Set criteria in the management of severely malnourished children in Zambia: evidence from the evaluation of an 'outpatient therapeutic care program (OTP)'

Abstract

Background: Severe malnutrition is still a leading cause of morbidity and mortality in sub-Saharan Africa. The Outpatient Therapeutic Care Program (OTP) is one of the interventions that seek to reduce the burden associated with severe malnutrition in children. Performance of the OTP against the Integrated Management of Acute Malnutrition (IMAM) set criteria in the selected public health facilities in Lusaka urban, Zambia was evaluated.
Methods: Records of children (n=828), discharged from OTP between September 2005 and September 2007 in eleven health centres where this program was running, were evaluated for performance. The selection process adapted a multistage sampling technique using proportional to size approach in order to get the number of records for each site. Performance was determined by developing a compost indicator from weight gain, length of period of stay in the OTP, recovery rate, default rate and mortality. Logistic regression was used to assess performance and its determinants. In addition, a sampling frame of health care staff working in the OTP was made for each health facility from which twenty five of them participated in in-depth interviews assessing corroborative evidence for performance of the program (results reported elsewhere). Health facility and sex were used as indicator for completeness of data and as a measure for non-participation. Lack of completeness of records was the most important cause of non-response.
Findings: Overall prevalence of good performance was 86% (n=828). However, the study showed contrasting differential performance by health facility (Ranging from 73% for N'gombe to 100% for Matero). Disaggregating the composite indicators revealed that 60% of children gained acceptable weight (above 4 g per kg body weight per day, mean weight gain of 5.7 g per day, SD 1.2); 75% stayed less than 60 days recommended (median length of stay of 48 days); Recovery rate of 59%, 31% default rate and 3.2% death rate. In multivariate logistic regression, source of admission and appetite were the main determinants of performance. Poor performance was associated with referrals from a health facility (Prevalence, 86.7%; OR=0.01, 95CI%CI 0.001-0.301) and reported lack of or inadequate breastfeeding at the time of admission to the program (OR=0.481, 95%CI 0.27-.85).
Conclusion: Good overall program performance of the OTP suggests high feasibility to fight severe malnutrition in this setting. However, it was not clear how some factors such as poor appetite affected performance, suggests that there may be interplay of factors at work and further research is needed to explore them. Nonetheless, finding that breastfeeding was associated with good performance suggests how important this factor might be to child survival as a whole. Inversely, its lack could be pointing to limitations to breastfeeding interventions in the community.