CMAM Coverage
Of the 497 malnourished children surveyed, 217 were SAM cases (125 in KSSM and 92 in AAS)); Only the SAM cases were used in the coverage indicator calculations. The urban district recorded a SAM prevalence of 52.1% while the rural recorded 35.8%. Overall, the rural and the urban districts shared honors in terms of coverage indicators per the primary data from the field survey. The urban district had a point coverage of 40.9% compared with a very low figure of 9.8% for the rural district. Geographical coverage, probably the proxy indicator for all three coverage types, was low in both districts but was nearly five times higher in the rural district when compared with the urban setting; 29.0% versus 6.0%. Programme coverage in the urban district (40.9%) was nearly four times that recorded in AAS (9.8%). However, in terms of treatment coverage, AAS fared better than KSSM 30.4 and 9.6 respectfully).
When secondary data for the study period (2016/2017) were retrieved from the District Health Information Management System (DHIMS-2) and computed for the same coverage indicators, we observed a different trend from what was seen in the primary data. Except for geographical coverage, the urban district had better coverage indicators. Point coverage in KSSM was 10 percentage points higher than in AAS; 80.9% versus 71.0%. The secondary data figures for geographical coverage stayed the same as the primary data figures – 6.0% in KSSM and 29.0% in AAS. Treatment coverage was much higher in the urban district as compared to the rural site (73.0% versus 6.0%). In general, when compared with the primary data, the secondary data provided higher coverage indicators in both districts. (Table 2)
Table 2
Indicators (OPC data) | KSSM (DHIMS-2) | KSSM (FIELD DATA) | AAS (DHIMS-2) | AAS (FIELD DATA) |
Point coverage | 80.9% | 40.9% | 71.0% | 9.8% |
Treatment coverage | 73.0% | 9.6% | 6.0% | 30.4% |
Geographic coverage | 6.0% | 6.0% | 29.0% | 29% |
Programme coverage | 80.9% | 40.9% | 71.0% | 9.8% |
A total of 105 women/caregivers in KSSM answered these questions while 132 did similar in AAS; the mothers/caregivers in KSSM were only slightly more knowledgeable when compared with those in AAS.
Enrollment of SAM cases (coverage) into the CMAM programme was generally low; of the 125 SAM cases in KSSM, only 40.8% had enrolled in CMAM while in AAS, 32.6% of the 92 cases were in the programme. We proceeded to further interview this sub-sample (51 out of 125, and 30 out of 92 for KSSM and AAS respectfully) on issues related to programme utilization as part of the coverage assessment. In both districts, the CHO/N was most likely to have ensured the enrollment of the malnourished child. Only six children (three in each district), had enrolled more than once. While the vast majority (93.3%) of the women in the rural setting treated their children with either home-prepared or industry-prepared therapeutic foods. The children in the urban setting’s situation was different; - only 23.5% of these children received these foods. In both districts, there was a clear distancing away from resorting to faith-based treatment; only 3.3% of the women in AAS had ever followed that path of treatment. Similarly, the women whose children were enrolled in CMAM, very rarely ever bought medications from the open market or consulted traditional healers. Even though health workers, such as CHOs/Ns, play a key role in the community-based components of the CMAM programme, the majority (70%) of women in the urban communities did not have such health workers in their communities. The presence of a health worker in the community did not appear to have translated into frequent home visits and subsequently guidance on feeding practices.
Very few women were likely to have been visited more than once a month – none in AAS and 20% in KSSM (Table 3).
Table 3
Variables | KSSM | AAS |
Coverage of CMAM | Coverage of CMAM |
Frequency 51 | Percentage (100%) | Frequency 30 | Percentage (100%) |
How Child was Enrolled CHN/CHO Parent Prescriber | 29 8 14 | 56.9 15.7 27.5 | 27 0 3 | 90.0 0.0 10.0 |
First Time Child was Enrolled Yes No | 48 3 | 94.1 5.9 | 27 3 | 90.0 10.0 |
Number of Times Two Three | 3 0 | 100.0 0.0 | 2 1 | 66.7 33.3 |
Why Child Discontinued Child not growing well Travelled | 2 1 | 66.7 33.3 | 1 2 | 33.3 66.7 |
Treatment with Herbs Yes No | 0 51 | 0.0 100.0 | 8 22 | 26.7 73.3 |
Treatment with home-prepared or industrially prepared therapeutic foods Yes No | 12 39 | 23.5 76.5 | 28 2 | 93.3 6.7 |
Ever resorted to faith-based treatment Yes No | 0 51 | 0.00 100.0 | 1 29 | 3.3 96.7 |
Ever purchased medication from open market Yes No | 1 50 | 2.0 98.0 | 1 29 | 3.3 96.7 |
Ever purchased medication from pharmacy Yes No | 17 34 | 33.3 66.7 | 2 28 | 6.7 93.3 |
Ever consulted traditional healer Yes No | 2 49 | 4.0 96.0 | 0 30 | 0.0 100.0 |
Choice of treatment Father Myself | 13 38 | 25.5 74.5 | 3 27 | 10.0 90.0 |
Health worker in the community Yes No | 15 35 | 30.0 70.0 | 25 5 | 83.3 16.7 |
Number of health workers 1 2 3 4 | 4 7 3 1 | 26.7 46.7 20.0 6.7 | 4 21 0 0 | 16.0 84.0 0.0 0.0 |
Regularity of house to house visits Twice weekly Monthly | 3 12 | 20.0 80.0 | 0 25 | 0.0 100.0 |
Health workers guide feeding practices at home Yes No | 4 11 | 73.3 26.7 | 0 25 | 0.0 100.0 |
Acceptability, accessibility and availability coverage levels of CMAM
During the FGDs and KIIs, coverage was also looked at in three aspects: acceptability, accessibility and availability of services. Focus group discussants opined that the CMAM programme did not go against their culture and so was acceptable to them.
“We accepted the program because it is part of the hospital services and not against our culture and religion that is why our husbands and leaders have not stopped us from coming here. Our people don’t have problem with us using the hospital. ” [Focus group discussion 1, KSSM] .
Some focus groups bemoaned geographical and financial challenges to accessing the CMAM services. Women in a focus group in the Ahafo Ano South district shared this view:
“ We spend the little money on transportation to come here. We hardly can afford it. Coming all the way here also means not doing any productive work to earn the little proceeds we get from selling. There are many hospitals in the communities that I can walk to even when I don’t have money for transportation.” [Focus group discussion 4, AAS]
Service availability drew some strong comments in one of the focus groups in the rural district:
“Nutrition programme should be in all the hospitals/CHPS compound. We travel to the directorate sometimes on motor bike because there are no vehicles in our communities, only to come and meet supplies. Treatment should be effective, supportive and an encouragement. Also, the programme staff should be friendly and patient towards us.” [Focus group discussion 3, AAS]
The knowledgeable informants in both districts suggested a positive attitude towards the CMAM programme. One knowledgeable informant mentioned that those who come to their facility were always happy with their services. She noted:
"Whether the barrier is money for transportation or lack of information, one cannot tell; but those who come here are mostly happy with us.” [Pediatrician, Urban area]
In the rural district, long distances and high costs of transportation to the CMAM centre for review and collection of RUTF, the lack of trained personnel in the communities for community mobilization and home visits, and, insufficient RUTF and other feeds were some factors limiting community access to the CMAM centre.
“Our district is located in a farming area so most mothers earn little to no income. They consume what they grow. Coming to the district capital is a big challenge to most of them because they do not have money for transportation, if the road is good. During rainy seasons, too some communities can only be reached through motor bike. Poor compliance especially during farming and rainy seasons are another challenge. Because we don’t have community workers but CHNs and CHOs only, they do not practice home visits to complement our efforts” [ Nutrition Officer 1, Rural area].
One respondent mentioned that not all mothers can access the programme because they live far from the facility and this brings a lot of financial strain on them.
“Hmmm… not every mother can access the programme. We have a challenge with accessibility because some mothers have to travel for some hours to reach the facility. Some mothers can’t afford fare to and from the facility. So the facility is not that accessible to all the clients. [Nutrition Officer1, Urban area]
The CHNOs/Ns who work very closely with the mothers noted that most parents were poor and cannot commute to the CMAM centre weekly for their supplies amidst seasonal barriers such as rains and poor road network.
“Most of the parents (90%) are poor and cannot afford to be commuting to the directorates weekly or twice a week for their supplies. In addition, seasonal barriers like rains, poor road networks, planting of crops and so on are barriers for the parents. Culture, religion and gender issues are not barriers to the people in our catchment areas”[CHO 4, rural area]
According to a knowledgeable informant the lack of an in-patient unit, a pediatrician and technical training on CMAM as well as sporadic shortages of RUTFs coupled with zero means of transport to follow up cases within the community, reduced service availability to the mothers/caregivers and the children who needed the services most. One respondent mentioned that within her facility, services were available in the in-patient care unit it run out of supplies, this she explained has led to referral cases for parents who could not afford to buy the foods. She noted this:
“We are always here for the in-patient service; we refer new cases to KATH when our wards are full or when the client cannot afford some of the services which is rare. The service is not available in the communities but everyone who comes here is attended to. Since we don’t have enough community health workers, the parents who cannot come here are left out. [Pediatrician, Urban]
CHOs highlighted that inadequate staff for CHPS zones, the lack of staff training in CMAM and, lack of modern tools and equipment for the full implementation of CMAM as issues that affect the availability of the services within programme. One of them indicated this:
“Our numbers are not adequate in the CHPs Zones/compounds. Most of us are the only health staff living in the compound so we cannot leave the compound for home visits. The government should pay allowances to the Community Health Workers so that they can help with the community visits and supervised feeding of the children. We, the staff should also be given allowances and more staff added to our numbers for community visits. Also, the directorates should be supplied with more Plumpy Nuts for easy distribution to prevent parents traveling long distance to get them. Most of the parents can walk to the CHPS compound for the feeds even when they do not have money for transportation.” [CHO 5, Rural area]
“We also don’t have volunteers anymore to take care of home visits because they demand money for their services and the money is not available.” [PA, Rural area]
Some services are not available on a 24/7 basis. A knowledgeable informant further explained that the in-patient unit is run throughout the week whereas the out-patient services are available only on specific days at specific times which is mostly Wednesdays. She stated this:
We run 24/7 for the inpatient unit but for the outpatients they are given specific times to visit the facility to get the service. The clinic days for the out-patient component is held on Wednesdays”. [Nutrition Officer1, Urban area]
Pull factors for CMAM utilization
All mothers/caregivers in study sample were asked about the factors that would attract them to utilize the CMAM services. In both study sites, free service (98% urban versus 100% rural) and a cured child (52.9% urban versus 83.3% rural), were the most likely factors of attraction to program utilization for the mothers/caregivers. The most unlikely pull factors in both sites were access and company; all the mothers in KSSM and 93.3% of the mothers in ASS were not attracted by difficult access to the service while the company of friends at the service sites served as a pull factor for only 3.9% and 6.7% mothers/caregivers in KSSM and AAS respectively.
More than half of the urban study sample was attracted by the following factors, to utilize CMAM services: programme staff attitude (54.9%), RUTF availability (70.6%), and access to Plumpy Nuts (54.9%). On the other hand, the mothers/caregivers in AAS, had a wider variety of factors that attracted more than half of them to utilize CMAM services: funds for transport (83.3%), partner’s support (86.7%), family support (76.7%), CHW support (96.7%), neighbors (80.0%), treatment type (80.0%), and treatment efficacy (76.7%) as depicted in (Table 4).
Table 4
Pull factors for CMAM utilization
Variables | KSSM (n=240) | AAS (n=257) |
Coverage of CMAM | Coverage of CMAM |
Yes | No | Yes | No |
Attracted by Access | 0.0 | 100.0 | 6.7 | 93.3 |
Attracted by Funds for Transport | 12.2 | 87.8 | 83.3 | 16.7 |
Attracted by Availability of Transport | 17.7 | 82.3 | 30.0 | 70.0 |
Attracted by friends | 3.9 | 96.1 | 6.7 | 93.3 |
Attracted by partner’s support | 35.3 | 64.7 | 86.7 | 13.3 |
Attracted by Family Support | 17.7 | 82.3 | 76.7 | 23.3 |
Attracted by CMAM Parents | 5.9 | 94.1 | 3.3 | 96.7 |
Attracted by CHW Support | 19.6 | 80.4 | 96.7 | 3.3 |
Attracted by Neighbours | 2.0 | 98.0 | 80.0 | 20.0 |
Attracted by community leaders | 13.7 | 86.3 | 23.3 | 76.7 |
Attracted by community appreciation | 19.6 | 80.4 | 30.0 | 70.0 |
Attracted by program staff | 54.9 | 45.1 | 30.0 | 70.0 |
Attracted by RUTF available | 70.6 | 29.4 | 3.3 | 96.7 |
Attracted by treatment type | 41.2 | 58.8 | 80.0 | 20.0 |
Attracted by free service | 98.0 | 2.0 | 100.0 | 0.0 |
Attracted by treatment efficacy | 51.0 | 49.0 | 76.7 | 23.3 |
Attracted by cured child | 52.9 | 47.1 | 83.3 | 16.7 |
Attracted by access to peanuts | 54.9 | 45.1 | 16.7 | 83.3 |
Attracted by other | 33.3 | 66.7 | 0.0 | 100.0 |
Multiple responses accepted |