Detecting severe acute malnutrition in children under five at scale : the challenges of anthropometry to reach the missed millions

Objective: Severe Acute Malnutrition (SAM) interventions aim to detect and treat children at highest risk of death who benefit most from treatment. SAM services reach less than 20% of affected children worldwide, and innovative policy changes are needed to scale up services. This paper discusses anthropometry to diagnose SAM as one pathway to improve the effectiveness coverage of SAM services. Results: WHO defines SAM by either MUAC <115 mm or WHZ <−3 or the presence of nutritional oedema. Both MUAC and WHZ are proxy indicators of a clinical condition, and neither is a gold standard. Because they measure different characteristics of the same illness, MUAC and WHZ identify different SAM populations that overlap differently in different contexts across and within countries. MUAC is a better predictor of mortality and has the practical advantages of simplicity, reliability and accuracy. Using both indicators independently identifies more children and loses sensitivity to risk of death. Discussion and Conclusion: Based on current evidence and operational and policy considerations, using MUAC only for diagnosing SAM with a countryadapted cut-off could feasibly scale up SAM services and improve coverage to reach the millions of missed children. Meanwhile, continued research on the biomedical consequences and policy implications of this approach, as well as innovations such as system dynamics modeling, may contribute to the evidence

Exploring the health system for sustainable and integrated acute malnutrition services applying a systems lens: the case of Afghanistan

Introduction: Afghanistan has an estimated annual burden of severe acute malnutrition in children under five of over 600,000, with less then 30% accessing care. Since 2009, acute malnutrition has been part of the country’s Basic Package of Health Services, which is outsourced for implementation to local partners and regulated by the Ministry of Public Health. A gradual transition to government implementation is expected to change the dynamics of health system functions and actors, with unpredictable outcomes. Building competencies in applying systems thinking by taking into account tacit knowledge may strengthen adaptive management and leadership for improving sustainable and integrated acute malnutrition interventions. We explored the dynamics of the health system with a systems lens to identify opportunities for improving sustainable and integrated acute malnutrition services to inform policies. Methods: A mixed method design involved over 70 health actors to explore the health system capacity through participatory system dynamics mapping based on rapid observation, key informant interviews, group discussions and document review. The policy analysis investigated acute malnutrition coverage. A network analysis explored involvement and influences of health actors. A framework approach appraised key health system functions and explored the level of integration of acute malnutrition. System changes over time and causal loop analyses explored system dynamics to identify leverages for improving and sustaining health outcome. Results: Key policies and strategies were in place but did not consistently recognise severe acute malnutrition as a major childhood illness. Narrow involvement of health actors missed opportunities for ‘learning together’ and developing sustainable and broad-based technical leadership. The health actors network showed two scale free hubs of the Public Nutrition Directorate and health workers of health facilities making the link between government and partners at and between the national/provincial and community levels. The Basic Package of Health Services left community-based nutrition underdeveloped and 40% of the hard-to-reach population uncovered. Most funding remained emergency based, and quality and ownership were limited despite major training efforts. The extent of integration was stronger at implementation level than at policy and organisational level. Behaviour-over-time, mapping the effects of financial and technical support on effective coverage, showed late but fast expansion of coverage. Causal loop analysis, building on tacit knowledge to describe the complexity of interactions and influences, found reinforcing effects from policy, competency and community involvement and dumping effects from financial and technical support on improving quality. Based on the learning from the change mechanisms, an initial theory of change identified assumptions that should be tested and refined in evaluations. Conclusion: The exploration of health system capacity and dynamics uncovered strengths and missed opportunities for sustaining integrated acute malnutrition services in Afghanistan. This study is an initial step in applying systems thinking using tacit knowledge through participative approaches to explain unpredictable behaviour and foster dialogue and ‘learning together’ for improving sustainable and integrated acute malnutrition services. Further research should encourage applying systems thinking to further understand dynamic complexity by opening the black box to understand why change happens, how and under what circumstances, and design effective interventions

Effective therapeutic feeding with chickpea sesame based ready-to-use therapeutic food (CS-RUTF) in wasted adults with confirmed or suspected AIDS

Wasting has been observed as a common feature of the human immunodeficiency virus (HIV) disease since the first reports and its presence increases the risk of death. There is no consensus on how to manage wasting associated with HIV. The goal of this study was to assess the effectiveness of a locally made Chickpea Sesame Based RUTF (CS-RUTF) in treating wasting associated with HIV in developing countries. Chronically sick adults from Mangochi Health District (Malawi) with wasting and confirmed or presumptive clinical diagnosis of HIV were recruited for the study. Subjects received a daily ration of 500 grams of CS-RUTF for 3 to 5 months. Nutrition status changes and mortality were used to assess the effectiveness of the intervention. There were 3 patterns of anthropometric responses continuous weight gain (WG), static weight (SW) and continuation weight loss (WL). The distribution of the 3 patterns is 53.9% (82/154) for the WG pattern, 9.1% (14/154) for the SW pattern and 37.0% (57/154) for the WL pattern. For the WG pattern, the overall median weight gain was 4.6 (2.4 to 7.1) kg. It was 5.7 (3.5 to 7.8) kg for those who completed 3 months of supplementation. MUAC and BMI changes followed similar pattern than weight change. Not being on HAART, acute diarrhoea during follow up, episode of reduced appetite during follow up, missing at least one visit were identified as risk factors for intervention failure. Overall, 38.5% (72/187) of study participants died during the intervention. In conclusion, despite that the study confirms the limited impact of food based interventions on mortality among wasted HIV positive individuals, it also suggests that supplementation with CS-RUTF may be an effective intervention for reversing wasting associated with HIV if combined with HAART and specific treatment of severe opportunistic infection causing diarrhoea and reducing appetite

Agent-based modelling for rethinking the socioeconomic determinants of child health in sub-Saharan Africa

Socioeconomic factors play distal roles in shaping populations’ health. In sub-Saharan Africa, these structural health determinants are strongly associated with intermediate determinants of under-5 mortality such as lifestyle factors, health seeking behaviour, or exposure to a health threat. The aim of the study was to use simulation tools for rethinking the dynamics between socioeconomic factors, preventive health measures, and child health. An agent-based model was developed, consisting of rules and equations based on data from four Demographic and Health Surveys conducted in sub-Saharan countries. The model, visualizing the impact of different factors and complex effects, enhanced the understanding and debate on causal pathways of socioeconomic inequalities in under-5 mortality

Impact of household food insecurity on the nutritional status and the response to therapeutic feeding of people living with human immunodeficiency virus

Background: The role of household food security (HFS) in the occurrence of wasting and the response to food-based intervention in people living with human immunodeficiency virus (PLHIV), especially adults, is still controversial and needs investigation. Methods: Face-to-face interviews to collect data for Coping Strategies Index score and Dietary Diversity Score estimation were conducted during a noncontrolled and nonrandomized study assessing the effectiveness of ready-to-use therapeutic food in the treatment of wasting in adults with HIV. Coping Strategies Index score and Dietary Diversity Score were used to determine HFS, and the participants and tertiles of Coping Strategies Index score were used to categorize HFS. Results: The study showed that most participants were from food insecure households at admission, only 2.7% (5/187) ate food from six different food groups the day before enrolment, and 93% (180/194) were applying forms of coping strategy. Acute malnutrition was rare among, <5-year-old children from participants' households, but the average (standard deviation) mid-upper arm circumference of other adults in the same households were 272.7 (42.1) mm, 254.8 (33.8) mm, and 249.8 (31.7) mm for those from the best, middle, and worst tertile of HFS, respectively (P = 0.021). Median weight gain was lower in participants from the worst HFS tertile than in those from the other two tertiles combined during therapeutic feeding phase (0.0 [-2.1 to 2.6] kg versus 1.9 [-1.7 to 6.0] kg; P = 0.052) and after ready-to-use therapeutic food discontinuation (-1.9 [-5.2 to 4.2] kg versus 1.8 [-1.4 to 4.7] kg; P = 0.098). Being on antiretroviral therapy influenced the response to treatment and nutritional status after discontinuation of ready-to-use therapeutic food supplementation. Conclusion: Food insecurity is an important contributing factor to the development of wasting in PLHIV and its impact on therapeutic feeding response outlines the importance of food-based intervention in the management of wasting of PLHIV. © 2011 Bahwere et al, publisher and licensee Dove Medical Press Ltd.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Enhancing loco-regional adaptive governance for integrated chronic care through agent based modelling (ABM)

Introduction: Moving from existing segmented care to integrated care is complex and disruptive. It is complex in the sense that the type of changes and the timeframe of these changes are not completely predictable. It is disruptive in the sense that the process of change modifies but also is influenced by the nature of interactions at the individual and organisational level. As a consequence, building competences to govern the necessary changes towards integrated care should include capacity to adapt to unexpected situations. Therefore, the tacit knowledge of the stakeholders (“knowledge-in-practice developed from direct experience; subconsciously understood and applied”1) should be at the centre. However, the usual research and training practices using such a knowledge (i.e. action research or case studies), are highly time-consuming. New approaches are therefore needed to elicit tacit knowledge. One of them is agent based modelling (ABM)2 through computer simulation. The aim of this paper is to make a “showcase” of an agent-based model that uses the emergence of tacit knowledge and enhances loco-regional adaptive governance for improving integrated chronic care. Theory/Methods: We used a complex adaptive system’s lens to study the health systems integration process. We applied key components of ABM to assess how health systems adapts through the dynamics of heterogeneous and interconnected agents (agents are characterised by their level of autonomy, heterogeneity, and interactions with other agents). The agent-based model was developed through a process where concept maps, causal loop diagrams, object-oriented unified modelling language diagrams and computer simulation (using Netlogo©) were iteratively used. Results: The agent-based model was presented to health professionals with variable experience in healthcare to elicit their perceptions and tacit knowledge. It consisted of agents with certain characteristics and transition rules. Agents included providers, patients, networks’ or health systems’ managers. Agents can adopt or influence the adoption of integrated care through learning and because of being aware, motivated and capable of decision making. The environment includes institutional arrangements (e.g., financing, training, information systems and legislation) and leadership. Different scenarios were created and discussed. Key rules to strengthen adaptive governance were reflected on. Discussion and conclusion: This study is an initial step of an exercise to use ABM as a means to elicit of and enhance tacit knowledge to strengthen governance for integrated care. It is expected that the study will foster dialogue between actors of loco-regional projects to integrate health and social care for chronic diseases in Belgium (a new program initiated by federal authorities). Suggestions for future research: Future research is expected to continue developing methods that combine ABM with participative exploration approaches to make better use of tacit knowledge in strengthening loco-regional governance for the development of integrated care

Low mid-upper arm circumference identifies children with a high risk of death who should be the priority target for treatment

Background: Severe acute malnutrition (SAM) is currently defined by the WHO as either a low mid-upper arm circumference (i.e. MUAC <115 mm), a low weight-for-height z-score (i.e. WHZ <- 3), or bilateral pitting oedema. MUAC and WHZ do not always identify the same children as having SAM. This has generated broad debate, as illustrated by the recent article by Grellety & Golden (BMC Nutr. 2016;2:10). Discussion: Regional variations in the proportion of children selected by each index seem mostly related to differences in body shape, including stuntedness. However, the practical implications of these variations in relation to nutritional status and also to outcome are not clear. All studies that have examined the relationship between anthropometry and mortality in representative population samples in Africa and in Asia have consistently showed that MUAC is more sensitive at high specificity levels than WHZ for identifying children at high risk of death. Children identified as SAM cases by low MUAC gain both weight and MUAC in response to treatment. The widespread use of MUAC has brought enormous benefits in terms of the coverage and efficiency of programs. As a large high-risk group responding to treatment, children with low MUAC should be regarded as a public health priority independently of their WHZ. Conclusion: While a better understanding of the mechanism behind the discrepancy between MUAC and WHZ is desirable, research in this area should not delay the implementation of programs aiming at effectively reducing malnutrition-related deaths by prioritising the detection and treatment of children with low MUAC

Precision, time, and cost: a comparison of three sampling designs in an emergency setting

The conventional method to collect data on the health, nutrition, and food security status of a population affected by an emergency is a 30 × 30 cluster survey. This sampling method can be time and resource intensive and, accordingly, may not be the most appropriate one when data are needed rapidly for decision making. In this study, we compare the precision, time and cost of the 30 × 30 cluster survey with two alternative sampling designs: a 33 × 6 cluster design (33 clusters, 6 observations per cluster) and a 67 × 3 cluster design (67 clusters, 3 observations per cluster). Data for each sampling design were collected concurrently in West Darfur, Sudan in September-October 2005 in an emergency setting. Results of the study show the 30 × 30 design to provide more precise results (i.e. narrower 95% confidence intervals) than the 33 × 6 and 67 × 3 design for most child-level indicators. Exceptions are indicators of immunization and vitamin A capsule supplementation coverage which show a high intra-cluster correlation. Although the 33 × 6 and 67 × 3 designs provide wider confidence intervals than the 30 × 30 design for child anthropometric indicators, the 33 × 6 and 67 × 3 designs provide the opportunity to conduct a LQAS hypothesis test to detect whether or not a critical threshold of global acute malnutrition prevalence has been exceeded, whereas the 30 × 30 design does not. For the household-level indicators tested in this study, the 67 × 3 design provides the most precise results. However, our results show that neither the 33 × 6 nor the 67 × 3 design are appropriate for assessing indicators of mortality. In this field application, data collection for the 33 × 6 and 67 × 3 designs required substantially less time and cost than that required for the 30 × 30 design. The findings of this study suggest the 33 × 6 and 67 × 3 designs can provide useful time- and resource-saving alternatives to the 30 × 30 method of data collection in emergency settings

The health condition of spinal cord injuries in two Afghan towns

Study design: Cross-sectional. Objectives: To describe the population with spinal cord injury (SCI) in two major towns of Afghanistan. Setting: Kabul and Herat, Afghanistan, March-July 2001. Methods: The residents of Kabul and Herat (N = 311) with traumatic SCI were retrieved and investigated. They underwent standardised interviews and clinical examinations assessing socio-demographic characteristics and information on health condition, injury, quality of life and rehabilitation outcome. Results: The study population could be considered as the survivors in the harsh living conditions in Afghanistan of a supposedly much larger group, counting proportionately fewer females and fewer cervical lesions than expected. Acute care was practically nonexistent. Prevalences of urinary tract infections and pressure sores were high as no good management was available. Basic rehabilitation helped persons with SCI to attain a fairly good level of independence (total functional independence measure score mean = 95, SD = 19). Their quality of life was significantly lower than their neighbours of same age and sex (P < 0.0001). Along with the economic security and good access to the home, the use of the orthopaedic Centre of the International Committee of the Red Cross (ICRC) contributed to a better quality of life. Conclusion: Thanks to the rehabilitation programme of the ICRC providing a basic but comprehensive rehabilitation, persons with SCI in Afghanistan are coping rather well. This result is remarkable considering the difficult economic and sanitary circumstances in the poorest country in the world

Understanding pathways of integrating severe acute malnutrition interventions into national health systems in low-income countries : applying systems thinking to study the complexity of health systems

The study explored pathways of integrating severe acute malnutrition interventions into health systems using a theory-driven approach to understand how and why integration progressed in given contexts. Different methodologies under the realist paradigm provided increasing insights into complexity. A scoping study explored integration concepts and attributes, policies and evidence. Using a framework approach, causal loop analysis and agent-based modelling, case studies described the extent of integration and identified factors and system dynamics that influenced its speed and outcome. The refined theory reinforced the finding that understanding integration and considering the complexity of the health system gave health actors a common vision and strengthened their capacity to adapt and implement the integration policy in their context. Subsequent research and operational guidance applying systems thinking may contribute to improved comprehensive child healthcare and health outcome.(SP - Sciences de la santé publique) -- UCL, 201