105, 95% CI = 0.558-2.190) and average weight gain (AHR = 0.239, 95% CI = 0.169-0.340) were found to be significant predictors of time-to-recovery with p values < 0.05. CONCLUSION The study showed that, despite a high turnover of complicated SAM cases in the stabilization centres, the community approach to inpatient management of acute malnutrition enabled early detection and reduced delays in access to care of complicated SAM cases. In the face of health workforce shortage in rural communities to provide pediatric specialist care for SAM children, we recommend task shifting to community health care workers through in service training could bridge the gap and save more lives of children dying from the complication of SAM in rural communities in Nigeria.
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Affiliation(s)
- Friday Ilop Joseph
- Department of Paediatrics, Federal Teaching Hospital, Katsina, Katsina State, Nigeria.
| | - Adewale Falade
- Department of Public Health, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Jane Earland
- Department of Public Health and Policy, School of Medicine, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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Kokeb M, Mariyo A. Time to Discharge and its Predictors among Children Aged 1-60 Months with Severe Acute Malnutrition Admitted to the Therapeutic Feeding Center in A Tertiary Hospital, North West Ethiopia. Ethiop J Health Sci 2022; 32:1107-1116. [PMID: 36475254 PMCID: PMC9692151 DOI: 10.4314/ejhs.v32i6.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/05/2022] [Indexed: 12/13/2022] Open
Abstract
Background Standard treatment of severe acute malnutrition with medical complication and/or failed appetite test is admission in therapeutic feeding centers for stabilization. Once stabilized, patients will be linked to Outpatient treatment program for rehabilitation. Information regarding time to discharge from inpatient therapeutic feeding centers is limited in Ethiopia. The main objective of this study was to assess the time to discharge and its predictors among children 1-60 months with Severe Acute Malnutrition admitted to University of Gondar Hospital. Methods Hospital Based retrospective follow up study was conducted in Gondar University Hospital among 282 children aged 1-60 months admitted to inpatient Therapeutic Feeding Center from June 2018 to December 2020. Participants were selected by Simple random sampling technique. Time to discharge from inpatient treatment was estimated using Kaplan-Meir procedure and Log Rank test was used to test observed difference between covariates. Identification of predictors for time to discharge was done by Stratified cox regression model. Results Overall 282 children were studied; 242 (85.8%) were discharged improved and 40 (14.2%) were censored. The median time to Discharge was 13 days (IQR: 9-18) and the Incidence of discharge was found to be 6.4 (95% CI: 5.6-7.2) per 100 person- day observations. Kwash-dermatosis (AHR=2.4, 95% CI: 1.17-4.8), Anemia (AHR=1.7, 95% CI: 1.1-2.6), pneumonia at admission (AHR=1.6, 95% CI: 1.01-2.63) and Hospital acquired infection (AHR=4.4, 95% CI: 2.4-8.2) were predictors of time to discharge. Conclusion Hospital stay at the stabilization center was prolonged. Pneumonia, anemia, kwash dermatosis and Nosocomial infections were significant predictors of time to discharge.
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Affiliation(s)
- Mehretie Kokeb
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Abinet Mariyo
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, University of Gondar, Ethiopia
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Takele WW, Ayele AD, Haile TG, Debie A, Amare AT, Tsehay CT, Mekonnen EG. Evaluation of the community-based outpatient therapeutic feeding program implementation for managing children with severe acute malnutrition in Northwest Ethiopia: A mixed-method evaluation protocol. PLoS One 2022; 17:e0275964. [PMID: 36219618 PMCID: PMC9553038 DOI: 10.1371/journal.pone.0275964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/27/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Community-based outpatient therapeutic feeding program (C-OTP) in Ethiopia has been launched to manage uncomplicated severe acute malnutrition (SAM) by trained Health Extension Workers (HEWs). This program is believed to be the most effective strategy for reaching a large group of children suffering from SAM in rural and disadvantaged communities. Nonetheless, poor treatment outcomes, notably mortality and prolonged recovery time, become pressing public health problems, which could be a result of suboptimal implementation and poor service quality. OBJECTIVES To evaluate the implementation of C-OTP for managing uncomplicated severe acute malnutrition in the Central Gondar Zone. METHODS Multiple studies involving both qualitative and quantitative will be conducted. Availability of essential drugs and equipment, acceptability of the program by mothers/caregivers, health extension workers' compliance to the treatment protocol, and treatment outcome will be assessed employing different methods. Likewise, knowledge of health extension workers about SAM diagnosis and management and their skills to diagnose and manage uncomplicated malnutrition will be determined. Health extension workers, mothers/caregivers, supervisors, and healthcare administrators will be enrolled in the study. Besides, children's medical records registered between 2017 and 2020 will be reviewed to determine the treatment outcome. The data will be collected using pretested self-administered and face-to-face interviewer-administered questionnaires. Similarly, focus group discussions (FGDs), in-depth interviews, and observation checklists will be applied. Binary logistic regression analysis will be conducted, while the qualitative data will be analyzed using thematic content analysis. DISCUSSION Severe acute malnutrition is a public health problem that remains the underlying cause for over half of under-five mortality in Ethiopia. As a result, community-based therapeutic care has been launched in the country to address these problems and maximize population-level impact by improving treatment coverage, access, and cost-effectiveness. Despite its achievement, the program has been threatened with unfavourable treatment outcomes and a shortfall of resources. Hence, this implementation evaluation study will also identify gaps between healthcare systems and service users. The output will help programmers pass evidence-based and sound decisions to tackle the key barriers.
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Affiliation(s)
- Wubet Worku Takele
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Amare Demsie Ayele
- Department of Pediatrics, Child Health Nursing, and Public Health Nutrition College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tsegaye Gebremedhin Haile
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ayal Debie
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ashenafi Tazebew Amare
- Department of Child Health and Pediatrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Chalie Tadie Tsehay
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Eskedar Getie Mekonnen
- Department of Reproductive, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Renzaho AMN, Dachi G, Ategbo E, Chitekwe S, Doh D. Pathways and approaches for scaling-up of community-based management of acute malnutrition programs through the lens of complex adaptive systems in South Sudan. Arch Public Health 2022; 80:203. [PMID: 36064608 PMCID: PMC9442594 DOI: 10.1186/s13690-022-00934-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Funds 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. METHODS The 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. RESULTS Findings 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. CONCLUSION Addressing 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.
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Affiliation(s)
- Andre M. N. Renzaho
- Translational Health Research Institute, School of Medicine, Western Sydney, University, Sydney, Australia
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC 3004 Australia
| | - Gilbert Dachi
- UNICEF South Sudan; Totto Chan Compound, PO Box 45, Juba, South Sudan
| | - Eric Ategbo
- UNICEF South Sudan; Totto Chan Compound, PO Box 45, Juba, South Sudan
| | | | - Daniel Doh
- School of Social Sciences, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
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King S, D'Mello-Guyett L, Yakowenko E, Riems B, Gallandat K, Mama Chabi S, Mohamud FA, Ayoub K, Olad AH, Aliou B, Marshak A, Trehan I, Cumming O, Stobaugh H. A multi-country, prospective cohort study to measure rate and risk of relapse among children recovered from severe acute malnutrition in Mali, Somalia, and South Sudan: a study protocol. BMC Nutr 2022; 8:90. [PMID: 36002905 PMCID: PMC9404649 DOI: 10.1186/s40795-022-00576-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Community-Based Management of Acute Malnutrition (CMAM) model transformed the treatment of severe acute malnutrition (SAM) by shifting treatment from inpatient facilities to the community. Evidence shows that while CMAM programs are effective in the initial recovery from SAM, recovery is not sustained for some children requiring them to receive treatment repeatedly. This indicates a potential gap in the model, yet little evidence is available on the incidence of relapse, the determinants of the phenomena, or its financial implications on program delivery. METHODS This study is a multi-country prospective cohort study following "post-SAM" children (defined as children following anthropometric recovery from SAM through treatment in CMAM) and matched community controls (defined as children not previously experiencing acute malnutrition (AM)) monthly for six months. The aim is to assess the burden and determinants of relapse to SAM. This study design enables the quantification of relapse among post-SAM children, but also to determine the relative risk for, and excess burden of, AM between post-SAM children and their matched community controls. Individual -, household-, and community-level information will be analyzed to identify potential risk-factors for relapse, with a focus on associations between water, sanitation, and hygiene (WASH) related exposures, and post-discharge outcomes. The study combines a microbiological assessment of post-SAM children's drinking water, food, stool via rectal swabs, dried blood spots (DBS), and assess for indicators of enteric pathogens and immune function, to explore different exposures and potential associations with treatment and post-treatment outcomes. DISCUSSION This study is the first of its kind to systematically track children after recovery from SAM in CMAM programs using uniform methods across multiple countries. The design allows the use of results to: 1) facilitate understandings of the burden of relapse; 2) identify risk factors for relapse and 3) elucidate financial costs associated with relapse in CMAM programs. This protocol's publication aims to support similar studies and evaluations of CMAM programs and provides opportunities for comparability of an evidence-based set of indicators for relapse to SAM.
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Affiliation(s)
- Sarah King
- Action Against Hunger, New York, NY, USA
| | - Lauren D'Mello-Guyett
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Karin Gallandat
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Khamisa Ayoub
- Nutrition Department, Ministry of Health for the Republic of South Sudan, Juba, South Sudan
| | - Ahmed Hersi Olad
- Research Department, Federal Ministry of Health for the Federal Republic of Somalia, Mogadishu, Somalia
| | - Bagayogo Aliou
- Nutrition Sub-Directorate, General Directorate of Health and Public Hygiene, Ministry of Health and Social Development for the Republic of Mali, Bamako, Mali
| | | | - Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Oliver Cumming
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Heather Stobaugh
- Action Against Hunger, New York, NY, USA. .,Tufts University, Boston, MA, USA.
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15
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Isanaka S, Tang K, Berthé F, Grais RF, Pandya A. Cost-effectiveness of routine versus indicated antibiotic therapy in the management of severe wasting in children. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:38. [PMID: 35922807 PMCID: PMC9351197 DOI: 10.1186/s12962-022-00374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background In the outpatient management of severe wasting, routine antibiotic therapy is recommended for all children upon admission regardless of whether clinical signs of infection are present. Indicated antibiotic therapy, where antibiotics are provided only upon presentation of clinical signs of infection, may be considered for its potential to allow for more prudent antibiotic use and greater program coverage, reducing the risk of antibiotic resistance as well as costs and logistical burdens associated with treatment. We therefore conducted a cost-effectiveness analysis to measure the effects of indicated antibiotic therapy compared to routine antibiotic therapy in terms of incremental cost-per-life-year saved in Niger. Methods We used a cohort model to conduct a cost-effectiveness analysis from a healthcare system perspective to project and weigh the lifetime discounted costs and effects of indicated antibiotic therapy compared to routine antibiotic therapy in the treatment of uncomplicated severe wasting in children in Niger. We calculated incremental cost-effectiveness ratios (ICERs) in terms of treatment-related healthcare costs per discounted life-years saved (LYS), and conducted program coverage scenario and sensitivity analyses to assess model uncertainty. Results The ICER for indicated antibiotic therapy compared to routine antibiotic therapy was $8.5/LYS, which is under the cost-effectiveness threshold for Niger. The probability of the indicated strategy being optimal was 76.1% when program coverage was equal to coverage associated with routine therapy but was 100% likely to be optimal in probabilistic sensitivity analysis scenarios where indicated program coverage improved 5 percentage points. Conclusions Indicated antibiotic therapy likely represents a cost-effective strategy, particularly if indicated treatment can result in expanded coverage. With the risk of increasing antibiotic resistance worldwide, antibiotic stewardship and simplified treatment protocols for severe wasting using indicated antibiotic therapy may represent good value for money in some low risk populations. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-022-00374-z.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, 14-34 avenue Jean Juarès, 75019, Paris, France. .,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Kevin Tang
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Rebecca F Grais
- Department of Research, Epicentre, 14-34 avenue Jean Juarès, 75019, Paris, France
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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16
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Rashid MY, Kebira JY, Oljira L, Dheresa M. Time to Recovery From Moderate Acute Malnutrition and Its Predictors Among Children 6–59 Months of Age Enrolled in Targeted Supplementary Feeding Program in Darolebu District, Eastern Ethiopia: A Retrospective Cohort Study. Front Public Health 2022; 10:914837. [PMID: 35910899 PMCID: PMC9330372 DOI: 10.3389/fpubh.2022.914837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Acute malnutrition is a major global public health problem, particularly in low and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the treatment outcome and predictors of recovery time from moderate acute malnutrition among children 6–59 months of age in Darolebu district, Eastern Ethiopia. Methods A retrospective cohort study design was conducted on 540 children with moderate acute malnutrition. A Kaplan–Meier survival analysis was used to estimate the recovery time. Cox proportional hazard regression model was used to determine the association between the independent and the outcome variables. The proportional hazard assumption of the model was checked graphically and statistically. Any violation of the proportional hazard assumption of the model was also considered and adjusted in the analysis. Finally, a variable with a P-value <0.05 in the multivariate cox regression model was considered statistically significant. Results The overall recovery rate was 73% (95% CI 69.4–76.4%) with the median time to recovery of 16 weeks. Being between the ages of 24 and 59 months (AHR = 1.24, 95% CI: 1.01–1.54), having a mid-upper arm circumference (MUAC) at admission between 11.5 and 11.9 cm (AHR = 1.27, 95% CI: 1.34–2.61), walking for an hour or less to receive services (AHR = 1.2, 95% CI: 1.02–1.89), using ready-to-use supplementary food (AHR= 1.8, 95%CI: 1.38–2.39) were significant predictors of recovery time. Conclusion The recovery rate was slightly below the accepted minimum international standard, suggesting that further work is needed to improve the treatment outcomes and mortality and morbidity associated with moderate acute malnutrition.
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Affiliation(s)
| | - Jemal Yusuf Kebira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- *Correspondence: Jemal Yusuf Kebira
| | - Lemessa Oljira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Merga Dheresa
- School Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Wun J, Kemp C, Puett C, Bushnell D, Crocker J, Levin C. Measurement of benefits in economic evaluations of nutrition interventions in low- and middle-income countries: A systematic review. MATERNAL & CHILD NUTRITION 2022; 18:e13323. [PMID: 35137531 PMCID: PMC8932707 DOI: 10.1111/mcn.13323] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/24/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022]
Abstract
Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority-setting. However, there are unique challenges to synthesizing the findings of multi-sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost-effectiveness, cost-utility and benefit-cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low- and middle-income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty-seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty-one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non-health and multi-sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.
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Affiliation(s)
- Jolene Wun
- Independent ConsultantWashingtonDistrict of ColumbiaUSA
| | - Christopher Kemp
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Chloe Puett
- Program in Public HealthStony Brook UniversityStony BrookNew YorkUSA
| | - Devon Bushnell
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Jonny Crocker
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Carol Levin
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
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Joshi A, Pakhare AP, Nair SK, G R, Chouhan M, Pandey D, Kokane AM. Data-Driven Monitoring in Community Based Management of Children With Severely Acute Malnutrition (SAM) Using Psychometric Techniques: An Operational Framework. Cureus 2021; 13:e18589. [PMID: 34760426 PMCID: PMC8572322 DOI: 10.7759/cureus.18589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/05/2022] Open
Abstract
Background The success of the Community Based Management of Severe Malnutrition (CSAM) programme largely depends on the knowledge and skills of Front-Line Workers (FLWs). A robust supportive supervision system in CSAM should be tailored to individualistic learning needs by distinguishing the FLWs as per their ability and simultaneously identifying the task domains to be emphasized more in supervisory visits. This paper details the ability assessment strategy developed and employed in the selected geographical locations in Madhya Pradesh (Central India) among the 197 Anganwadi workers (FLWs involved in CSAM implementation). Methodology A 25 items tool was developed based on an analytical construct for ability estimation through Rasch Analysis (RA). RA models the probability of right/wrong answers as a function of a person (participants) and item (questions) parameters and calculates the item difficulty in relation to personability on the same unidimensional linear scale. Suitable visualization like item characteristic curve (ICC), person item map (PIM) and quadratic allocation were plotted in RA. The data fitting to the Rasch model (Rasch diagnostic) was tested by numeric (Anderson LR and Wald test) and graphical methods. Results The item easiness parameter (β) value related to Diarrhoeal assessment was lowest (-2.32, -2.91 to -1.73) and related to peer assessment meaningful action (2.009, 1.669- 2.348)) was highest (most difficult). Anderson LR test (LR=31.32, df=24, p=0.079) showed the absence of global outliers. Quadrant analysis using the permutations of ability score and adjusted burden of malnutrition further mapped 41/197 (20.8%) FLWs to low ability -high burden quadrant and 44/197(25%) as low ability low burden quadrant. Conclusion Rasch assessment may address the innate challenges to maintain homogeneity, discrimination capacity and linearity in a raw score-based measurement construct. The monitoring strategy developed on this thus may offer a judicious, pragmatic and thematic approach to supportive supervision in the CSAM program.
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Affiliation(s)
- Ankur Joshi
- Epidemiology and Public Health, All India Institute of Medical Sciences, Bhopal, IND
| | - Abhijit P Pakhare
- Epidemiology and Public Health, All India Institute of Medical Sciences, Bhopal, IND
| | - Sivaja K Nair
- Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, IND
| | - Revadi G
- Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, IND
| | - Manoj Chouhan
- Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, IND
| | - Deepak Pandey
- Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, IND
| | - Arun M Kokane
- Epidemiology and Public Health, All India Institute of Medical Sciences, Bhopal, IND
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N'Diaye DS, Wassonguema B, Nikièma V, Kangas ST, Salpéteur C. Economic evaluation of a reduced dosage of ready-to-use therapeutic foods to treat uncomplicated severe acute malnourished children aged 6-59 months in Burkina Faso. MATERNAL AND CHILD NUTRITION 2021; 17:e13118. [PMID: 33621428 PMCID: PMC8189238 DOI: 10.1111/mcn.13118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/06/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Ready‐to‐use therapeutic foods (RUTF) used to treat children with severe acute malnutrition (SAM) are costly, and the prescribed dosage has not been optimized. The MANGO trial, implemented by Action Contre la Faim in Burkina Faso, proved the non‐inferiority of a reduced RUTF dosage in community‐based treatment of uncomplicated SAM. We performed a cost‐minimization analysis to assess the economic impact of transitioning from the standard to the reduced RUTF dose. We used a decision‐analytic model to simulate a cohort of 399 children/arm, aged 6–59 months and receiving SAM treatment. We adopted a societal perspective: direct medical costs (drugs, materials and staff time), non‐medical costs (caregiver expenses) and indirect costs (productivity loss) in 2017 international US dollar were included. Data were collected through interviews with 35 caregivers and 20 informants selected through deliberate sampling and the review trial financial documents. The overall treatment cost for 399 children/arm was $36,550 with the standard and $30,411 with the reduced dose, leading to $6,140 (16.8%) in cost savings ($15.43 saved/child treated). The cost/consultation was $11.6 and $9.6 in the standard and reduced arms, respectively, with RUTF accounting for 56.2% and 47.0% of the total. The savings/child treated was $11.4 in a scenario simulating the Burkinabè routine SAM treatment outside clinical trial settings. The reduced RUTF dose tested in the MANGO trial resulted in significant cost savings for SAM treatment. These results are useful for decision makers to estimate potential economic gains from an optimized SAM treatment protocol in Burkina Faso and similar contexts.
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Affiliation(s)
- Dieynaba S N'Diaye
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France
| | - Bibata Wassonguema
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France
| | | | - Suvi T Kangas
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France.,Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Cécile Salpéteur
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France
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Bitew ZW, Alemu A, Worku T. Treatment outcomes of severe acute malnutrition and predictors of recovery in under-five children treated within outpatient therapeutic programs in Ethiopia: a systematic review and meta-analysis. BMC Pediatr 2020; 20:335. [PMID: 32631260 PMCID: PMC7339430 DOI: 10.1186/s12887-020-02188-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/02/2020] [Indexed: 12/03/2022] Open
Abstract
Background Severe acute malnutrition affects around 17 million under-five children in the world, of which the highest burden is accounted by Sub-Saharan Africa where Ethiopia is found. Though there are few individual, inconsistent and inconclusive studies, there is no nationally representative study on treatment outcomes of SAM in outpatient therapeutic feeding programs of Ethiopia. This study aimed at estimating the pooled treatment outcomes and predictors of recovery rate among under- five children with SAM in Ethiopia. Methods Electronic databases (PubMed, Medline (EBSCOhost), EMBASE (Elsevier), CINAHL (EBSCOhost), web of science, Scopus, Science Direct and Food Science and Technology Abstracts (FSTA)), and grey literature sources (Google scholar, Mednar, World Cat and google) were used to retrieve articles. The random effect model was used to estimate the pooled treatment outcomes. Hazard ratios were used to determine the predictors of recovery rate. Cochran’s Q, I2, and univariate Meta regression were done for heterogeneity. Begg’s & Egger’s tests were used for publication bias. Results Nineteen articles with a total number of 23,395 under-five children with SAM were used for this meta-analysis. The pooled recovery, death, defaulter and non-recovery rates were 70% (95% CI: 64, 76), 2% (95% CI: 1, 2), 10% (95%CI: 7, 12), 15% (95% CI: 10, 20), respectively. Diarrhea (HR = 0.8, 95% CI: 0.75, 0.94), no edema (HR = 0.41, 95% CI: 0.33, 0.50) and amoxicillin (HR = 1.81, 95% CI: 1.18, 2.44) were independent predictors of recovery rate of children with SAM in Ethiopia. Publication year was found to be the potential source of heterogeneity between included studies. Conclusion The treatment outcomes of children with SAM from outpatient therapeutic feeding programs of Ethiopia are lower than the sphere guidelines, WHO and national recommendations. Diarrhea and no edema antagonized the recovery rate of children, while amoxicillin enhanced the recovery rate of children from SAM. Community health workers need to be trained. Especial attention should be given while treating children with diarrhea and severe wasting. Community mobilization is also recommended to improve community awareness about the therapeutic foods.
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Laillou A, Baye K, Meseret Z, Darsene H, Rashid A, Chitekwe S. Wasted Children and Wasted Time: A Challenge to Meeting the Nutrition Sustainable Development Goals with a High Economic Impact to Ethiopia. Nutrients 2020; 12:E3698. [PMID: 33266008 PMCID: PMC7760409 DOI: 10.3390/nu12123698] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022] Open
Abstract
Despite some progress in the reduction of the prevalence of child wasting in Ethiopia, the pace of progress has been slow. Despite millions of dollars being spent on the treatment of wasting every year, the increased frequency and magnitude of environmental and anthropogenic shocks has halted progress. This study aimed to present the trends of child wasting in Ethiopia and estimate the economic losses related to the slow progress towards meeting the sustainable development goal (SDG) targets. Weather shocks and civil unrest between 2015 and 2018 have halted progress. We used a "consequence model" to apply the coefficient risk-deficit on economic losses established in the global scientific literature to the Ethiopian health, demographic, and economic data to estimate economic losses related to child wasting. The impact of wasting on the national economy of Ethiopia is estimated to be 157.8-230.2 million United States dollars (USD), annually. The greatest contributor to the economic burden (43.5-63.5% of the burden depending on the discount rate) is the cost of supplies and human resources to treat wasting. To reach the 2030 SDGs, Ethiopia should increase its annual average reduction rate (AARR) in the numbers of child (<59 months) wasting from 0.1% to 5.4%. This will avert the wasting in 7.9 million cases and prevent additional economic costs of up to 803.7 million USD over the next decade. Increasing the reach of therapeutic interventions, but also identifying and implementing wasting prevention interventions, will be critical if the SDG targets are to be met and the opportunity of the children to thrive is not to be wasted.
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Affiliation(s)
- Arnaud Laillou
- United Nations Children’s Fund (UNICEF), Addis Ababa 12000, Ethiopia; (A.R.); (S.C.)
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa 12000, Ethiopia;
| | - Zelalem Meseret
- Department for Maternal, Child Health and Nutrition, Federal Ministry of Health, Addis Ababa 12000, Ethiopia; (Z.M.); (H.D.)
| | - Hiwot Darsene
- Department for Maternal, Child Health and Nutrition, Federal Ministry of Health, Addis Ababa 12000, Ethiopia; (Z.M.); (H.D.)
| | - Abdulai Rashid
- United Nations Children’s Fund (UNICEF), Addis Ababa 12000, Ethiopia; (A.R.); (S.C.)
| | - Stanley Chitekwe
- United Nations Children’s Fund (UNICEF), Addis Ababa 12000, Ethiopia; (A.R.); (S.C.)
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22
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Makhani LA, Moran V, Sadique Z, Singh NS, Revill P, Roberts B. Examining the use of economic evaluations in health-related humanitarian programmes in low- and middle-income countries: a systematic review. Health Policy Plan 2020; 35:210-218. [PMID: 31697373 DOI: 10.1093/heapol/czz144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2019] [Indexed: 01/08/2023] Open
Abstract
The costly nature of health sector responses to humanitarian crises and resource constraints means that there is a need to identify methods for priority setting and long-term planning. One method is economic evaluation. The aim of this systematic review is to examine the use of economic evaluations in health-related humanitarian programmes in low- and middle-income countries. This review used peer-reviewed literature published between January 1980 and June 2018 extracted from four main electronic bibliographic databases. The eligibility criteria were full economic evaluations (which compare the costs and outcomes of at least two interventions and provide information on efficiency) of health-related services in humanitarian crises in low- and middle-countries. The quality of eligible studies is appraised using the modified 36-question Drummond checklist. From a total of 8127 total studies, 11 full economic evaluations were identified. All economic evaluations were cost-effectiveness analyses. Three of the 11 studies used a provider perspective, 2 studies used a healthcare system perspective, 3 studies used a societal perspective and 3 studies did not specify the perspective used. The lower quality studies failed to provide 7information on the unit of costs and did not justify the time horizon of costs and discount rates, or conduct a sensitivity analysis. There was limited geographic range of the studies, with 9 of the 11 studies conducted in Africa. Recommendations include greater use of economic evaluation methods and data to enhance the microeconomic understanding of health interventions in humanitarian settings to support greater efficiency and transparency and to strengthen capacity by recruiting economists and providing training in economic methods to humanitarian agencies.
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Affiliation(s)
- Lizna A Makhani
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Valerie Moran
- Luxembourg Institute of Health, 1 A-B Rue Thomas Edison, 1445 Strassen, Luxembourg.,Luxembourg Institute of Socio-Economic Research, 11 Porte des Sciences, 4366 Esch-sur-Alzette, Luxembourg
| | - Zia Sadique
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Neha S Singh
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Paul Revill
- Centre for Health Economics, University of York, Alcuin 'A' Block, University of York, Heslington, York YO10 5DD, UK
| | - Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Njuguna RG, Berkley JA, Jemutai J. Cost and cost-effectiveness analysis of treatment for child undernutrition in low- and middle-income countries: A systematic review. Wellcome Open Res 2020; 5:62. [PMID: 33102783 PMCID: PMC7569484 DOI: 10.12688/wellcomeopenres.15781.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Undernutrition remains highly prevalent in low- and middle-income countries, with sub-Saharan Africa and Southern Asia accounting for majority of the cases. Apart from the health and human capacity impacts on children affected by malnutrition, there are significant economic impacts to households and service providers. The aim of this study was to determine the current state of knowledge on costs and cost-effectiveness of child undernutrition treatment to households, health providers, organizations and governments in low and middle-income countries (LMICs). Methods: We conducted a systematic review of peer-reviewed studies in LMICs up to September 2019. We searched online databases including PubMed-Medline, Embase, Popline, Econlit and Web of Science. We identified additional articles through bibliographic citation searches. Only articles including costs of child undernutrition treatment were included. Results: We identified a total of 6436 articles, and only 50 met the eligibility criteria. Most included studies adopted institutional/program (45%) and health provider (38%) perspectives. The studies varied in the interventions studied and costing methods used with treatment costs reported ranging between US$0.44 and US$1344 per child. The main cost drivers were personnel, therapeutic food and productivity loss. We also assessed the cost effectiveness of community-based management of malnutrition programs (CMAM). Cost per disability adjusted life year (DALY) averted for a CMAM program integrated into existing health services in Malawi was $42. Overall, cost per DALY averted for CMAM ranged between US$26 and US$53, which was much lower than facility-based management (US$1344). Conclusion: There is a need to assess the burden of direct and indirect costs of child undernutrition to households and communities in order to plan, identify cost-effective solutions and address issues of cost that may limit delivery, uptake and effectiveness. Standardized methods and reporting in economic evaluations would facilitate interpretation and provide a means for comparing costs and cost-effectiveness of interventions.
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Affiliation(s)
- Rebecca G Njuguna
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Public Health, School of Health and Human Sciences, Pwani University, Kilifi, Kenya
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Julie Jemutai
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
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Bitew ZW, Alebel A, Worku T, Alemu A. Recovery rate and its predictors among children with severe acute malnutrition in Addis Ababa, Ethiopia: A retrospective cohort study. PLoS One 2020; 15:e0235259. [PMID: 32701985 PMCID: PMC7377431 DOI: 10.1371/journal.pone.0235259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/11/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Malnutrition is a public health problem in under-five children in several parts of the world even after decades of the implementation of management protocols. An estimated 17 million children under the age of five years are living with severe acute malnutrition and the majorities are found in Asia and Africa, including Ethiopia. OBJECTIVE The main objective of this study was to determine the recovery rate and its predictors among under-five children who were admitted to St. Paul's Hospital Millennium Medical College from 2012 to 2019. METHODS An institution based retrospective cohort study was employed at St. Paul's Hospital Millennium Medical College from May 20, 2019 to June 28, 2019. Data were collected by reviewing children's' medical records using a structured checklist. A total of 534 charts were selected using a simple random sampling method and 515 of them were used for the final analysis. Ep-info version 7 software was used for data entry and STATA Version 15 for analysis. The Kaplan Meier failure estimate with Log-rank test was used to determine the survival estimates. Bi-variable and multivariable Cox proportional hazards regression model were fitted to identify predictors of mortality. Finally, variables with p-values less than 0.05 in the multivariable Cox regression were considered as independent predictors. The proportional hazards assumption was checked using the Schoenfeld residuals test and the final model fitness was checked using the Cox-Snail residual test. RESULT In this study, a total of 515 subjects were followed for 8672 child-days and 79% of the subjects recovered from SAM with the median time of 17 days. The incidence density rate of recovery was 46 per 1000 child-days. Tuberculosis (AHR(Adjusted Hazard Ratio) 0.44 & 95% CI: 0.32, 0.62), pale conjunctiva (AHR,0.67 & 95% CI: 0.52, 0.88), IV fluid infusion (AHR, 0.71 & 95 CI: 0.51, 0.98), feeding F100 (AHR, 1.63 & 95% CI:1.04,2.54), Vitamin A supplementation (AHR, 1.3 & 95% CI:1.07, 1.59) and bottle feeding (AHR, 0.79 & 95CI%: 0.64-0.98) were the independent predictors of time to recovery from SAM. CONCLUSION In conclusion, the recovery rate was relatively higher than the Sphere standard and the national SAM management protocol. Co-morbidities and the treatments given were the main determinants of recovery of children. Co-morbidities must be managed as early as possible and the treatments given during the SAM management process need to be given with precaution.
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Affiliation(s)
- Zebenay Workneh Bitew
- Department of Pediatric Nursing, School of Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- * E-mail:
| | - Animut Alebel
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Teshager Worku
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Ayinalem Alemu
- Department of Medical Microbiology, Ethipian Public Health Institute, Addis Ababa, Ethiopia
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25
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Abitew DB, Yalew AW, Bezabih AM, Bazzano AN. Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study. PLoS One 2020; 15:e0231524. [PMID: 32320426 PMCID: PMC7176369 DOI: 10.1371/journal.pone.0231524] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) is an effective program to manage children with acute malnutrition, including both severe and moderate acute malnutrition. However, little is known about continued child nutritional status after discharge from community based management of acute malnutrition programs in Ethiopia. OBJECTIVE The study aimed to identify factors associated with relapse of acute malnutrition among children 6-59 months after been discharged recovered from community based management program in South Gondar Zone, Northwest Ethiopia. METHODS A case-control study was conducted in three districts of South Gondar Zone by tracing children age 6-59 months who were reported as recovered from the community based management program. Sample size calculated for the first objective of assessing prevalence of severe acute malnutrition among children following discharge as recovery using Epi- Info version 7.1.3.3 StatCalc taking 95% CL, 17.8% post discharge relapse (Ashraf H, et al. (2012), 3% margin of error, design effect of 2 and adding 5% non-response rate was the largest sample size and used to this study. Children with Mid Upper Arm Circumference (MUAC) <12.5cm constituted cases and children with > = 12.5cm served as controls. Data were collected from 10 November 2017 to 30 January 2018 using a survey questionnaire and families were asked to bring children to a health facility for anthropometric measurements, following which data were entered and analyzed. Bivariate and multivariable logistic regression models were utilized to measure association between the risk factors and acute malnutrition. RESULTS Overall, 1,273 participants were interviewed. The mean age in months of children was 23.1 (±9.1 SD) for cases and 23.1 (±8.9 SD) for controls. About 40% of the cases and 50% of the controls were female children. The factors associated with acute malnutrition were: male children (AOR = 1.84, 95% CI: 1.42-2.39), living in a food insecure household (AOR = 1.67, 95% CI:1.15-2.44), non-receipt of Vitamin A supplement (AOR = 1.76, 95% CI: 1.28-2.41), prelacteal feeding (AOR = 2.81 (95%CI, 1.57-5.05), distance to water source more than 15 walk (AOR = 1.88, 95% CI:1.32-2.71), less frequent self-reported hand washing (AOR = 1.35, 95% CI:1.05-1.75), mother not having consumed extra food during this pregnancy/lactation (AOR = 1.36, 95% CI: 1.03-1.78), and respondent age above 30 years (AOR = 1.43, 95% CI:1.10-1.87). CONCLUSION The key factors contributing to relapse of acute malnutrition were related to childcare and feeding practices. Social and behavior change communication strategies targeting families at risk of undernutrition, along with improved food security and integrated programming are recommended to prevent relapse of acute malnutrition.
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Affiliation(s)
| | | | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States of America
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26
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Njuguna RG, Berkley JA, Jemutai J. Cost and cost-effectiveness analysis of treatment for child undernutrition in low- and middle-income countries: A systematic review. Wellcome Open Res 2020; 5:62. [DOI: 10.12688/wellcomeopenres.15781.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Undernutrition remains highly prevalent in low- and middle-income countries, with sub-Saharan Africa and Southern Asia accounting for majority of the cases. Apart from the health and human capacity impacts on children affected by malnutrition, there are significant economic impacts to households and service providers. The aim of this study was to determine the current state of knowledge on costs of child undernutrition treatment to households, health providers, organizations and governments in low and middle-income countries (LMICs). Methods: We conducted a systematic review of peer-reviewed studies in LMICs up to September 2019. We searched online databases including PubMed-Medline, Embase, Popline, Econlit and Web of Science. We identified additional articles through bibliographic citation searches. Only articles including costs of child undernutrition treatment were included. Results: We identified a total of 6436 articles, and only 50 met the eligibility criteria. Most included studies adopted institutional/program (45%) and health provider (38%) perspectives. The studies varied in the interventions studied and costing methods used with treatment costs reported ranging between US$0.44 and US$1344 per child. The main cost drivers were personnel, therapeutic food and productivity loss. Conclusion: There is a need to assess the burden of direct and indirect costs of child undernutrition to households and communities in order to plan, identify cost-effective solutions and address issues of cost that may limit delivery, uptake and effectiveness. Standardized methods and reporting in economic evaluations would facilitate interpretation and provide a means for comparing costs and cost-effectiveness of interventions.
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27
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The recovery rate from severe acute malnutrition among under-five years of children remains low in sub-Saharan Africa. A systematic review and meta-analysis of observational studies. PLoS One 2020; 15:e0229698. [PMID: 32187182 PMCID: PMC7080262 DOI: 10.1371/journal.pone.0229698] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/11/2020] [Indexed: 11/19/2022] Open
Abstract
Background Globally, Severe Acute Malnutrition (SAM) has been reduced by only 11% over the past 20 years and continues to be a significant cause of morbidity and mortality. So far, in Sub-Saharan Africa, several primary studies have been conducted on recovery rate and determinants of recovery from SAM in under-five children. However, comprehensive reviews that would have a shred of strong evidence for designing interventions are lacking. So, this review and meta-analysis was conducted to bridge this gap. Methods A systematic review of observational studies published in the years between 1/1/2000 to 12/31/2018 was conducted following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. Two reviewers have been searched and extracted data from CINAHL (EBSCO), MEDLINE (via Ovid), Emcare, PubMed databases, and Google scholar. Articles' quality was assessed using the Newcastle-Ottawa Scale by two independent reviewers, and only studies with fair to good quality were included in the final analysis. The review presented the pooled recovery rate from SAM and an odds ratio of risk factors affecting recovery rate after checking for heterogeneity and publication bias. The review has been registered in PROSPERO with protocol number CRD42019122085. Result Children with SAM from 54 primary studies (n = 140,148) were included. A pooled rate of recovery was 71.2% (95% CI: 68.5–73.8; I2 = 98.9%). Children who received routine medication (Pooled Odds ratio (POR):1.85;95% CI: 1.49–2.29; I2 = 0.0%), older age (POR: 1.99;95% CI: 1.29–3.08; I2 = 80.6%), and absence of co-morbidity (POR:3.2;95% CI: 2.15–4.76; I2 = 78.7%) had better odds of recovery. This systematic review and meta-analysis suggestes HIV infected children had lower recovery rate from SAM (POR; 0.19; 95% CI: 0.09–0.39; I2 = 42.9%) compared to those non-infected. Conclusion The meta-analysis deciphers that the pooled recovery rate was below the SPHERE standard, and further works would be needed to improve the recovery rate. So, factors that were identified might help to revise the plan set by the countries, and further research might be required to explore health fascilities fidelity to the WHO SAM management protocol.
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Time to Recovery from Severe Acute Malnutrition and Its Predictors among Admitted Children Aged 6-59 Months at the Therapeutic Feeding Center of Pawi General Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study. Int J Pediatr 2020; 2020:8406597. [PMID: 32231706 PMCID: PMC7086446 DOI: 10.1155/2020/8406597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/01/2020] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Background Ethiopia is one of the countries in sub-Saharan Africa with the highest rates of severe acute malnutrition. Early recovery is a performance indicator for severe acute malnourished children for the therapeutic feeding. Despite the available interventions to tackle nutritional problems, there is scarce information on time to recovery and its determinants among children with SAM in Ethiopia. Objective The study is aimed at assessing time to recovery from severe acute malnutrition and its predictors among admitted children aged 6-59 months at the therapeutic feeding center of Pawi General Hospital, northwest Ethiopia, from January 2013 to December 2017. Methods An institution-based retrospective follow-up study was conducted among 398 children aged 6-59 months. The data were collected by using data extraction sheet. The data were cleaned and entered using EpiData version 4.2.0.0 and exported to Stata version 14 statistical software for further analysis. Kaplan-Meier survival curve was used to estimate median nutritional recovery time after initiation of inpatient treatment, and log-rank test was used to compare time to recovery between groups. The Cox proportional regression model was used to identify the predictors of recovery time. Adjusted hazard rate with its 95% CI was reported to show strength of relationship. Results The recovery rate was 5.3 per 100 person-day observations, and the median recovery time was 14 days (95% CI: 13-15). The lower chance of early recovery was found among children who were not fully vaccinated (AHR: 0.73 (95% CI: 0.56, 0.96)), while high chance of recovery was found among children who had no anemia (AHR: 1.66 (95% CI: 1.23, 2.23)), TB (AHR: 2.03 (95% CI: 1.11, 3.71)), and malaria infection (AHR: 1.54 (95% CI: 1.09, 2.17)) at admission. Conclusion and Recommendation. The overall nutritional recovery rate was below the accepted minimum standard. Children not fully vaccinated and children without malaria, anemia, and TB comorbidities at admission had a higher chance of recovering early from severe acute malnutrition. Hence, treating comorbidities is vital for prompt nutritional recovery.
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Potential consequences of expanded MUAC-only programs on targeting of acutely malnourished children and ready-to-use-therapeutic-food allocation: lessons from cross-sectional surveys. BMC Nutr 2020; 6:5. [PMID: 32153978 PMCID: PMC7050718 DOI: 10.1186/s40795-019-0328-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/10/2019] [Indexed: 01/08/2023] Open
Abstract
Background Some of the recently piloted innovative approaches for the management of acute malnutrition in children use the “expanded MUAC-only” approach, with Mid Upper Arm Circumference (MUAC) < 125 mm as the sole anthropometric criterion for screening and admission, classification of cases as severe using the 115 mm cut-off, and use Ready-to-Use-Therapeutic-Food (RUTF) for the management of both moderate (MAM) and severe (SAM) cases of acute malnutrition. Our study aimed at exploring the potential consequences of this “expanded MUAC-only” program scenario on the eligibility for treatment and RUTF allocation, as compared with the existing WHO normative guidance. Methods We analyzed data from 550 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as SAM and MAM according to currently used case definitions, and calculated the proportions of SAM children who would be excluded from treatment, misclassified as MAM, or whose specific risks (because of having both MUAC and weight-for height deficits) would be ignored. We also analyzed the expected changes in the number and demographics (sex, age) of children meant to receive RUTF according to the new approach. Results We found that approximately one quarter of SAM children would not be detected and eligible for treatment under the “expanded MUAC-only” scenario, and another 20% would be classified as MAM. A further 17% of the total SAM children would be admitted and followed only according to their MUAC or oedema status, while they also present with a severe weight-for height deficit on admission. Considering MAM targeting, about half of the MAM children would be left undetected. This scenario also shows a 2.5 time increase in the number of children targeted with RUTF, with approximately 70% of MAM and 30% of SAM cases among this new RUTF target. Conclusions This empirical evidence suggests that adoption of “expanded MUAC-only” programs would likely lead to a priori exclusion from treatment or misclassifying as MAM a large proportion of SAM cases, while redirecting programmatic costs in favor of those less in need. It underscores the need to explore other options for improving the impact of programs addressing the needs of acutely malnourished children.
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30
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Abitew DB, Worku A, Mulugeta A, Bazzano AN. Rural children remain more at risk of acute malnutrition following exit from community based management of acute malnutrition program in South Gondar Zone, Amhara Region, Ethiopia: a comparative cross-sectional study. PeerJ 2020; 8:e8419. [PMID: 32071802 PMCID: PMC7008819 DOI: 10.7717/peerj.8419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition has been reported effective in terms of recovery rate, but recovered children may be at increased risk of developing acute malnutrition after returning to the same household (HH) environment. OBJECTIVE Compare the magnitude and factors associated with acute malnutrition among recovered and never treated children in South Gondar Zone, Amhara Region, Ethiopia. METHOD A comparative cross-sectional study was conducted in three districts of South Gondar Zone by tracing 720 recovered and an equal number of age matched children who were never treated for acute malnutrition. Parents were asked to bring children to health post for survey data collection, anthropometric measurements, and edema assessment. Data were collected using a survey questionnaire, entered in to EpiData and analyzed using SPSS v20. Anthropometric indices were generated according to the WHO's 2006 Child Growth Standards using WHO Anthro software version 3.2.2. Bivariate and multivariable logistic regression was utilized. Values with P < 0.05 were considered statistically significant and Odds Ratio with 95% CI was used to measure strength of association. RESULT A total of 1,440 parents were invited, of which 1,414 participated (98.2% response rate). Mean age in months of children (±SD) was 23.7 (±10.4) for recovered and 23.3 (±10.8) for comparison group. About 49% of recovered and 46% of comparison children were females. A significant difference was observed on magnitude of acute malnutrition between recovered (34.2% (95% CI [30.9-38.0]) and comparison groups (26.7% (95% CI [23.5-30.2]), P = 0.002. Factors associated with acute malnutrition among recovered were district of Ebnat (AOR = 3.7; 95% CI [1.9-7.2]), Tach-Gayint (AOR = 2.4; 95% CI [1.2-4.7]); male child (AOR = 1.4; 95% CI [1.0-2.0]); prelactal feeding (AOR = 2.6; 95% CI [1.3 -5.1]); not feeding colostrum (AOR = 1.5; 95% CI [1.1-2.3]); not consuming additional food during pregnancy/lactation (AOR = 1.6; 95% CI [1.1-2.3]); not given Vitamin A supplement (AOR = 2.1; 95% CI [1.4-3.2]); and safe child feces disposal practice (AOR = 1.7; 95% CI [1.2-2.5]) while district of Tach-Gayint (AOR = 2.5; 95% CI [1.3-4.8]); male child (AOR = 1.5; 95% CI [1.1-2.1]), not feeding colostrum (AOR = 1.7; 95% CI [1.2-2.5]), poor hand washing practice (AOR = 1.6; 95% CI [1.1-2.2]); food insecure HH (AOR = 1.6; 95% CI [1.1-2.4]), birth interval <24 months (AOR = 1.9; 95% CI [1.2-3.2]), and poor access to health facility (AOR = 1.7; 95% CI [1.2-2.4]) were factors associated with acute malnutrition among comparison group. CONCLUSION Recovered children were more at risk of acute malnutrition than the comparison group. Nutrition programs should invest in improving nutrition counseling and education; as well as the hygienic practices to protect children against post-discharge relapse of acute malnutrition.
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Affiliation(s)
- Dereje B. Abitew
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
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Adimasu M, Sebsibie G, Abebe F, Baye G, Abere K. Recovery time from severe acute malnutrition and associated factors among under-5 children in Yekatit 12 Hospital, Addis Ababa, Ethiopia: a retrospective cohort study. Epidemiol Health 2020; 42:e2020003. [PMID: 32023778 PMCID: PMC7056942 DOI: 10.4178/epih.e2020003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/02/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Recovery time from severe acute malnutrition (SAM) is often a neglected topic despite its clinical impact. Although a few studies have examined nutritional recovery time, the length of hospitalization in those studies varied greatly. Therefore, the aim of this study was to determine the recovery time from SAM and to identify predictors of length of hospitalization among under-5 children. METHODS A retrospective cohort study was conducted among 423 under-5 children with SAM who had been admitted to Yekatit 12 Hospital. Kaplan-Meier analysis was used to estimate time to nutritional recovery, and Cox proportional hazard regression analysis was performed to determine independent predictors. RESULTS The nutritional recovery rate was 81.3%, and the median recovery time was 15.00 days (95% confidence interval [CI], 13.61 to 16.39). Age, daily weight gain per kilogram of body weight, vaccination status, and the existence of at least 1 comorbidity (e.g., pneumonia, stunting, shock, and deworming) were found to be significant independent predictors of nutritional recovery time. The adjusted hazard ratio (aHR) for nutritional recovery decreased by 1.9% for every 1-month increase in child age (aHR, 0.98; 95% CI, 0.97 to 0.99). CONCLUSIONS The overall nutritional recovery time in this study was within the Sphere standards. However, approximately 13.0% of children stayed in the hospital for more than 28.00 days, which is an unacceptably large proportion. Daily weight gain of ≥8 g/kg, full vaccination, and deworming with albendazole or mebendazole reduced nutritional recovery time. Conversely, older age, pneumonia, stunting, and shock increased nutritional recovery time.
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Affiliation(s)
- Mekonen Adimasu
- School of Nursing, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Girum Sebsibie
- School of Nursing, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Fikrtemariam Abebe
- School of Nursing, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Getaneh Baye
- Debre Berhan University College of Medicine, Debre-Berhan, Ethiopia
| | - Kerebih Abere
- School of Nursing, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
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Rogers E, Tappis H, Doocy S, Martínez K, Villeminot N, Suk A, Kumar D, Pietzsch S, Puett C. Costs and cost-effectiveness of three point-of-use water treatment technologies added to community-based treatment of severe acute malnutrition in Sindh Province, Pakistan. Glob Health Action 2019; 12:1568827. [PMID: 30888265 PMCID: PMC6427553 DOI: 10.1080/16549716.2019.1568827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Severe acute malnutrition (SAM) is a major global public health concern. Despite the cost-effectiveness of treatment, ministries of health are often unable to commit the required funds which limits service coverage. Objective: A randomised controlled trial was conducted in Sindh Province, Pakistan, to assess whether adding a point of use water treatment to the treatment of SAM without complications improved its cost-effectiveness. Three treatment strategies – chlorine disinfection (Aquatabs); flocculent disinfection (Procter and Gamble Purifier of Water [P&G PoW]) and Ceramic Filters – were compared to a standard SAM treatment protocol. Methods: An institutional perspective was adopted for costing, considering the direct and indirect costs incurred by the provider. Combining the cost of SAM treatment and water treatment, an average cost per child was calculated for the combined interventions for each arm. The costs of water treatment alone and the incremental cost-effectiveness of each water treatment intervention were also assessed. Results: The incremental cost-effectiveness ratio for Aquatabs was 24 US dollars (USD), making it the most cost-effective strategy. The P&G PoW arm was the next least expensive strategy, costing an additional 149 USD per additional child recovered, though it was also the least effective of the three intervention strategies. The Ceramic Filters intervention was the most costly strategy and achieved a recovery rate lower than the Aquatabs arm and marginally higher than the P&G PoW arm. Conclusions: This study found that the addition of a chlorine or flocculent disinfection point-of-use drinking water treatment intervention to the treatment of SAM without complications reduced the cost per child recovered compared to standard SAM treatment. To inform the feasibility of future implementation, further research is required to understand the costs of government implementation and the associated costs to the community and beneficiary household of receiving such an intervention in comparison with the existing SAM treatment protocol.
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Affiliation(s)
| | - Hannah Tappis
- b Department of International Health , Johns Hopkins Bloomberg School of Public Health, Department of International Health , Baltimore , MD , USA
| | - Shannon Doocy
- b Department of International Health , Johns Hopkins Bloomberg School of Public Health, Department of International Health , Baltimore , MD , USA
| | - Karen Martínez
- c Operations department , Action Against Hunger USA , New York , NY , USA
| | - Nicolas Villeminot
- c Operations department , Action Against Hunger USA , New York , NY , USA
| | - Ann Suk
- d Programme department , Action Against Hunger Pakistan , Islamabad , Pakistan
| | - Deepak Kumar
- d Programme department , Action Against Hunger Pakistan , Islamabad , Pakistan
| | - Silke Pietzsch
- c Operations department , Action Against Hunger USA , New York , NY , USA
| | - Chloe Puett
- c Operations department , Action Against Hunger USA , New York , NY , USA
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Wagnew F, Dessie G, Takele WW, Tadesse A, Islam SMS, Mulugeta H, Haile D, Negesse A, Abajobir AA. A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia. BMC Public Health 2019; 19:1175. [PMID: 31455292 PMCID: PMC6712890 DOI: 10.1186/s12889-019-7466-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/11/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Severe forms of malnutrition have drastic effects on childhood morbidity and mortality in sub-Saharan countries, including Ethiopia. Although few studies have previously estimated treatment outcomes of severe acute malnutrition (SAM) in Ethiopia, the findings were widely varied and inconsistent. This study thus aimed to pool estimates of treatment outcomes and identify predictors of mortality among children with SAM in Ethiopia. METHODS A systematic review was carried out to select 21 eligible articles from identified 1013 studies (dating from 2000 to 2018) that estimated treatment outcomes and predictors of mortality among SAM children. Databases including PubMed, CINHAL, Web of Sciences; Cochrane, Psych INFO and Google Scholar were comprehensively reviewed using medical subject headings (MESH) and a priori set criteria PRISMA guideline was used to systematically review and meta-analyze eligible studies. Details of sample size, magnitude of effect sizes, including Hazard Ratio (HRs) and standard errors were extracted. Random-effects model was used to calculate pooled estimates in Stata/se version-14. Cochran's Q, I2, and meta-bias statistics were assessed for heterogeneity and Egger's test for publication bias. RESULT Twenty-one studies were included in the final analysis, which comprised 8057 under-five children with SAM in Ethiopia. The pooled estimates of treatment outcomes, in terms of death, recovery, defaulter and transfer out and non-response rates were 10.3% (95% CI: 8.3, 12.3), 70.5% (95% CI: 65.7, 72.2), 13.8% (95% CI: 10.8, 16.9) and 5.1% (95% CI: 3.3, 6.9), respectively. Diarrhea (HR: 1.5, 95% CI: 1.1, 2.2), dehydration (HR: 3.1, 95% CI: 2.3, 4.2) and anemia (HR: 2.2, 95% CI: 1.5, 3.3) were statistically significant predictors of mortality among these children. No publication bias was detected. CONCLUSION Treatment outcomes in under-five children with SAM are lower than the World Health Organization (WHO) standard, where mortality is being predicted by comorbidities at admission. Children with SAM need to be treated for diarrhea, dehydration and anemia at the primary point of care to reduce mortality.
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Affiliation(s)
- Fasil Wagnew
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Getenet Dessie
- College of Health Sciences, Bahirdar University, Bahirdar, Ethiopia
| | | | - Aster Tadesse
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | | | - Henok Mulugeta
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Dessalegn Haile
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Ayenew Negesse
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Amanuel Alemu Abajobir
- Faculty of Medicine/school of Public Health, The University of Queensland, Brisbane, Australia
- African Population and Health Research Center, Maternal and Child Wellbeing Unit, Nairobi, Kenya
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Kangas ST, Salpéteur C, Nikièma V, Talley L, Ritz C, Friis H, Briend A, Kaestel P. Impact of reduced dose of ready-to-use therapeutic foods in children with uncomplicated severe acute malnutrition: A randomised non-inferiority trial in Burkina Faso. PLoS Med 2019; 16:e1002887. [PMID: 31454351 PMCID: PMC6711495 DOI: 10.1371/journal.pmed.1002887] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/23/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children with uncomplicated severe acute malnutrition (SAM) are treated at home with ready-to-use therapeutic foods (RUTFs). The current RUTF dose is prescribed according to the weight of the child to fulfil 100% of their nutritional needs until discharge. However, there is doubt concerning the dose, as it seems to be shared, resulting in suboptimal cost-efficiency of SAM treatment. We investigated the efficacy of a reduced RUTF dose in community-based treatment of uncomplicated SAM. METHODS AND FINDINGS We undertook a randomised trial testing the non-inferiority of weight gain velocity of children with SAM receiving (a) a standard RUTF dose for two weeks, followed by a reduced dose thereafter (reduced), compared with (b) a standard RUTF dose throughout the treatment (standard). A mean difference of 0.0 g/kg/day was expected, with a non-inferiority margin fixed at -0.5 g/kg/day. Linear and logistic mixed regression analyses were performed, with study site and team as random effects. Between October 2016 and July 2018, 801 children with uncomplicated SAM aged 6-59 months were enrolled from 10 community health centres in Burkina Faso. At admission, the mean age (± standard deviation [SD]) was 13.4 months (±8.7), 49% were male, and the mean weight was 6.2 kg (±1.3). The mean weight gain velocity from admission to discharge was 3.4 g/kg/day and did not differ between study arms (Δ 0.0 g/kg/day; 95% CI -0.4 to 0.4; p = 0.92) confirming non-inferiority (p = 0.013). However, after two weeks, the weight gain velocity was significantly lower in the reduced dose with a mean of 2.3 g/kg/day compared with 2.7 g/kg/day in the standard dose (Δ -0.4 g/kg/day; 95% CI -0.8 to -0.02; p = 0.041). The length of stay (LoS) was not different (p = 0.73) between groups with a median of 56 days (interquartile range [IQR] 35-91) in both arms. No differences were found between reduced and standard arm in recovery (52.7% and 55.4%; p = 0.45), referral (19.2% and 20.1%; p = 0.80), defaulter (12.2% and 8.5%; p = 0.088), non-response (12.7% and 12.5%; p = 0.95), and relapse (2.4% and 1.8%; p = 0.69) rates, respectively. However, the reduced RUTF dose had a small 0.2 mm/week (95% CI 0.04 to 0.4; p = 0.015) negative effect on height gain velocity with a mean height gain of 2.6 mm/week with reduced and 2.8 mm/week with standard RUTF dose. The impact was more pronounced in children under 12 months of age (interaction, p = 0.019) who gained 2.8 mm/week with reduced and 3.1 mm/week with standard dose (Δ -0.4 mm/week; 95% CI -0.6 to -0.2; p < 0.001). Limitations include not blinding participants to the RUTF dose received and excluding all children with negative appetite test. The results are generalisable for relatively food secure contexts with a young SAM population. CONCLUSIONS Reducing the RUTF dose provided to children with SAM after two weeks of treatment did not reduce overall weight or mid-upper arm circumference (MUAC) gain velocity nor affect recovery or lengthen treatment time. However, it led to a small but significant negative effect on linear growth, especially among the youngest. The potential effect of reducing the RUTF dose in a routine program on treatment outcomes should be evaluated before scaling up. TRIAL REGISTRATION ISRCTN registry ISRCTN50039021.
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Affiliation(s)
- Suvi T. Kangas
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
- * E-mail:
| | - Cécile Salpéteur
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
| | - Victor Nikièma
- Nutrition and Health Department, Action Against Hunger (ACF) mission, Ouagadougou, Burkina Faso
| | - Leisel Talley
- Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, University of Tampere School of Medicine, Tampere University, Tampere, Finland
| | - Pernille Kaestel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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Isanaka S, Berthé F, Nackers F, Tang K, Hanson KE, Grais RF. Feasibility of engaging caregivers in at-home surveillance of children with uncomplicated severe acute malnutrition. MATERNAL AND CHILD NUTRITION 2019; 16:e12876. [PMID: 31336045 PMCID: PMC7038908 DOI: 10.1111/mcn.12876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/29/2019] [Accepted: 07/03/2019] [Indexed: 11/25/2022]
Abstract
Many factors can contribute to low coverage of treatment for severe acute malnutrition (SAM), and a limited number of health facilities and trained personnel can constrain the number of children that receive treatment. Alternative models of care that shift the responsibility for routine clinical and anthropometric surveillance from the health facility to the household could reduce the burden of care associated with frequent facility-based visits for both healthcare providers and caregivers. To assess the feasibility of shifting clinical surveillance to caregivers in the outpatient management of SAM, we conducted a pilot study to assess caregivers' understanding and retention of key concepts related to the surveillance of clinical danger signs and anthropometric measurement over a 28-day period. At the time of a child's admission to nutritional treatment, a study nurse provided a short training to groups of caregivers on two topics: (a) clinical danger signs in children with SAM that warrant facility-based care and (b) methods to measure and monitor their child's mid-upper arm circumference. Caregiver understanding was assessed using standardized questionnaires before training, immediately after training, and 28 days after training. Knowledge of most clinical danger signs (e.g., convulsions, edema, poor appetite, respiratory distress, and lethargy) was low (0-45%) before training but increased immediately after and was retained 28 days after training. Agreement between nurse-caregiver mid-upper arm circumference colour classifications was 77% (98/128) immediately after training and 80% after 28 days. These findings lend preliminary support to pursue further study of alternative models of care that allow for greater engagement of caregivers in the clinical and anthropometric surveillance of children with SAM.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France.,Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Kevin Tang
- Department of Research, Epicentre, Paris, France
| | - Kerstin E Hanson
- Médecins Sans Frontières Operational Center of Paris, Paris, France
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Schoonees A, Lombard MJ, Musekiwa A, Nel E, Volmink J. Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age. Cochrane Database Syst Rev 2019; 5:CD009000. [PMID: 31090070 PMCID: PMC6537457 DOI: 10.1002/14651858.cd009000.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch-up growth is the main focus and the recommended energy and protein requirements are much higher. In-hospital rehabilitation of children with SAM is not always desirable or practical - especially in rural settings - and home-based care can offer a better solution. Ready-to-use therapeutic food (RUTF) is a widely used option for home-based rehabilitation, but the findings of our previous review were inconclusive. OBJECTIVES To assess the effects of home-based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain. SEARCH METHODS We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost-effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes. DATA COLLECTION AND ANALYSIS We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random-effects meta-analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison. MAIN RESULTS We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source.The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta-analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV-infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV-uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes.We found seven studies with 2261 children comparing home-based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate-quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low-quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low-quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low-quality evidence).Two quasi-randomised cluster trials compared standard, home-based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta-analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low-quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low-quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low-quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI - 0.74 to 3.16; very low-quality evidence).Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home-based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre- and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high-quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high-quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate-quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI -0.32 to 0.54; 6 studies, 3807 children; low-quality evidence) whether standard or alternative formulation RUTF is used. AUTHORS' CONCLUSIONS Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well-designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed.
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Affiliation(s)
- Anel Schoonees
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
| | - Martani J Lombard
- North‐West UniversityCentre of Excellence for Nutrition (CEN)Hoffman StreetPotchefstroomPotchefstroomNorth West ProvinceSouth Africa2025
| | - Alfred Musekiwa
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
| | - Etienne Nel
- Stellenbosch UniversityDepartment of Paediatrics and Child Health, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
| | - Jimmy Volmink
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesFrancie van Zijl DriveCape TownWestern CapeSouth Africa7505
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Wagnew F, Worku W, Dejenu G, Alebel A, Eshetie S. An overview of the case fatality of inpatient severe acute malnutrition in Ethiopia and its association with human immunodeficiency virus/tuberculosis comorbidity-a systematic review and meta-analysis. Int Health 2019; 10:405-411. [PMID: 29986102 DOI: 10.1093/inthealth/ihy043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background Mortality of children with severe acute malnutrition (SAM) is a devastating problem in Ethiopia. This study estimated the pooled case fatality ratio of SAM among children <5 y of age and its association with comorbidity. Methods An electronic search was carried out using the database of MEDLINE/PubMed through the HINARI Programme, Google Scholar and Google for grey literature. A random effects model was used to estimate the pooled case fatality ratio of SAM and the hazard ratio (HR) of human immunodeficiency virus (HIV)/tuberculosis (TB) comorbidity using Stata/SE version 14. Results A total of 13 studies were included in the meta-analysis. The overall case fatality ratio of SAM among children <5 y of age in Ethiopia was 11.3% (95% confidence interval [CI] 8.8-13.7) with the I2 heterogeneity test (I2=89.5%). Furthermore, the HR of SAM children was 3.4 (95% CI 1.91-6.06) in HIV and 2.08 (95% CI 1.2-3.61) in TB comorbidity as compared with their counterparts without comorbidity. Conclusions In the aggregate, the pooled case fatality ratio was unacceptably high in Ethiopia. The case fatality ratio of SAM children is higher in HIV and TB comorbidity. Therefore, escalation of the existing nutritional strategies and early case detection of comorbidity are strongly recommended to mitigate the case fatality ratio of SAM.
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Affiliation(s)
- Fasil Wagnew
- Department of Nursing, College of Medicine and Health Sciences, DebreMarkos University, Debre Markos, Ethiopia
| | - Wubet Worku
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getiye Dejenu
- Department of Public Health College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Animut Alebel
- Department of Nursing, College of Medicine and Health Sciences, DebreMarkos University, Debre Markos, Ethiopia
| | - Setegn Eshetie
- College of Health Science, University of Gondar, Gondar, Ethiopia
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Rogers E, Guerrero S, Kumar D, Soofi S, Fazal S, Martínez K, Morán JLA, Puett C. Evaluation of the cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by lady health workers as compared to an outpatient therapeutic feeding programme in Sindh Province, Pakistan. BMC Public Health 2019; 19:84. [PMID: 30654780 PMCID: PMC6337795 DOI: 10.1186/s12889-018-6382-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Due to the limited evidence of the cost-effectiveness of Community Health Workers (CHW) delivering treatment for severe acute malnutrition (SAM), there is a need to better understand the costs incurred by both implementing institutions and beneficiary households. This study assessed the costs and cost-effectiveness of treatment for cases of SAM without complications delivered by government-employed Lady Health Workers (LHWs) and complemented with non-governmental organisation (NGO) delivered outpatient facility-based care compared with NGO delivered outpatient facility-based care only alongside a two-arm randomised controlled trial conducted in Sindh Province, Pakistan. METHODS An activity-based cost model was used, employing a societal perspective to include costs incurred by beneficiaries and the wider community. Costs were estimated through accounting records, interviews and informal group discussions. Cost-effectiveness was assessed for each arm relative to no intervention, and incrementally between the two interventions, providing information on both absolute and relative costs and effects. RESULTS The cost per child recovered in outpatient facility-based care was similar to LHW-delivered care, at 363 USD and 382 USD respectively. An additional 146 USD was spent per additional child recovered by outpatient facilities compared to LHWs. Results of sensitivity analyses indicated considerable uncertainty in which strategy was most cost-effective due to small differences in cost and recovery rates between arms. The cost to the beneficiary household of outpatient facility-based care was double that of LHW-delivered care. CONCLUSIONS Outpatient facility-based care was found to be slightly more cost-effective compared to LHW-delivered care, despite the potential for cost-effectiveness of CHWs managing SAM being demonstrated in other settings. The similarity of cost-effectiveness outcomes between the two models resulted in uncertainty as to which strategy was the most cost-effective. Similarity of costs and effectiveness between models suggests that whether it is appropriate to engage LHWs in substituting or complementing outpatient facilities may depend on population needs, including coverage and accessibility of existing services, rather than be purely a consideration of cost. Future research should assess the cost-effectiveness of LHW-delivered care when delivered solely by the government. TRIAL REGISTRATION NCT03043352 , ClinicalTrials.gov. Retrospectively registered.
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Affiliation(s)
- Eleanor Rogers
- Action Against Hunger UK, 161-163 Greenwich High Road, London, SE10 0JA UK
| | - Saul Guerrero
- Action Against Hunger USA, One Whitehall St, New York, NY 10004 USA
| | - Deepak Kumar
- Action Against Hunger Pakistan, 3rd Floor, 65 West Executive Heights, Fazal E Haq Road, Blue Area, Islamabad, Pakistan
| | - Sajid Soofi
- Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800 Pakistan
| | - Shahid Fazal
- Action Against Hunger Pakistan, 3rd Floor, 65 West Executive Heights, Fazal E Haq Road, Blue Area, Islamabad, Pakistan
| | - Karen Martínez
- Action Against Hunger USA, One Whitehall St, New York, NY 10004 USA
| | | | - Chloe Puett
- Action Against Hunger USA, One Whitehall St, New York, NY 10004 USA
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Goudet S, Jayaraman A, Chanani S, Osrin D, Devleesschauwer B, Bogin B, Madise N, Griffiths P. Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India. PLoS One 2018; 13:e0205688. [PMID: 30412636 PMCID: PMC6226164 DOI: 10.1371/journal.pone.0205688] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 09/28/2018] [Indexed: 11/19/2022] Open
Abstract
Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously. This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted. The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition.
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Affiliation(s)
- S. Goudet
- Loughborough University, School of Sport Exercise and Health Sciences, Loughborough, United Kingdom
- * E-mail:
| | | | | | - D. Osrin
- UCL Institute for Global Health, London, United Kingdom
| | - B. Devleesschauwer
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
- Department of Veterinary Public Health and Food Safety, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - B. Bogin
- Loughborough University, School of Sport Exercise and Health Sciences, Loughborough, United Kingdom
| | - N. Madise
- African Institute for Development Policy, Lilongwe, Malawi
| | - P. Griffiths
- Loughborough University, School of Sport Exercise and Health Sciences, Loughborough, United Kingdom
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Wagnew F, Tesgera D, Mekonnen M, Abajobir AA. Predictors of mortality among under-five children with severe acute malnutrition, Northwest Ethiopia: an institution based retrospective cohort study. Arch Public Health 2018; 76:64. [PMID: 30275951 PMCID: PMC6158814 DOI: 10.1186/s13690-018-0309-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 08/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, approximately 19 million children under 5 years are suffering from Severe Acute Malnutrition (SAM). It is a major cause of morbidity and mortality in low-income countries including Ethiopia. However, little is known regarding predictors of mortality among these children in Ethiopia. The current study aimed to assess the potential predictors of mortality among under-five children with SAM admitted to a stabilization center. METHOD A retrospective cohort study was conducted in 527 under-five children who were admitted for SAM at the University of Gondar comprehensive specialized hospital from 2014 to 2016. Data were collected from a randomly selected chart after getting ethical clearance. Data were cleaned, coded and entered to Epi-info (version 7) and analyzed using STATA (version14). The outcome was computed by using tables and graphs. A multivariable cox proportional hazards model was fitted to identify predictors of mortality. RESULT Overall, the median follow-up period was 10 days with interquartile range (Q1, Q3: 8, 17). At the end of the follow-up, the mortality rate was 66(12.52%). Anemia (AHR(Adjusted Hazard Ratio): 2.3, 95% CI: 1.2, 4.5), Shock (AHR: 7.9, 95% CI: 3.7, 16.7), no intake of antibiotics (AHR: 2.3 95% CI: 1.2, 4.4), IV-Fluid (AHR: 3.2, 95% CI: 1.7, 5.8), no intake of F75 (AHR: 6.6,95% CI: 2.9, 14.7) and no intake of F100 (AHR: 3, 95% CI: 1.6, 5.4) were independent predictors of mortality. CONCLUSION The survival status of under-five children with SAM was lower than the national standard protocol. Altered general conditions such as shock, anemia, not adhering to medical and nutritional therapies were identified as predictors of mortality among SAM children. Health education on early medical seeking behavior and adherence on the routine regimens may improve this gap in child survival.
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Affiliation(s)
- Fasil Wagnew
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Treatment Outcome of Severe Acute Malnutrition and Its Determinants among Pediatric Patients in West Ethiopia. Int J Pediatr 2018; 2018:8686501. [PMID: 30154873 PMCID: PMC6091446 DOI: 10.1155/2018/8686501] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/30/2018] [Accepted: 07/18/2018] [Indexed: 11/18/2022] Open
Abstract
Background Malnutrition is a silent killer that is underreported, underaddressed, and as a result underprioritized. It is reported that severe acute malnutrition is the commonest reason for pediatrics hospital admission in many poor countries; 25 to 30% of children with severe malnutrition die during hospital admissions. Objective To determine treatment outcome of severe acute malnutrition and identify its determinants among pediatric patients in pediatrics ward of Nekemte Referral Hospital. Methods A retrospective hospital-based cross-sectional study was done from November 2015 to April 2017. Data had been collected by using checklist for recording information from patient card and register book. Association between independent variables and depend variable was assessed using bivariate and stepwise multivariable logistic regression, respectively. Level of statistical significance was declared at p value < 0.05. Results Out of 205 admitted children with severe acute malnutrition, 137 (66.8%) cases were cured from SAM, 9 (4.4%) cases were died because of SAM, and (16.6%) cases were defaulter from SAM management, and 25 (12.2%) cases were transferred out. Multivariable logistic regression showed that children admitted with both edema and wasting AOR = 8.30, 95% CI (1.72, 40.09) P=0.008, children without hypothermia AOR = 2.91, 95%CI (1.10, 7.69) P=0.031, children who stay 8-14 days AOR = 3.86, 95%CI (1.01, 14.75) P=0.048, children without pneumonia AOR = 7.82, 95%CI (2.74, 222.29) P=0.001, children without anemia AOR = 3.22, 95%CI (1.04, 9.97) P=0.042, and children without HIV AOR = 9.21, 95% CI (2.20, 38.54) P=0.002 were more likely to be cured from severe acute malnutrition. Conclusion Treatment outcome of severe acute malnutrition in this study is good. It shows that around three-fourths of the children were cured. Factors such as admission criteria, hypothermia, length of stay, pneumonia, anemia, and presence of HIV were associated with treatment response.
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Isanaka S, Hedt-Gauthier BL, Grais RF, Allen BGS. Estimating program coverage in the treatment of severe acute malnutrition: a comparative analysis of the validity and operational feasibility of two methods. Popul Health Metr 2018; 16:11. [PMID: 29970172 PMCID: PMC6029157 DOI: 10.1186/s12963-018-0167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 06/19/2018] [Indexed: 11/18/2022] Open
Abstract
Background Many health programs can assess coverage using standardized cluster survey methods, but estimating the coverage of nutrition programs presents a special challenge due to low disease prevalence. Used since 2012, the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) employs both qualitative and quantitative methods to identify key barriers to access and estimate coverage of therapeutic feeding programs. While the tool has been increasingly used in programs, the validity of certain methodological elements has been the subject of debate. Methods We conducted a study comparing a SQUEAC conjugate Bayesian analysis to a two-stage cluster survey estimating the coverage of a therapeutic feeding program in Niger in 2016. Results We found that the coverage estimate from the conjugate Bayesian analysis was sensitive to the prior estimation. With the exception of prior estimates produced by an external support team, all prior estimates resulted in a conflict with the likelihood result, excluding interpretation of the final coverage estimate. Allowing for increased uncertainty around the prior estimate did not materially affect conclusions. Conclusion SQUEAC is a demanding analytical method requiring both qualitative and quantitative data collection and synthesis to identify program barriers and estimate coverage. If the necessary technical capacity is not available to objectively specify an accurate prior for a conjugate Bayesian analysis, alternatives, such as a two-stage cluster survey or a larger likelihood survey, may be considered to ensure valid coverage estimation. Trial registration NCT03280082. Retrospectively registered on September 12, 2017. Electronic supplementary material The online version of this article (10.1186/s12963-018-0167-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, 8 rue Saint Sabin, 75011, Paris, France. .,Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA.
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Rebecca F Grais
- Department of Research, Epicentre, 8 rue Saint Sabin, 75011, Paris, France
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Puett C, Salpéteur C, Houngbe F, Martínez K, N'Diaye DS, Tonguet-Papucci A. Costs and cost-efficiency of a mobile cash transfer to prevent child undernutrition during the lean season in Burkina Faso: a mixed methods analysis from the MAM'Out randomized controlled trial. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:13. [PMID: 29686539 PMCID: PMC5899398 DOI: 10.1186/s12962-018-0096-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 03/28/2018] [Indexed: 12/03/2022] Open
Abstract
Background This study assessed the costs and cost-efficiency of a mobile cash transfer implemented in Tapoa Province, Burkina Faso in the MAM’Out randomized controlled trial from June 2013 to December 2014, using mixed methods and taking a societal perspective by including costs to implementing partners and beneficiary households. Methods Data were collected via interviews with implementing staff from the humanitarian agency and the private partner delivering the mobile money, focus group discussions with beneficiaries, and review of accounting databases. Costs were analyzed by input category and activity-based cost centers. cost-efficiency was analyzed by cost-transfer ratios (CTR) and cost per beneficiary. Qualitative analysis was conducted to identify themes related to implementing electronic cash transfers, and barriers to efficient implementation. Results The CTR was 0.82 from a societal perspective, within the same range as other humanitarian transfer programs; however the intervention did not achieve the same degree of cost-efficiency as other mobile transfer programs specifically. Challenges in coordination between humanitarian and private partners resulted in long wait times for beneficiaries, particularly in the first year of implementation. Sensitivity analyses indicated a potential 6% reduction in CTR through reducing beneficiary wait time by one-half. Actors reported that coordination challenges improved during the project, therefore inefficiencies likely would be resolved, and cost-efficiency improved, as the program passed the pilot phase. Conclusions Despite the time required to establish trusting relationships among actors, and to set up a network of cash points in remote areas, this analysis showed that mobile transfers hold promise as a cost-efficient method of delivering cash in this setting. Implementation by local government would likely reduce costs greatly compared to those found in this study context, and improve cost-efficiency especially by subsidizing expansion of mobile money network coverage and increasing cash distribution points in remote areas which are unprofitable for private partners.
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Affiliation(s)
- Chloe Puett
- Research and Technical Department, Action Against Hunger, New York, NY USA
| | - Cécile Salpéteur
- 2Department of Expertise and Advocacy, Action contre la Faim, Paris, France
| | - Freddy Houngbe
- 2Department of Expertise and Advocacy, Action contre la Faim, Paris, France
| | - Karen Martínez
- Research and Technical Department, Action Against Hunger, New York, NY USA
| | - Dieynaba S N'Diaye
- 2Department of Expertise and Advocacy, Action contre la Faim, Paris, France
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Lelijveld N, Bailey J, Mayberry A, Trenouth L, N’Diaye DS, Haghparast-Bidgoli H, Puett C. The "ComPAS Trial" combined treatment model for acute malnutrition: study protocol for the economic evaluation. Trials 2018; 19:252. [PMID: 29690899 PMCID: PMC5916722 DOI: 10.1186/s13063-018-2594-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/14/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child's weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM. METHOD This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant. DISCUSSION We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies. TRIAL REGISTRATION ISRCTN 30393230 , date: 16/03/2017.
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Affiliation(s)
- Natasha Lelijveld
- No Wasted Lives, Action Against Hunger UK, London, UK
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeanette Bailey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- International Rescue Committee, New York, NY USA
| | - Amy Mayberry
- No Wasted Lives, Action Against Hunger UK, London, UK
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Garg CC, Mazumder S, Taneja S, Shekhar M, Mohan SB, Bose A, Iyengar SD, Bahl R, Martines J, Bhandari N. Costing of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition from a randomised trial in India. BMJ Glob Health 2018. [PMID: 29527358 PMCID: PMC5841493 DOI: 10.1136/bmjgh-2017-000702] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Trial design Three feeding regimens—centrally produced ready-to-use therapeutic food, locally produced ready-to-use therapeutic food, and augmented, energy-dense, home-prepared food—were provided in a community setting for children with severe acute malnutrition (SAM) in the age group of 6–59 months in an individually randomised multicentre trial that enrolled 906 children. Foods, counselling, feeding support and treatment for mild illnesses were provided until recovery or 16 weeks. Methods Costs were estimated for 371 children enrolled in Delhi in a semiurban location after active survey and identification, enrolment, diagnosis and treatment for mild illnesses, and finally treatment with one of the three regimens, both under the research and government setting. Direct costs were estimated for human resources using a price times quantity approach, based on their salaries and average time taken for each activity. The cost per week per child for food, medicines and other consumables was estimated based on the total expenditure over the period and children covered. Indirect costs for programme management including training, transport, non-consumables, infrastructure and equipment were estimated per week per child based on total expenditures for research study and making suitable adjustments for estimations under government setting. Results No significant difference in costs was found across the three regimens per covered or per treated child. The average cost per treated child in the government setting was estimated at US$56 (<3500 rupees). Conclusion Home-based management of SAM with a locally produced ready-to-use therapeutic food is feasible, acceptable, affordable and very cost-effective in terms of the disability-adjusted life years saved and gross national income per capita of the country. The treatment of SAM at home needs serious attention and integration into the existing health system, along with actions to prevent SAM. Trial registration number NCT01705769; Pre-results.
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Affiliation(s)
- Charu C Garg
- International Consultant and Visiting Professor, Institute for Human Development, New Delhi, India
| | - Sarmila Mazumder
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Medha Shekhar
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Anuradha Bose
- Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sharad D Iyengar
- Research and Evaluation Department, Action Research and Training for Health, Udaipur, Rajasthan, India
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Jose Martines
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
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Rogers E, Martínez K, Morán JLA, Alé FGB, Charle P, Guerrero S, Puett C. Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali. HUMAN RESOURCES FOR HEALTH 2018; 16:12. [PMID: 29458382 PMCID: PMC5819265 DOI: 10.1186/s12960-018-0273-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 01/29/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.
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Affiliation(s)
- Eleanor Rogers
- Action Against Hunger UK, First Floor - Rear Premises - 161-163 Greenwich High Road - London, London, SE10 8JA UK
| | - Karen Martínez
- Action Against Hunger USA, One Whitehall St, New York, NY 10004 USA
| | - Jose Luis Alvarez Morán
- Action Against Hunger UK, First Floor - Rear Premises - 161-163 Greenwich High Road - London, London, SE10 8JA UK
| | - Franck G. B. Alé
- Area of Preventive Medicine and Public Health, Rey Juan Carlos University, Avda. Atenas s/n, 28922 Alcorcón (Madrid), Spain
| | - Pilar Charle
- Fundación Acción Contra el Hambre | ACF-Spain, C/ del Duque de Sevilla, 328002 Madrid, Spain
| | - Saul Guerrero
- Action Against Hunger USA, One Whitehall St, New York, NY 10004 USA
| | - Chloe Puett
- Action Against Hunger USA, One Whitehall St, New York, NY 10004 USA
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Skar AMS, De Abreu RM, Vaughn MJ. Strengthening a Whole Child Approach within Residential Care Settings Through Psychosocial Support and Nutritional Guidance. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/13575279.2017.1371670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lanyero B, Namusoke H, Nabukeera-Barungi N, Grenov B, Mupere E, Michaelsen KF, Mølgaard C, Christensen VB, Friis H, Briend A. Transition from F-75 to ready-to-use therapeutic food in children with severe acute malnutrition, an observational study in Uganda. Nutr J 2017; 16:52. [PMID: 28854929 PMCID: PMC5577749 DOI: 10.1186/s12937-017-0276-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND World Health Organization now recommends the transition from F-75 to ready-to-use therapeutic foods (RUTF) in the management of severe acute malnutrition (SAM). We described the transition from F-75 to RUTF and identified correlates of failed transition. METHODS We conducted an observational study among children aged 6-59 months treated for SAM at Mulago hospital, Kampala, Uganda. Therapeutic feeding during transition phase was provided by first offering half of the energy requirements from RUTF and the other half from F-75 and then increasing gradually to RUTF as only energy source. The child was considered to have successfully transitioned to RUTF if child was able to gradually consume up to 135 kcal/kg/day of RUTF in the transition phase on first attempt. Failed transition to RUTF included children who failed the acceptance test or those who had progressively reduced RUTF intake during the subsequent days. Failure also included those who developed profuse diarrhoea or vomiting when RUTF was ingested. RESULTS Among 341 of 400 children that reached the transition period, 65% successfully transitioned from F-75 to RUTF on first attempt while 35% failed. The median (IQR) duration of the transition period was 4 (3-8) days. The age of the child, mid-upper arm circumference, weight-for-height z-score and weight at transition negatively predicted failure. Each month increase in age reflected a 4% lower likelihood of failure (OR 0.96 (95% CI 0.93; 0.99). Children with HIV (OR 2.73, 95% CI 1.27; 5.85) and those rated as severely ill by caregiver (OR 1.16, 95% CI: 1.02; 1.32) were more likely to fail. At the beginning of the rehabilitation phase, the majority (95%) of the children eventually accepted RUTF while only 5% completed rehabilitation in hospital on F-100. CONCLUSION Transition from F-75 to RUTF for hospitalized children with SAM by gradual increase of RUTF was possible on first attempt in 65% of cases. Younger children, severely wasted, HIV infected and those with severe illness as rated by the caregiver were more likely to fail to transit from F-75 to RUTF on first attempt.
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Affiliation(s)
- Betty Lanyero
- Mwanamugimu Nutrition Unit, Department of Paediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
| | - Hanifa Namusoke
- Mwanamugimu Nutrition Unit, Department of Paediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda
| | - Nicolette Nabukeera-Barungi
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Kim Fleischer Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
| | | | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, -1958 Frederiksberg C, DK Denmark
- Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Lääkärinkatu 1, 33014 Tampere, Finland
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Isanaka S, Kodish SR, Berthé F, Alley I, Nackers F, Hanson KE, Grais RF. Outpatient treatment of severe acute malnutrition: response to treatment with a reduced schedule of therapeutic food distribution. Am J Clin Nutr 2017; 105:1191-1197. [PMID: 28404577 DOI: 10.3945/ajcn.116.148064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Community-based management of severe acute malnutrition (SAM) has been shown to be safe and cost-effective, but program coverage remains low. Treatment models that maintain high levels of clinical effectiveness but allow for increased coverage are still needed. A reduced schedule of follow-up, in which children receive clinical follow-up and therapeutic foods on a monthly rather than weekly basis, may be one alternative.Objective: We aimed to describe the safety and feasibility of a monthly distribution of ready-to-use therapeutic food (RUTF) in the treatment of uncomplicated SAM, in terms of clinical response to treatment and household RUTF use.Design: We conducted a nonrandomized pilot intervention study in which 115 children eligible for outpatient treatment of SAM were provided a monthly ration of RUTF. Anthropometric measurements were taken weekly for 4 wk to monitor treatment response. Unannounced household spot checks were conducted over 4 wk to assess household use of RUTF and storage practices.Results: Adequate weight and midupper arm circumference (MUAC) gain were found throughout the 4-wk follow-up period. Observed mean ± SD weight gain from admission was 9.8 ± 6.8 g · kg-1 · d-1 in week 1 and 4.2 ± 2.1 g · kg-1 · d-1 by week 4. Unplanned household spot checks found an average surplus of RUTF sachets compared with the number expected based on the date of distribution and recommended dosing throughout the 4 wk of follow-up. The frequency at which more than the recommended dose was used (i.e., deviance of >2 sachets between available and expected stocks) was 4% and 22% of households visited in week 1 and week 4, respectively.Conclusion: Adequate treatment response and RUTF use in the outpatient treatment of SAM was maintained over 4 wk of follow-up with a monthly schedule of RUTF distribution. This study was registered at clinicaltrials.gov as NCT02994212.
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Affiliation(s)
- Sheila Isanaka
- Departments of Nutrition and .,Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
| | | | | | | | | | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | - Rebecca F Grais
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
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Isanaka S, Menzies NA, Sayyad J, Ayoola M, Grais RF, Doyon S. Cost analysis of the treatment of severe acute malnutrition in West Africa. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27921381 DOI: 10.1111/mcn.12398] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 10/06/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
Abstract
We present an updated cost analysis to provide new estimates of the cost of providing community-based treatment for severe acute malnutrition, including expenditure shares for major cost categories. We calculated total and per child costs from a provider perspective. We categorized costs into three main activities (outpatient treatment, inpatient treatment, and management/administration) and four cost categories within each activity (personnel; therapeutic food; medical supplies; and infrastructure and logistical support). For each category, total costs were calculated by multiplying input quantities expended in the Médecins Sans Frontières nutrition program in Niger during a 12-month study period by 2015 input prices. All children received outpatient treatment, with 43% also receiving inpatient treatment. In this large, well-established program, the average cost per child treated was €148.86, with outpatient and inpatient treatment costs of €75.50 and €134.57 per child, respectively. Therapeutic food (44%, €32.98 per child) and personnel (35%, €26.70 per child) dominated outpatient costs, while personnel (56%, €75.47 per child) dominated in the cost of inpatient care. Sensitivity analyses suggested lowering prices of medical treatments, and therapeutic food had limited effect on total costs per child, while increasing program size and decreasing use of expatriate staff support reduced total costs per child substantially. Updated estimates of severe acute malnutrition treatment cost are substantially lower than previously published values, and important cost savings may be possible with increases in coverage/program size and integration into national health programs. These updated estimates can be used to suggest approaches to improve efficiency and inform national-level resource allocation.
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Affiliation(s)
- Sheila Isanaka
- Epicentre, Paris, France.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nicolas A Menzies
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Mudasiru Ayoola
- Operations Department, Médecins Sans Frontières Logistics, Mérignac, France
| | | | - Stéphane Doyon
- Médecins Sans Frontières Operational Center of Barcelona, Dakar, Senegal
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