Associations between type of health workers and clinical outcomes of children (0 - 59 months) treated in Ghanaian referral hospitals for severe acute malnutrition - the SAMAC study

MSc (Nutrition), North-West University, Potchefstroom CampusThe high prevalence of undernutrition in infants and children under five years remains a global problem. Undernutrition and micronutrient deficiencies are responsible for over 3.1 million deaths annually. Several reports have shown the great progress in the reduction of under-five mortality(u5M) due to improved in-patient management of children with severe acute malnutrition (SAM) globally. Sub-Saharan Africa (SSA) was, though, reported as one of the regions with an insufficient decrease in u5M. Inadequate health workforce has been identified as a core factor contributing to u5M and thus more research are needed. This sub-study aimed to determine the association between the health workers involved in hospital management of SAM and treatment outcomes. Methods: In this retrospective study, data were collected from the medical records of children aged 0-59 months, admitted with SAM at Konfo Anokye Teaching Hospital (KATH), Tamale Teaching Hospital (TTH) and Princess Marie Louise (PML) between January 2013 and July 2018.Based on the medical records, the clinical conditions and nutritional status were assessed at admission. The identified clinical signs and medical conditions were reported according to the assessment of health workers, of whom included dieticians, general practitioners (GP), house officers, nutrition officers and paediatricians. At discharge, the treatment outcomes including length of stay (LOS), weight-gain and resolution of infections were evaluated in relation to the type of health workers who cared for the patient. Continuous variables were described with median and interquartile range and categorical data with frequencies and percentages. SAS software version 9.4 was used for statistical analysis. Results Five hundred and ninety-six medical records of infants and children between the ages of 0 to 59 months admitted to three hospitals for the treatment of SAM were included; 304 were boys and 292 were girls. SAM was higher amongst the children aged 12 to 24 months (n=226, 38%) followed by 6 to 12 months (n=169, 28%), and lower in older children aged 36 to 48 months and 48 to 59 months (n=24, 4% and n=14, 2% respectively). The children presented with malaria, HIV, tuberculosis (TB), gastroenteritis, diarrhoea, respiratory infection, meningitis, urinary tract infection and/ or oedema at admission; 51% of the children had diarrhoea. Comorbidities were higher amongst the children aged 12 to 24 months. Starter feeds were mainly prescribed by the nutrition officers (37%) and the house officers (36%) across the hospitals. Transition feeds were mostly prescribed by nutrition officers at TTH, by dieticians at PML and by house officers and nutrition officers at KATH. At all the hospitals, micronutrients and medication were mostly prescribed by house officers. Health worker who prescribed the transition feed, electrolytes and micronutrients were not reported in 166, 347 and 279 children respectively. Discharge rate was 80% and mortality was 17%; and was higher in children aged 12 to 24 months (31% and 7% respectively). Seventy percent had a good appetite and 44% had their infections resolved. Median weight-gain was 6.25 g/kg/day and median LOS was 10 days.The data from three Ghanaian referral hospitals alone was not sufficient to address the association between the health workers and clinical outcomes because of a large number of missing data and a large possibility of reverse association. Conclusion and recommendation There was considerable heterogeneity in service delivery between the three hospitals. However, most of the children admitted with SAM across the hospital were attended to by nutrition officers and house officers. Therapeutic feeding including starter feeds and transition feeds were mainly prescribed by dieticians, nutrition officers and house officers at PML, TTH and KATH respectively, and medication was mainly prescribed by house officers across all the hospital. There was a high possibility of reverse association because more skilled health workers such as paediatricians were likely attended to more severe children.The high mortality rate in this study highlights a need for further health facilities' research on factors that contributed to the results of this study including the challenges hindering the health workers to provide services according to their scope of practice, and the reasons behind the premature discharge of children treated for SAM at hospitals. It also emphasises an urgent requirement for the Ghanaian health facilities to prioritise on implementing the new WHO guidelines for the treatment of SAM in order to improve the treatment outcomes. This study, furthermore, recommends the future studies to use a large sample size when investigating the association between types of health workers involved in SAM treatment at hospitals and clinical outcomes of SAM.Master