Proposal for Community Based Interventions for severe acute malnutrition in Oromiya Region in Ethiopia Group 5 Nathan Chimbatata Liao Sha Zhao Yuxin Wang

Proposal for Community Based Interventions for severe acute malnutrition

in Oromiya Region in Ethiopia

Group 5

Nathan ChimbatataLiao Sha

Zhao YuxinWang YingYin Xiaoxu

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• Background• Preparation• Project implementation

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Background

• Severe acute malnutrition (SAM) is defined by WHO as a child having “very low weight for height…by visible severe wasting, or by the presence of nutritional edema,” which is a form of body swelling caused by severe protein deficiency in the body.

4WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children . Geneva: World Health Organization; 2013.

Background

• Malnutrition is a major global health problem• About 10 million children are estimated to be

malnourished globally

5Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A: Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull 2006, 27:S49–S82.

Background.......

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Background.....

• Globally there are about 2.2 million deaths due to malnutrition annually

• Greatest number of children suffer from stunting

• Africa has the highest prevalence of malnutrition

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Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate SadlerThe sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne Forsythe and Paul-Rees Thomas

Background....

• UNICEF estimates that 126,000 children are in need of urgent therapeutic care for severe malnutrition in Ethiopia

• In Oromiya Region, in particular, 34.4% of all children under-five are underweight

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Background.......

• Prevalence of malnutrition in Ethiopia is at an alarming level

• Ethiopia is ranked the sixth worst country in terms of nutritional outcomes worldwide.

• Literature shows that 51 % of children under five years of age are stunted and chronically malnourished.

• About 53 % of all under five deaths in Ethiopia are due to malnutrition

9Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A: Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull 2006, 27:S49–S82.

Background......

• Prevention of Malnutrition remains a priority in many settings.

• Ethiopia is implementing a decentralised service delivery platform/health extension programme to promote universal PHC access

• Health extension workers are used in the programme and this has improved health and nutrition care practices

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Background.....• Facility based and community based (RUTF) are the

treatment modalities currently used to manage severe acute malnutrition

• Challenges for facility-based treatment are: # The shortage of skilled health workers and health infrastructure # Infections transmission # Poor accessibility (physical and economic) to these facilities # Travel costs incurred by the mother (or caregiver) getting to,

and staying at, the health center with her child.

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Background.....

• Studies show that community based treatment modality of acute malnutrition has more advantages over the other strategies

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Case

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Community Based Interventions (CBI) for severe acute

malnutrition management

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Outline

Case identification Case identification

EvaluationEvaluation

Treatment Treatment

MornitoringMornitoring

Target population

Criteria for diagnosis

Community mobilization

Referral

OTP

Follow-up

Programme appropriateness

Programme effectiveness

Programme coverage15

What we need to ensure the implementation of the interventions?

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Medical staff

Outreach workers

Volunteers

Human resource

Management team

Community commissioners

Government Ministry of HealthPrivate companies

The foundation

Health service package for SAM

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Financial resources

The Phil and Linda Bates Foundation Production of RUTFAdvertisement Health system strengtheningSubsidy for workersReferral …….

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Material resources

RUTF

Produced locally

Government

patent

import

Private companies

Local food producers

Food and Drug Administration

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Other material resources

Posters and brochures for this programmeSuits for the outreach workers and volunteersAnthropometric tools for each communityTransport

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Outline



Treatment Treatment


Target population



Referral

OTP

Follow-up




Case Identification(Screening)

• Target population SAM Children aged between 6 - 59 months

• Diagnostic method Mid-upper-arm-circumference(MUAC),bipedal edema

Tools: color banded strap

A review of methods to detect cases of severely malnourished children in the community for their admission into communitybased therapeutic care programs.Mark Myatt, Tanya Khara and Steve Collins

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Criteria: MUAC < 115 mm OR the presence of bipedal edema

Assessment of outpatient therapeutic programme for severe acute malnutrition in three regions of ethiopia.T.Belachew and H.Nekatibeb,East African Medical Journal,december 2007,577-588 24

Case Identification（ Mobilization）

medical staff and volunteers

outreach wokersand volunteers

health care workersand mother

self-referralsself-referrals

active case findingactive case finding

mother to mothermother to mother

who

howhow

parents education

household seeking

health education

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Self-referrals

How to achieve self-referrals? 1.Give training and health education about SAM and

treatment to parents

2.Distributed brochures and pictures to parents

Participants: Medical staffs, volunteers and parents

Location 1. Health posts, schools, and during the screening

2. Distribute brochures to the streets and every household

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Active case finding

How to find cases actively and quickly？ 1.Point-to-point to look for cases

2.Give children a simple measurement 3.Health education to parents

Participants: Volunteers and outreach workers

Location Households in their own community

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Mother to mother

How to promote other mothers? 1.Medical staffs recommend treated children’s mothers to

promote other mothers

2.Treated mother share experience and benefits of treatment

with other mothers

Participants: Medical staffs, volunteers , outreach workers and mothers

Location patients’ villages and poor shelters

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Outline



Treatment Treatment


Target population



Referral

OTP

Follow-up




Treatment

Cases classification Cases classification

Cases foundthrough identification

Cases foundthrough identification

Have any of the following conditions:•With complications•Severe oedema (+++)•Poor appetite•With one or more IMCI danger signs

Have any of the following conditions:•With complications•Severe oedema (+++)•Poor appetite•With one or more IMCI danger signs

Meet all the following conditions:•Without medical complications•Pass the appetite test•Clinically well

Meet all the following conditions:•Without medical complications•Pass the appetite test•Clinically well

Referral to inpatient treatment

Referral to inpatient treatment Outpatient therapeutic

programme with RUTFOutpatient therapeutic programme with RUTF

Follow-upFollow-up

Follow-up after discharge

Follow-up after discharge

In a health post, through the examination by health-care workers with appropriate

training

In a health post, through the examination by health-care workers with appropriate

training

Collaboration with other programmes

Collaboration with other programmes

MUAC ≥125 mm and have had no oedema for at least 2 weeks

Discharge from the programme

Discharge from the programme

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Outpatient Therapeutic Programme (OTP)

Admission: •basic condition evaluation•Provision of RUTF and routine medicine•Education of the carer•Fill the patient monitoring cards

weekly or every-two-week visit for check-ups and more supplies of RUTF

High level health-care

facilities

Continuous and sustainable availability of

RUTF and medicine supplies

A health postA health post Child for OTP

Child for OTP

Follow-up between two clinical visits

Follow-up between two clinical visits

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Key education messages

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Follow-up during treatment

a skilled health-care worker in a

nearby clinic or in the community

Outreach workers or volunteers to

arrange

Child for OTPChild for OTP

• Children during the first two weeks after admission into the OTP

• Children who are losing weight or whose medical condition is deteriorating

• Children whose carers have refused to inpatient treatment, though they were suggested to

Non responders

Responsers

Assessment of medical condition and

care environment

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Outline



Treatment Treatment


Target population



Referral

OTP

Follow-up




Monitoring and evaluation

Aim ----- provide useful information that can form the

basis for decisions to adjust programme design to better

tailor implementation to the context specific factors.

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Monitoring and Evaluation

Monitoring and Evaluation

Process MonitoringProcess Monitoring Programme EvaluationProgramme Evaluation

Quality of RUTF

Quality of RUTF

Availability of RUTF


Treatment InformationTreatment

Information CoverageCoverage Appropriateness

Appropriateness EffectivenessEffectiveness

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Process MonitoringQuality of RUTF

The monitoring team will cooperate with the local health and food

supervision department, make quality standards of RUTF, randomly

sample and monitor the quality.


The monitoring team will communicate with the health centers every

week to ensure that there are sufficient RUTF for SAM children.

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Process Monitoring

Treatment Information

In a CBI programme, children will move between the

components (SC, OTP, SFP) as their condition improves or

deteriorates. They may also move between the decentralised

OTP distribution sites. It is therefore important to be able to

track children between the programme components and

distribution sites.

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Process MonitoringTreatment Information Firstly, this project will establish a patient monitoring cards for every

children. Health workers should examine the clinical cards at monthly

meetings to identify children with static weight, weight loss or those not

recovered after thee months.

Secondly, this project will establish a numbering system to ensure that each

patient receives a unique registration number when he/she is first admitted into

the programme.

At last, on admission to the CBI all children should receive an identity

bracelet with their patient number written in indelible ink.

Based on this, it will be easy to track and exchange treatment information

on

individual children 39

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Programme Evaluation

Appropriateness The target populations and client’s perception of the programme should be

monitored regularly and programme design and implementation adjusted

accordingly.

Two kinds of community-level monitoring can be used: focus group

discussions and key informant interviews.

To shed light on:

Coverage, Access, Recovery, Service delivery, Cultural

appropriateness, Lessons learned.

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Appropriateness• Coverage - whether there are individuals or groups in the community who could be

in the programme but are not, the reasons why and how it could be changed.

• Access- whether there are barriers preventing people from accessing the programme

and what might be done about them.

• Recovery- whether carers perceive changes in children treated in the programme

and whether anything can be done to strengthen the recovery process.

• Service delivery- whether beneficiaries are happy with the CBI services they

receive and the means of delivery, and whether they could be improved.

• Cultural appropriateness- whether the programme is culturally sensitive or

doing anything inappropriate.

• Lessons learned- what should be done differently and what should be replicated in

future programmes.42

Programme EvaluationEffectiveness

Routine treatment monitoring data will be used to evaluate the programme effectiveness.

Measurement indicators:

Total number of children admitted in the programme

Cure rate

Non-recovery rate

Default rate

Average weight gain and length of stay

Relapses (readmissions after discharge) rate

Case fatality rate

Additional information, such as Cause of death, Reasons for default, etc..

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Programme EvaluationProgramme coverage

We calculate two estimates of coverage from the data: the point coverage estimate and

the period coverage estimate.

Period coverage calculation

Number of respondents attending the programme

Number of cases not attending OTP + Number of respondents attending OTP

Point coverage calculation

Number of children in OTP with MUAC still < 115mm

Total number of children with MUAC < 115mm

The period coverage estimate shows how well the programme has been doing in the

recent past whilst the point coverage estimate tells you how well the programme is doing

at the time of the survey.

X 100

X 100

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Budget

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How to achieve the sustainability of CBI ?

• Political will• Community participation• Parents education• Women empowerment• Seeking external support• ……..

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Documents

Proposal for Community Based Interventions for severe acute malnutrition in Oromiya Region in Ethiopia Group 5 Nathan Chimbatata Liao Sha Zhao Yuxin Wang