Treatment outcome and factors affecting time to recovery among children with severe acute malnutrition receiving outpatient therapeutic care in Nakivale refugee settlement

Abstract

Introduction: Outpatient therapeutic care (OTC) has been decentralized to the health centre level in Uganda. In order to facilitate assessment, care and support of children with uncomplicated severe acute malnutrition (SAM), however, there is lack of sufficient evidence about the treatment outcomes, factors affecting time-to-recovery and influencing factors to defaulting among children 6–59 months of age with SAM managed within the health centres of Nakivale refugee settlement, Southern western Uganda. General objective: To determine the treatment outcomes of outpatient therapeutic care, factors affecting time to recovery and to explore factors influencing defaulting of children 6-59 month with uncomplicated SAM in Nakivale refugee settlement, Southern western Uganda. Methods: A mixed-methods study involving both quantitative and qualitative components was conducted. The quantitative data was extracted from 386 records collected in integrated nutrition register. Qualitative data was collected through in-depth interviews among 10 mothers of the defaulted children from outpatient therapeutic care using a semi-structured interview guide. The collected data were entered into EPI-data version 3.1 software and exported to Stata version 13.0 for analysis. Descriptive analysis was conducted using; median, frequency, proportions, and Kaplan Meier, Cox proportional-hazard regression was used to assess factors affecting time to recovery. All statistical tests in this study were declared significant at p <0.05. Interviews were translated, transcribed and exported to open code software for analysis. This study sought approval from Makerere University School of Medicine Research and Ethics Committee reference number #REC REF 2019-070. Results: The overall recovery rate was 64.2% (95% CI: 59.2% - 68.9%), 29.1%, (95% CI: 24.7% - 33.9%) of participants defaulted while 4.6%, (95% CI: 2.8% - 7.2%) were categorized as non-respondent, 1.3%, (95% CI: 0.6 % - 3.2%) transferred and 0.8%, (95% CI: 0.3%-2.5%) died from the outpatient therapeutic care. The median recovery time was 61 days (IQR= 39, 89), mean rate of weight gain 3.5g/kg/day and the factors associated with time to recovery were: the type of the facility (aHR=0.47, 95% CI: 0.33-0.6, p<0.001), baseline Mid upper circumference (MUAC) (aHR=1.26, 95%CI 1.1-1.5, p.value 0.003) and clients follow up (aHR 2.79, 95% 1.14-6.83, p=0.025). Factors influencing defaulting among children with SAM were grouped into community, health system and client related factors including; irregular stock out of therapeutic rations and drugs, sharing and selling of therapeutic food, the long the distance to the facility. Conclusion: The recovery rate and rate of weight gain were below the acceptable Sphere International Standards, this means that the number of children cured and rate of weight gain are less than expected. The default rate and length of stay of children with SAM on the program were higher than the acceptable cutoff, this means that many children are likely to die at home. Baseline MUAC, facility type, and routine follow-up of children with SAM were significantly associated with time to recovery. This means that there gaps in the implementation of outpatient therapeutic care programs that affect program performance. Irregular availability of therapeutic rations and drugs, the long distance to facility, sharing and selling of therapeutic food, and comorbidities among children with SAM were factors mentioned to contribute to defaulting among children receiving therapeutic care in the OTC program. This means that children suffering from uncomplicated SAM not only are they getting insufficient RUTF doses but even the available doses are either not accessible due to long distances Recommendations: To the policymakers (government and medical teams international) there should be robust interventions that address follow up, community linkage system, and facility integrated outreaches, so as to increase access to services, number of children recovering from SAM, and reduce the number of children that default from the program. There should be regular monitoring and evaluation of outpatient therapeutic programs to create uniformity in the management of children with uncomplicated SAM. This will avoid giving less treatment time to children admitted with less MUAC cut-off and more time to those with higher MUAC values hence providing enough time for rehabilitation and also to observe the usage of therapeutic food at home.