Nutrition News for Africa
Abstract - June 30, 2007
An article entitled “The promise of a community-based approach to managing severe malnutrition : A case study from Ethiopia” was published by Chaiken et al. in the Food and Nutrition Bulletin 2006;27 (2):95-104.
Introduction: Community-based therapeutic care (CTC) has been recently implemented in several contexts of food crisis where severe malnutrition is widespread and where nongovernmental organizations were attempting to achieve the greatest program coverage while minimizing dependency. This paper reports on one such program administered in southern Ethiopia by Save the Children USA.
Methods: CTC is a recent innovation designed to treat severely malnourished children while having less disruptive effects on their families and household economies than the more traditional approaches that emphasize treatment in hospital-based nutrition rehabilitation units or therapeutic feeding centers. In 2003, the lowlands of south-central Ethiopia , especially the Sidama Zone, were hit by a significant drought where most families went from a precarious existence to total food insecurity. Save the Children USA proposed a pilot CTC approach to supplement traditional therapeutic feeding center services. It was decided to implement this pilot program in the one woreda (district) served by Save the Children USA , and it was eventually expanded to three woredas. Save the Children USA relied upon a participatory planning process in which local woreda officials, traditional birth attendants, local volunteer community health workers, community-based reproductive health agents, and other local officials were invited to a meeting to discuss the problems of malnutrition in their area and strategies that might be used to address these problems. In each community, parents voluntarily enrolled their children in the CTC program to receive treatment for undernutrition. After the medical screening, caregivers received instruction in the use of the ready-to-eat therapeutic food, Plumpynut. Each child was sent home with sufficient Plumpynut rations to last for one week, plus a supplementary ration of flour, oil, and soap. Children were monitored weekly by a trained health worker at one of the community-designated program sites, and those who continued to make progress received the next week’s ration of Plumpynut, flour, oil, and soap, as well as health and nutritional education. Failure to thrive might result in medical referrals or more intensive monitoring and health education by the outreach worker, depending upon the child’s condition. After a child had attained a weight-for-height of more than 80% of the median at two successive weighings, the child graduated to the supplemental feeding program. Children in the supplementary feeding program either were admitted directly because of moderate malnutrition or graduated from the more intensive outpatient therapeutic program. After anthropometric assessment, registration, and a clinical check, the caretaker of the child was given a bar of soap and 4.6 kg of premixed fortified flour. A child was discharged from the supplementary feeding program after two successive weight-for-height values of at least 85% of the median .
Results: Data from this initial effort to apply a community-based approach demonstrate that the prevalence of malnutrition is reduced both by directly addressing the needs of affected children and by preventing those at risk from a deterioration in nutritional status through preemptive public health services and supplemental food rations. In September 2003, the daily under-five mortality was 1.47/10,000 and the rate of severe acute malnutrition was 1.0% (95% confidence interval, 0.5–2.0); by March 2004 these rates had improved to 0.45/10,000 and 0.6% (95% confidence interval, 0.2–0.9), respectively. The Save the Children programs admitted 5,799 severely malnourished children over a 5-month period, 3,765 of whom (64.9%) progressed sufficiently to graduate to the supplementary feeding program. An additional 7,961 children received services through the supplemental feeding program. The default rate was low, indicating community acceptance of the approach. Mortality was extremely low.
Conclusion: Local participation in the planning and implementation of the CTC program at many levels accounts for its effectiveness. The community mobilization presents an effective entry point for the complementary activities that target improvements in food security, local knowledge of improved health and nutrition practices, and infrastructure. The authors believe that wider implementation of community- based care has the potential to foster the transition from effective emergency to development programming, and that future application of CTC strategies should examine the feasibility of this goal at the planning stages.
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