Community-based therapeutic care: treating severe acute malnutrition in sub-Saharan Africa

Severe acute malnutrition (SAM) affects approximately 13 million children under-five and is associated with over 1.5 million preventable child deaths each year. Case fatality rates in hospitals treating SAM remain at 20-30%, and coverage of those affected remains low. Training and support to improve centre-based management can reduce case fatality rates. However, an exclusive inpatient approach does not consider the many barriers to accessing treatment that exist for poor people in the developing world. Community-based therapeutic care (CTC) is a new approach for the management of SAM that uses Ready-to-Use Therapeutic Foods (RUTF) and triage to refer cases without complications to outpatient care and those with complications to inpatient treatment. This thesis aims to test the hypotheses that a CTC strategy can treat children with SAM effectively and can achieve better population treatment coverage than a centre-based approach. Five studies, using primary data, are presented. The first 3 studies evaluate the clinical effectiveness of CTC through examination of individual outcome data from research programmes in Ethiopia and Malawi. The fourth study examines the coverage of a CTC programme for SAM in Malawi and compares this with coverage of a centre- based programme. The final study is a multi-country evaluation of 17 CTC programmes implemented across Africa. Results from all studies that use the CTC treatment model show that outcomes can meet the international Sphere standard indicators of < 10% mortality and > 50% coverage. Coverage of a CTC programme in Malawi was three times that of a centre-based programme in the same region (73.64% (95% C.I. 66.0%, 81.3%) vs. 24.5% (95% C.I. 17.8%, 31.4%). A number of factors were vital to achieving low mortality and high coverage in these programmes. These included decentralisation of outpatient treatment services and community mobilisation techniques to encourage early presentation, and the use of appropriate triage criteria, to identify children suffering from SAM with no complications that could be treated safely as outpatients. The use of triage did not appear to increase mortality (OR 0.51 95% CI 0.28, 0.94). This thesis suggests that CTC does not increase case fatality rates associated with SAM and could reduce them, and that it could increase the number of children receiving treatment.

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of London

Year dc:date.issued

2009

Author dc:creator

• Sadler, K.

• Institute of Child Health

Language dc:language

en, eng