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British Journal of Healthcare and Medical Research - Vol. 11, No. 3
Publication Date: June 25, 2024
DOI:10.14738/bjhmr.113.16984.
Bidu, K. T., Ebiyo, D. H., Assegu, Y. B., Bekele, E. A., & Heyi, S. K. (2024). Evaluating the Level of Adherence to The Ministry of Health
Guideline in The Management of Severe Acute Malnutrition at Adama Hospital Medical College: A Cross-Sectional Study. British
Journal of Healthcare and Medical Research, Vol - 11(3). 107-126.
Services for Science and Education – United Kingdom
Evaluating the Level of Adherence to The Ministry of Health
Guideline in The Management of Severe Acute Malnutrition at
Adama Hospital Medical College: A Cross-Sectional Study
Kassahun Tegegne Bidu
Department of Emergency Preparedness and Response,
World Health Organization (WHO) – Addis Ababa, Oromia, Ethiopia
Derartu Hailu Ebiyo
Department of Ear, Nose and Throat,
St. Poul Hospital Millenium Medical College – Addis Ababa, Ethiopia
Yirga Bieza Assegu
Department of Emergency Preparedness and Response,
World Health Organization (WHO) – Addis Ababa, Oromia, Ethiopia
Esulalem Abebe Bekele
Department of Emergency Preparedness and Response,
World Health Organization (WHO) – Addis Ababa, Oromia, Ethiopia
Sadat Kasim Heyi
Department of Emergency Preparedness and Response,
World Health Organization (WHO) – Addis Ababa, Oromia, Ethiopia
ABSTRACT
Background: Severe Acute Malnutrition (SAM) is defined as a weight-for-height
(WFH) of < -3 standard deviations or MUAC of < 11.5cm, or bilateral pitting edema
among under-five children. WHO developed 10 steps with evidence generated from
multiple countries to reduce case fatality rate among SAM cases but their
implementation and impact on case fatality locally remain unknown. Objective: To
evaluate the level of adherence to MOH guidelines in the management of SAM
children. Methods: Descriptive cross-sectional study with systematic sampling
techniques was conducted from November 1st to 30th, 2023 on medical records of
SAM cases. Data analysis done using statistical package for social sciences (SPSS)
version 25. Results: Of 200 SAM cases, 103 (51.5%) were female and mean age and
SD were 23.56 + 11.93 months. The average length of stay in the hospital was 13.6
days. Overall adherence to MOH guidelines was 15.5%, and the appropriateness of
treatment in the management was: Step 1: 20.5%; Step 2: 65.5%; Step 3: 32%; Step
4: 28.5%; Step 5: 41.5%; Step 6: 34%; Step 7: 35%; and Step 8: 39%. Treatment
outcome for SAM cases were: stabilized to OTP, cured, transferred out, non- responder, defaulter, and died were 63%, 20%, 2.5%, 2.5%, 2%, and 0%,
respectively. Conclusion and Recommendations: Adherence level to MOH
guidelines was low at 15.5% and approprieteness for step of management ranges
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British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 03, June-2024
Services for Science and Education – United Kingdom
from 20.5 to 65.5%. Thus, improving adherence to MOH guidelines in SAM
management and further studies to determine factors affecting adherence and
length of hospital stay need to be conducted.
Keywords: Adherence, Children, MOH Guidelines, Severe Acute Malnutrition.
INTRODUCTION
Background
Overnutrition and undernutrition are referred to as malnutrition; undernutrition is further
divided into underweight, wasting, stunting, and micronutrient deficiencies. While it can affect
people of all ages and both genders to varying degrees, under five children, older adults, women
who are pregnant or lactating, and families with fewer than five children are more vulnerable
than other population groups. Individuals who suffer from malnutrition are more susceptible
to health problems, decreased efficiency, and poor academic performance in comparison to
those who are well nourished.
Background of the Study:
Nutrition promotes economic growth while also improving the mental health and physical
productivity of the labor force. Nutrition improvement make significant contribution to poverty
reduction and meeting health, education, and employment goals (1).
Malnutrition in all its forms is a global burden to almost every country in the globe, posing
asubstantial risk to public health and significant economic challenge (1). Acute malnutrition is
a condition that arises during an emergency as a result of illness and/or low food intake, most
commonly in children under the age of five and pregnant and lactating mothers. Wasting is
defined as a child that is too thin for his or her height. Wasting is caused by recent rapid weight
loss or an inability to gain weight. Severe acute malnutrition (SAM) is defined as a weight-for- height (WFH) of fewer than -3 standard deviations, Mid-Upper Arm Circumference (MUAC) of
less than 11.5cm, or bilateral pitting edema [2]. A kid who is moderately or severely wasted is
more likely to die [2, 3].
In 2022, globally, 148 million, 45 million, and 37 million children under the age of five were
stunted, wasted, and overweight, respectively. Most children with malnutrition live in Asia and
Africa which are a home to majority of malnourished children, with 52% and 43% stunted, 70%
and 27% wasted, and 48% and 28% overweight respectively [3].
Malnutrition is a major issue in developing and poor nations such as Sub-Saharan Africa,
impacting a large number of children and resulting in significant losses of human capital and
economic productivity in the region. Africa is home to 52 million stunted children (one-third of
the global total) and 14.1 million wasting children. Again, Africa is the second highest in the
world for children born small for gestational age accounting for 24%. These youngsters are at
danger of morbidity and mortality, with an average death rate 11 times higher than their
healthy counterparts [4].
In 2018, 256.1 million Africans were undernourished, affecting the continent’s socioeconomic
status, health, education, and total productivity. The increasing number of undernourishments
in the continent is largely due to food insecurity caused by drought, climate change, conflicts,
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Bidu, K. T., Ebiyo, D. H., Assegu, Y. B., Bekele, E. A., & Heyi, S. K. (2024). Evaluating the Level of Adherence to The Ministry of Health Guideline in
The Management of Severe Acute Malnutrition at Adama Hospital Medical College: A Cross-Sectional Study. British Journal of Healthcare and
Medical Research, Vol - 11(3). 107-126.
URL: http://dx.doi.org/10.14738/bjhmr.113.16984.
the COVID-19 pandemic, and an economic slump. In 2019, Africa accounted for 22% of global
undernutrition, with 57.6 million stunted, 12.7 million acutely malnourished, and 3.5 million
severely wasted (severe acute malnutrition) children. In 2019, the socioeconomic cost of child
undernutrition in Africa was estimated to be 3.2 billion USD in the health sector, 345 million
USD in education, and 4.17 billion USD in productivity [5].
Children suffering from wasting, a type of acute malnutrition, have reduced immunity, long- term developmental problems, an increased risk of mortality in general, and much more when
the wasting is severe [6, 7]. According to the global joint child malnutrition estimate for 2022,
45 million under five children were wasted, with 13.6 million severely wasted [3]. In Ethiopia,
7% of children under five years were wasted, 1% were severely wasted, 37% were stunted,
12% were severely stunted, 21% were underweight, and 6% were severely underweight [2, 6,
7]. A global hunger index (GHI) report, which is intended to determine the food security and
nutrition status of the population in countries using four key indicators: undernourishment,
child stunting, child wasting, and child mortality, shows an 18.2 index at the global level, with
an estimated 828 million people undernourished in 2021, and categorized Ethiopia in a serious
category (20.0–34.9) for the year 2022 with a hunger index of 27.6 [8].
Malnutrition costs the lives of children and has a negative impact on the population’s socio- economic level, health, education, and total productivity. According to the cost of hunger in
Africa and Ethiopia, the socio-economic cost of child undernutrition in the health sector,
education, and productivity was estimated to be 3.2 billion USD, 345 million USD, and 4.17
billion USD, respectively, in 2019 [9]. Ethiopia costs a total of 4.7 billion USD (55.5 billion ETB)
due to undernutrition related to health, education, and productivity, with a loss of 154 million
USD, 7.9 million USD, and 4.5 billion USD, respectively [5,10].
SAM is a leading cause of morbidity and mortality among under the age of five, and with children
with SAM being 9 to 11 times more likely to die than well-nourished children [2,4,6,11]. Several
factors contribute to SAM case fatality, including childhood co-morbidities such as diarrhea,
pneumonia, shock, and nonadherence to management guidelines by health care professionals
[2, 22].
Even though number of children with severe acute malnutrition in Africa is unacceptably high,
in different Africa countries level of adherence to WHO guideline was inadequate and needs
improvement [12], and case fatality rate among severely malnourished children ranges from
15% to 40% [13,15]. Appropriate management of SAM cases based on adopted guideline saves
the life of children with malnutrition, shorten average length of hospital stay and improves
economy of the individual, household, and country. With appropriate implementation of case
management practices and follow-up care case fatality rates reduced from 30 % to < 5% in
health facility providing services in Ethiopia [16] and from 40 - 50% to lower than 6% in
developing countries [17].
The WHO guidelines on SAM recommend careful clinical assessment of health problems of
children with SAM. This is to ensure early prevention or treatment of health issues common to
children with SAM, such as hypoglycaemia, hypothermia, dehydration, electrolytes imbalance,
infections, and micronutrient deficiencies [16,18].