Outpatient therapeutic feeding program outcomes and determinants in treatment of severe acute malnutrition in tigray, northern ethiopia: a retrospective cohort study

Abstract

Background: Outpatient Therapeutic feeding Program (OTP) brings the services for management of Severe Acute Malnutrition (SAM) closer to the community by making services available at decentralized treatment points within the primary health care settings, through the use of ready-to-use therapeutic foods, community outreach and mobilization. Little is known about the program outcomes. This study revealed the levels of program outcome indictors and determinant factors to recovery rate.

Methods: A retrospective cohort study was conducted on 628 children who had been managed for SAM under OTP from April/2008 to January/2012. The children were selected using systematic random sampling from 12 health posts and 4 health centers. The study relied on information of demographic characteristics, anthropometries, Plumpy'Nut, medical problems and routine medications intakes. The results were estimated using Kaplan-Meier survival curves, log-rank test and Cox-regression.

Results: The recovery, defaulter, mortality and weight gain rates were 61.78%, 13.85%, 3.02% and 5.23 gm/kg/day, respectively. Routine medications were administered partially and children with medical problems were managed inappropriately under the program. As a child consumed one more sachet of Plumpy'Nut, the recovery rate from SAM increased by 4% (HR = 1.04, 95%-CI = 1.03, 1.05, P<0.001). The adjusted hazard ratios to recovery of children with diarrhea, appetite loss with Plumpy'Nut and failure to gain weight were 2.20 (HR = 2.20, 95%-CI = 1.31, 3.41, P = 0.001), 4.49 (HR = 1.74, 95%-CI = 1.07, 2.83, P = 0.046) and 3.88 (HR = 1.95, 95%-CI = 1.17, 3.23, P<0.001), respectively. Children who took amoxicillin and de-worming had 95% (HR = 1.95, 95%-CI = 1.17, 3.23) and 74% (HR = 1.74, 95%-CI = 1.07, 2.83) more probability to recover from SAM as compared to those who didn't take them.

Conclusions: The OTP was partially successful. Management of children with comorbidities under the program and partial administration of routine drugs were major threats for the program effectiveness. The stakeholders should focus on creating the capacity of the OTP providers on proper management of SAM to achieve fully effective program.

Figure 1. Sampling procedures.

The phenomena regarding the child nutrition were assumed to be homogenous among the districts of the study zone. Thus, four districts out of nine were selected using simple random sampling. The health facilities rendering OTP were stratified into health centers and health posts. One health center and three satellite health posts were included from each district. Using the Probability Proportional to Size (PPS), the n1, n2, n3, and n4 samples were drawn. Finally, the OTP record card of each child was selected using systematic random sampling. HP: health post; HC: health center.

Figure 2. Kaplan Meier survival curves and Log-rank test for recovery rates over grouped factors.

The KM survival curves for each grouped factor were identified by color and pattern differences. They showed the recovery rates over the OTP intervention. The KM curves enable to compare the recovery rates between those with and without diarrhea, vomiting, loss of appetite with Plumpy'Nut, failure to gain weight and over children who took de-worming and amoxicillin drugs as compared to those who didn't take the drugs. The log-rank tests the significance of the observed differences in recovery rates on the KM survival curves between the grouped factors. X²: Chi-squared test.