The socio-demographic characteristics of the children (6-59 months) were summarized in Table 2. The results indicate that out of the total 637 children, 54% (n=343) were females, 47.4% (n=302) children were aged 6-12 months. Most of the children 54% (n=344) were being managed from health centre level IV and the average weight for the children at admission was 7.1+2.1 kg with over 64% (413) having an admission weight of 6 – 10 kg. The average height for the children was 71.5+27.8 cm with the majority (45.2% (n= 288) children in the range of 60-69.9 cm.
The study findings indicate that only 4.4% (n=28) were HIV positive. About 2.5% (n=16) of the HIV positive children were moderately malnourished. About 2% (n=174) of the children who participated in the study did not have HIV test results in their records. The majority of the children 71% (n=452) had SAM without Oedema. Admission was more from the community 96.7% (n=616) and only 8.5% (n=54) of the children were re-admitted into the program.
Programme outcome indicators in comparison with national IMAM and Sphere standards
The results of the programme indicators presented in Table 3 show that the cure rate was at 36.3% (n=231) while the death rate was at 1.1% (n=7). The results indicate that there was a high default rate of 58.6% (n=373). The non-response rate was at 0.6% (n=4). The results also indicate that the average length of stay on the programme was 21 days with about 20% (n= 124) staying on the programme for more than 30 days and referral rate at 3.5% (n=22). The average number of visits made by the children under the programme was 1.4+1.7 visits.
Results of bivariate and logistic regression analysis to establish the factors associated with cure rate are summarized in Table 4.
The bivariate analysis indicated that the health center where SAM management was done (OR= 0.6, 95% CI: 0.4 - 0.8, p = 0.02), the source where the child was coming from (OR = 0.3, 95% CI: 0.8 - 0.9, p = 0.033), the weight at admission (OR = 0.5, 95% CI: 0.4 – 0.7, p = 0.0006), the number of visits to the program (OR = 6.9, 95% CI: 4.0 – 11.9, p = 0.001) and the Length of stay on the program (OR = 7.0, 95% CI: 4.1 – 12.3, p = 0.001) were associated with the Cure rate. After adjusting for any possible confounders in multivariate analysis, only the Source of admission (AOR = 0.1, 95% CI: 0.0, 0.7, P = 0.012), Weight at admission (AOR = 0.5, 95% CI: 0.0, 0.9, P = 0.014) and Number of visits to the program (AOR = 14.9, 95% CI: 9.3, 24.2, P = 0.040) were the major factors influencing the recovery of children from severe acute malnutrition under the OTC programme.
Discussion of Results
The findings showed a Cure rate of 36.3% of the children who were enrolled into the OTC program which was very low compared to both the IMAM and the Sphere Standards that recommend a Cure rate of greater than 75% which puts the programme in the study into an alarming state. The results indicated a lower Cure rate than in similar studies done in Ethiopia, Pakistani and Zambia (Genene et al., 2019; Eleanor et al., 2019; Mwanza et al., 2016). However, the results of this study showed a slightly higher Cure rate than the one observed in a similar study done in Ghana in 2015 with a Cure rate of 33.6% (Mahama et al., 2015). The reason for this could be due to the frequent stock outs of the Ready to Use Therapeutic Feeds (RUTF) as confessed by many of the health centre in charges, which interferes with children’s recovery.
The Death rate, the Non-response rate and the average Length of stay were within acceptable levels based on both the national and international sphere standards. Death rate in the study were in line with studies done in Ethiopia (Negash et al., 2015; Binyam et al., 2019; Mulugeta et al., 2017) and in Pakistan (Eleanor et al., 2019). It was also noted that the Death rate in the current study was much lower than the one observed in Malawi (Saddler, 2003). This was because of proper adherence to the treatment protocol under the OTC programme.
The overall Default rate in this study was way out of the national and the international standards and also higher than findings in similar studies in other countries like Ghana (Mahama et al., 2015), Ethiopia (Tefera et al., 2014; Mulugeta et al., 2017), and Pakistani (Eleanor et al., 2019). However, the Default rate was found to be close to a recent study done in Ghana by Mahama et al in 2015 and the one done by Action against Hunger (2011) in Moroto Karamoja sub-region in North Eastern Uganda. In general, the default rate was very unacceptable and this was fuelled by frequent stock outs of RUTF and long distances walked by the caretakers to reach the health facilities as mentioned by the In charges and also as indicated by ACF in Karamoja sub-region Northern Uganda.
The average Length of stay on the program for children who cured from SAM was 21 days (3 weeks) which was within the acceptable national and international standards and this agrees with recent studies done in Ghana (Mahama et al., 2015)] and in Ethiopia (Tefera et al., 2014; Kabeta and Bekele, 2017; Muluken B.M, 2018). This was due to the caretaker compliance to the programme.
The Nonresponse to treatment was within the acceptable levels and this was due to early health seeking behaviours by the caretakers which reduces long stay to the OTC programme which is in line with sphere standards (2004) where it’s noted that seeking treatment late is associated with delayed or long stay on the programme.
The factors predicting Cure of children from severe acute malnutrition under the OTC programme
The source where the child was admitted from was significantly associated with the cure of the child from severe acute malnutrition. It was seen that children who were admitted from the community were 0.3 times less likely to cure from SAM than those admitted from other health facilities and finding was similar to studies done in Zambia and Ghana (Michelo and Muyode, 2012); Hamulembe, 2010) and this was because of the poor health seeking habits of children admitted from the communities as they report to the health facilities late. However this study was contrasting with a similar study done in Ghana by Mahama et al 2015 which did not find any association between source of admission and cure of children from severe acute malnutrition.
The weight of the child at admission was also associated with the child’s Cure from SAM. The admission weight between 6 - 10 kgs were 0.5 times less likely to cure from SAM as compared to those between 3-6 kgs with reason linking to the breastfeeding age. When cross tabulations were run, it was noted that majority children between the ages of 6 – 12 months were falling in the weight ranges of 3 – 6 kg meaning that breast feeding children if complemented with RUTF can have better cure rates than elder children. However this was contradicting with findings of the study done in Ghana by Mahama et al. in 2015.
The number of visits the child made to the programme was predicting cure of children from severe acute malnutrition who were admitted to the programme. Children who made between 1 – 4 visits where 4 visits are the standard recommended were 6.9 times more likely to cure from SAM than those who did not make a single visit and this was in line with a study done in Ghana and Ethiopia (Mahama et al., 2015 and Hamulembe, 2010). The reason was compliance to treatment that enabled cure of children.
Other factors like Length of stay on the programme, age of the child at admission and the health centre where the child sought treatment seemed to be associated with cure of children from severe acute malnutrition in Bivariate analysis but it was because of confounding that they appeared so. However these factors have been found significant in other studies done in south Sudan, Malawi and Zambia by other countries but in this particular one they were not predicting cure rate of children (Taylor, 2001; Saddler, 2003; Michelo and Muyode, 2012).
The study relied on secondary data, which lacked information on weight gain, history on breast feeding and distance from home to the health centre, which other studies elsewhere found significant in determining Recovery of children from severe acute malnutrition under the OTC programme.