Study area and design
An institution based retrospective cohort study was conducted among a cohort of children admitted and treated for SAM from 2014/2015-August 30/2020 among 20 selected health posts in Hadiya zone, SNNPR, Ethiopia from Aguste 1 – 30 /2020.
According to the May 24, 2004 World Bank memorandum, 6% of the inhabitants of Hadiya have access to electricity, this zone has a road density of 104.1 kilometers per 1000 square kilometers compared to the national average of 30 kilometers),(12) the average rural household has 0.6 hectare of land compared to the national average of 1.01 hectare(13) the equivalent of 0.6 heads of livestock. A fifth (22.8%) of the population has non-farm related jobs, compared to the national average of 25% and a regional average of 32%. A total of 74% of all eligible children are enrolled in primary school, and 21% in secondary schools and 43% of the zone is exposed to malaria and the memorandum gave this zone a drought risk (14). This zone is characterized by a predominant commitment to agricultural activities, especially the enset-growing, which is often combined with grain including, barley and maize, as well as the breeding of domestic animals(15).
In Hadiya Zone, there were 280 Health Posts (HPs), 60 rural Health Centers, one University teaching Hospital and 3 primary level Hospitals. Hadiya zone is divided into 11 districts for administrative purposes. The vast majority of the population were Hadiya in ethnic group and they earn their living through rain fed agriculture and it has 12 woradas and 2 administrates towns. The woredas were ; East Bedewacho, Siraro Bedewacho, West Bedewacho and Shone town administration separated from the rest of the zone by Kembeta Tambaro and the administrative center of Hadiya is Hosanna(16). Of which this was study conducted in two woradas and one town administration among 20 health posts with highest number of cases East Bedewacho (Tikere kokere,Tikare Anbesa,Mahal,Jariso,Amburse Anjulo,2nd Chafa,Eddo,Lenda,Jerso Kutube and Bente Wosen).
Siraro Bedewacho (Abuka,Langano,Dongaro Bonkoya,Wera Bonkoya,sheriko Gafarso,Kumudo,Beshilo,Mahal Korga and Woldia)and Shone Town administration(Wera Gere and Shone town ). The health posts were selected based on number of SAM cases.
Population
All records of under-five children who were admitted to the health posts of Hadiya Zone,in three woradas from November, 2014/2015-August 30/2020 were the source population. A total of 900 child records were eligible from which 760 were selected by simple random sampling methods using the ENA for SMART software. All records of under-five children with SAM admitted to 20 health post were included, but children with incomplete records, unknown admission dates and unknown discharge dates were excluded.
Sample size determination and sampling procedure
Sample size was determined from a study conducted in North Gondar zone, Northwest Ethiopia (17). Then, it is calculated by medcalc©version 119.1.1.3 survival analysis (logranktest) at http://www.medcal.org (18). And diarrhea on admission as the main exposure cured of 51, censored of 17, outcome of 75%, AHR of 0.81 and Log rank of 19 total event needed was 484. As we we selected zones to woradas and from worada to Kebeles, a design effect of 1.5 was considered giving a final sample size of 726 . Finally, the records were collected from the card room based on the MRN of the selected participants and the data were collected from these records.
Data collection procedure
A data extraction tool was prepared from the national treatment protocol for the management of SAM (3), SAM registration booklet, health management information system (HMIS) register. The data extraction format used consisted of socio-demographic data (age, sex) and anthropometric measurements (height, weight, MUAC, edema). Four data collectors (MPH) and one supervisor was recruited based on their experience in data collection. Data collectors received a one-day training on the Extraction tool and were deployed to collect data once the principal investigator was convinced about their competency. The primary investigator of the study and the supervisors critically followed the data collection process to minimize missing information and inconsistencies.
Operational definition
Relapse rate/repeated episodes; The proportion of children who re-enrolled after they recovered and discharged(19).
Wasting is defined; as low weight-for-height. It often indicates recent and severe weight loss, although it can also persist for a long time(20).
Severe acute malnutrition: It is diagnosed by weight for- height below -3 SD of the WHO standards, by a MUAC <11.5 cm and by Clinical sign like bilateral edema (21-23).
Kwashiorkor or edematous malnutrition; is also form of severe under nutrition, the child’s muscles were wasted, but wasting may not be apparent due to generalized edema or swelling from excess fluid in the tissues (21, 24).
Criteria for discharging children from treatment; weight-for-height/length is ≥–2 Z-scores and they have had no oedema for at least 2 weeks, or mid-upper-arm circumference is ≥125 mm and they had no oedema for at least 2 weeks(25).
Data processing and analysis
Data were coded, entered into Ep-data software version 4.2 and exported to SPSS for windows version 25 software for analysis. The presence of missing values, possible outliers, and multicollinearity were checked through exploratory analysis.
Both bi-variate and multivariable Cox regression analyses were performed. Kaplan Meier hazard curve with the log-rank test was fitted to identify the presence of a difference in recovery rate among the categorical variables. Mantel-Cox and Generalized Wilcoxon test of equality of survival distributions is significant and one minus survival function line is also parallel for those candidate variables of multivariable Cox regression (Fig1 and Fig2).
For the different levels, under-five children with SAM were followed in weeks from admission to the occurrence of the event (relapse). Person-time was calculated and the incidence was determined. In this study, person-time was reported in child-week. Child-week are total follow up times of each child from admission to the occurrence of the events (relapse or censored)
Those variables with p≤0.25 in the bi-variable Cox-regression were selected for the multivariable Cox-regression analysis. All statistical tests were considered significant at 95% confidence interval the final significant value is determined at p-values of 0.05.
Ethical Considerations: Before starting the data collection process, ethical clearance was given secured by Jimma University Health Research Ethics Review Committee (IHRERC). An official letter was written from Jimma University to the Hadiya Zonal Health Office.
Informed written consent was obtained from all health extension workers of selected health posts and woreda health office, confidentiality of the study documents was’ information was also ensured according to the Helsinki declaration of ethical code for human subjects.