Stigma as a barrier to treatment for child acute malnutrition in Marsabit County, Kenya

Abstract

Acute malnutrition affects millions of children each year, yet global coverage of life-saving treatment through the community-based management of acute malnutrition (CMAM) is estimated to be below 15%. We investigated the potential role of stigma as a barrier to accessing CMAM. We surveyed caregivers bringing children to rural health facilities in Marsabit County, Kenya, divided into three strata based on the mid-upper arm circumference of the child: normal status (n = 327), moderate acute malnutrition (MAM, n = 241) and severe acute malnutrition (SAM, n = 143). We used multilevel mixed effects logistic regression to estimate the odds of reporting shame as a barrier to accessing health care. We found that the most common barriers to accessing child health care were those known to be universally problematic: women's time and labour constraints. These constituted the top five most frequently reported barriers regardless of child acute malnutrition status. In contrast, the odds of reporting shame as a barrier were 3.64 (confidence interval: 1.66-8.03, P < 0.05) times higher in caregivers of MAM and SAM children relative to those of normal children. We conclude that stigma is an under-recognized barrier to accessing CMAM and may constrain programme coverage. In light of the large gap in coverage of CMAM, there is an urgent need to understand the sources of acute malnutrition-associated stigma and adopt effective means of de-stigmatization.

Keywords: access; acute malnutrition; community-based management of acute malnutrition; stigma.

Figure 1

Barriers to accessing health services for children in Marsabit County, Kenya. The 30 unique responses are named on the Y‐axis; the number of times that each response was given is shown to the right of the bars. Responses were categorized according to an adapted framework for access by Barton (2010). The total number of responses in each category is depicted in the pie chart.

Figure 2

The frequency of the most commonly reported barriers to accessing child health in Marsabit County, Kenya, by study group. The 10 most frequent barriers for each study group (SAM, MAM and Normal) are tabulated in order of decreasing frequency from left to right. The barrier of interest, shame, is depicted in red.

Figure 3

The odds of reporting one of the 10 most common health service barriers in Marsabit County, Kenya (moderate and severe groups consolidated and compared with the normal group). Odds ratios of significant findings (P < 0.05) are noted on the figure and were estimated using a multilevel mixed effects logistic regression model that adjusted for child age and sex, maternal age, marital status, education, household size, distance from the clinic, food security status and wealth, district and facility caseload. Health facility was treated as a random effect.

Figure 4

The odds of reporting one of the 10 most common barriers in a survey of access to health services at rural health facilities in Marsabit County, Kenya (moderate and severe groups stratified and compared with the normal group). Odds ratios of significant findings (P < 0.05) are noted on the figure. Estimates were produced by our multilevel mixed effects logistic regression model, which adjusted for child age and sex, maternal age, marital status, education, household size, distance from the clinic, food security status and wealth, district and facility caseload. Health facility was treated as a random effect.