Treatment Outcome of Severe Acute Malnutrition and associated factors among under-five children in outpatient therapeutics unit in Gubalafto Wereda, North Wollo Zone, Amara Regional State, North Ethiopia, 2019 G.C


 Background: In Ethiopia uncomplicated severe acute malnutrition is managed through the outpatient therapeutic program at health posts level. This brings the services for the management of Severe Acute Malnutrition closer to the community by making services available at decentralized treatment points within the primary health care settings. So far, evidence on the treatment outcome of the program is limited. Thus, the main aim of this study was to determine the magnitude of treatment outcomes of severe acute malnutrition and associated factors among under-five children at outpatient therapeutic feeding units. Methods: This was a retrospective cohort study conducted on 600 children who had been managed for SAM under OTP in Gubalafto Wereda from April to May/2019. The children were selected using systematic random sampling from 9 health posts. The structured, pre-tested and adapted questionnaire was used to collect the data. The data was entered by using EPI-data Version 4.2 and exported to SPSS version 24.0 for analysis. Bivariate and Multivariate regression was also carried out to determine the association between dependent and independent variables. Results: A total of 600 records of children with a diagnosis of severe acute malnutrition were reviewed. Of these cases of malnutrition, the recovery rate was revealed as 65 %. The death rate, default rate, and medical transfer were 2.0, 16.0, and 17.0 respectively. Children who took immunization were had 6.85 times higher odds of recovery than children who were not immunized (AOR=6.85 at 95% CI (3.68-12.76)). The likelihood of recovery was 3.78 times higher among children with new admission than those with re-admission (AOR=3.78at 95% CI ((1.77-8.07))). Likewise, children provided with amoxicillin were 3.38 times more likely to recover compared to their counterparts who were not provided (AOR=3.38 at 95% CI ((1.61-7.08))). Conclusions: The recovery rate and medical transfer were lower than sphere standard. Presence of cough, presence of diarrhea admission category, provision of amoxicillin, and immunization status were factors identified as significantly associated with treatment outcome of Sever Acute Malnutrition. Building capacity of OTP service providers and regular monitoring of service provision based on the management protocol were recommended.


Background
Malnutrition is a condition that results from deficiencies, excess or imbalance in a person's intake of energy or nutrients. It is broadly classified as undernutrition includes stunting, wasting, underweight and micronutrient deficiency and the other form is overweight and obesity (1).
Formerly in many countries, treatment of SAM had been restricted to facility-based approaches, greatly limiting its coverage and impact. However, evidence from emergency programs suggested that large numbers of SAM cases could be treated in their communities without being admitted to a health facility. The program was started in Ethiopia in 2003 using the CTC model, which depended upon significant external resources and expertise and was implemented parallel to the national health system rather than integrated (4,5).This community-based management of acute malnutrition (CMAM) reduce limitations of health facilities and therapeutic feeding centers (TFC) management of SAM .It addresses community based management of SAM children without medical complications (OTP) and MAM and designed as components of CMAM (1,3,6).
In Ethiopia, the program now expanded to every health center and health post of the country.
OTP serve the management of SAM in children aged 6-59 months (4,7). The management of SAM was mainly with ready-to-use therapeutic foods (RUTF); other routine medications like antibiotics, vitamin A, and folic acid; and deworming (7,8).
Globally, 52 million children of age less than five years were affected by acute malnutrition from which 17 million were severely wasted. Data shows that more than half of all wasted children in the world live in Southern Asia and Sub-Sahara African countries. Undernutrition is also a major cause of disability preventing children who survive from reaching their full development potentials (10,11) Severe acute malnutrition is still a major public health problem in many African countries affecting the overall health and development priorities due to the effects (11,14).
Despite the improvement made in child health and nutritional interventions, Ethiopia remains in a precarious situation where undernutrition is an underlying cause to half of its child deaths and wasting contributing to 23% of these deaths (15).
In Ethiopia, studies indicate that the recovery rate among children attending the inpatient facilities was still low and the defaulter rate was high compared to the acceptable minimum standard, this has the negative impact on the child health and survival (16,17).
Ethiopia Demographic and Health Survey (EDHS) 2016 report showed that 38%, 10% and 24% of under 5 years of age children in Ethiopia were stunted, wasted and underweight respectively.
In Amara region, 11.6% of under-five years of age children were wasted of which 3.5 are severely wasted (3).
Inpatient therapeutic feeding units are faced with a lot of challenges in handling cases of severe acute malnutrition. Some of the challenges include; limited in-patient capacity, lack of enough skilled staff in the hospitals to treat the large numbers needing care, the centralized nature of hospitals promotes late presentations and high opportunity cost for careers, serious risk of cross infections for immune-suppressed children such as children with SAM (18).
Besides the prevention strategies, the improved management of SAM is an integral part of the World Health Resolution on Infant and Young Child Nutrition to improve child survival.
Children with SAM have profoundly disturbed physiology and metabolism, such that if intensive refeeding is initiated before metabolic and electrolyte imbalances corrected (9).
Despite malnutrition is one of the major public health problems in Ethiopia, limited information exists regarding the outcome of SAM treatment provided through the outpatient decentralized approach. Besides, the high percentage of malnutrition is alarming which needs further study to describe the treatment outcome of SAM in OTP to assess the factors contributing to the treatment outcome. The study, therefore, is aimed at describing the treatment outcome among children of age less than five years and identifies factors contributing to the treatment outcome.

Study area and periods
The study was conducted in GubalaftoWereda from

Inclusion criteria
Records of under-five children at outpatient therapeutic feeding units

Exclusion criteria
Transferred cases and records with incomplete information will exclude.

Sampling technique and procedure
Multistage sampling technique was employed to select the study subject. The study area, Gubalafto Wereda has a total of 34 Kebeles (4 are urban and 30 are rural kebeles). From the total 34 kebeles, 7 rural and 2 urban kebeles was selected by simple random sampling method.
The samples are distributed proportionally based on probability proportional to size (PPS) allocation technique. Participants in each kebele are selected by using a systematic sampling technique after calculating the sampling interval (K) for each kebeles.
The sample frame is the list of under-five SAM children charts at OTP. It is identified after checking all 9 selected kebeles (study population) to identify charts of children from birth up to 59 months old and coding of those charts was done to prepare sampling frame for each kebele.
Those children with incomplete charts are considered as non-respondent. Finally, the OTP record card of each child was selected using systematic random sampling.

Sample size determination
For the first specific objective sample size for the magnitude of treatment, the outcome was determined using the sample size determination formula for a single population proportion. A study done in Wolaita zone showed a recovery rate of 64.9% and two different studies in Amhara region showed a recovery rate of 78% & 58.4%. For this calculation, we use the proportion that was done in Wolaita since the two lists above done in inpatient therapeutics unit.
A total sample size of 354 was determined using single sample proportion formula by considering 95% confidence, 5% margin of error and taking 64.9 % recovery rate from Wolaita.
By adding 10% non-respondent rate the final sample size was 390 Where, n = sample size derived from estimation formula Zα /2 = the value of z at a confidence level of 95%= 1.96 P= is recovery rates of children who had been managed for SAM = .64.9(64.9%) d = is the margin of error to be tolerated and taken as 5% Considering 10% contingency for missing data the final sample size for determining the treatment outcome For the second objective, the sample size was determined using a double population proportion formula by considering study done in Tigray and Wolaita recovery rate p=61.78,64.9 respectably to calculate the required sample size. Finally, it is calculated by using Epi info version 7 statistical packages.
: is a percent of exposed with the outcome  P2: is a percent of non-exposed with the outcome  Z α/2: is taking CI 95%,  ZB:80% of power  And r is the ratio of non-exposed to exposed 1:1

Sampling procedure
We used Open Epi-version 2.3 (20) to calculate the sample size with the following assumptions: The proportion recovered in the exposed (children with Comorbidities) group (33.3%), the proportion recovered in the non-exposed (children without Comorbidities) group (20.4%)(29), 95% CI (confidence interval), 5% marginal error (d), and power of 80%. Accordingly, the minimum sample size calculated for each group was374. We used a design effect of 1.5 to compensate for potential losses during multi-stage sampling and added 10% of the sample for missing and incomplete data. The final sample size obtained was600.
The study area, Gubalafto Wereda has a total of 34 Kebeles (4 are urban and 30 are rural kebeles). From the total 34 kebeles, 7 rural and 2 urban kebeles was selected by simple random sampling method.
The samples are distributed proportionally based on probability proportional to size (PPS) allocation technique. Participants in each kebele are selected by using a systematic sampling technique after calculating the sampling interval (K=2) for each kebeles.
The sample frame is the list of under-five SAM children charts at OTP. It is identified after checking all 9 selected kebeles (study population) to identify charts of children from birth up to 59 months old and coding of those charts was done to prepare sampling frame for each kebele.those children with incomplete charts are considered as non-respondent. Finally, the OTP record card of each child was selected using systematic random sampling. 3. Not recovered: defined as children discharged from outpatient therapeutic feeding units with outcome other than recovery in this study (death, default, and non-responder).

Data quality control
The data collectors and the supervisors were trained for two days on techniques of data collection and the importance of disclosing the possible purposes of the study to the study participants before the start of data collection. To assure the quality of the data, investigators closely supervised the data collection procedure daily. The review was made in the field for checking the completeness of questionnaire and correction was made in the field.
Each questionnaire and data sheet was check before the data entry. The data was entered one I data version 4.2 daily, basis and missing data were identified. Incorrectly filled or questioners that miss major content was not included in the study. The pretest was conducted in Woldia health center (which is not a study area) using 5% of the total sample size which is not included in the actual sampling and necessary adjustments were made on the tool.

Data processing and analysis
The data was entered and analyzed by using EPI-data Version 4.2 and exported to SPSS version 24.0 for analysis. Bivariate and Multivariate regression was also carried out to determine the association between dependent and independent variables.

Ethical consideration
Ethical approval was obtained from the research ethics review board of the WU faculty of health science. An official letter of permission was obtained from WU faculty of health science and was submitted to the respective administrative bodies of the Gubalafto woreda; permission from these administrative bodies was also given. Confidentiality was ensured throughout the research process. All incomplete charts were considered as non-response rate.

Socio-demographic characteristics of children
The study included 6oo eligible children who had been managed for SAM under the OTP from April to May (2016-2019); 50.8% of children enrolled in the study were males. Children beyond two years of age, 179(29.8%), were underrepresented in the OTP as compared to their middle age groups, 313(52.2%). About 18% of the children were younger. Concerning vaccination history: 444(74.0%) were fully vaccinated, 83(13.8%) were partially vaccinated, 40(6.7%) unknown vaccination status and 33(5.5%) were not vaccinated for age. The majority (90.2%) of children was identified as newly admitted children. Regarding treatment outcome 65% recovered,2% were dead (Table 1).

Routine medications
Admitted cases with severe acute malnutrition to OTP were managed following the federal ministry of health of Ethiopia guideline protocol for the treatment of severe acute malnutrition.
Out of 600 children whose medication records were available for review, the most prescribed medications were PO antibiotics (90%) Amoxicillin followed by Vitamin A supplementation (74.%). Of the total 44.6% of the children was dewormed with Albendazole or Mebendazole, 52.2% received folic acid (Table 3). 95% CI: 3.68-12.78)) was higher as compared to those who have been not vaccinated (Table 4). The overall defaulter rate in this study inline with study in Tigray 17.5%.This finding is higher as compared to study finding from Wolaita (3,8).This discrepancy might be due to the increased emphasis to community based therapeutic feeding program. . This could be explained as children whose readmitted come with more complication, which ultimately decrease the recovery rate.

Conclusions
Recovery rates in the study area are below the cut of points of the minimum standard sets in humanitarian and disaster prevention (or the sphere standards), it is low as compared to similar studies conducted in different parts of Ethiopia but the death rate was lower than the international standard. Presence of cough comorbidities was statistically significant factors that

Ethics approval and consent to participate
Ethical approval was obtained from the research ethics review board of the WU faculty of health science. An official letter of permission was obtained from WU faculty of health science and was submitted to the respective administrative bodies of the Gubalafto Woreda; permission from these administrative bodies was also given. Confidentiality was ensured throughout the research process. All incomplete charts were considered as non-response rate.