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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].