WHO guidelines for severe malnutrition: are they feasible in rural African hospitals?

Nadina Karaolis ¹, Debra Jackson ², Ann Ashworth ^1*, David Sanders ², Nonzwakazi Sogaula ², David McCoy ³, Mickey Chopra ² and Claire Schofield ¹

¹ London School of Hygiene & Tropical Medicine, United Kingdom
² University of the Western Cape, South Africa
³ Health Systems Trust, South Africa

^* To whom correspondence should be addressed. E-mail: ann.hill{at}lshtm.ac.uk.

Accepted 24 April 2006

Abstract

Aims: To assess the feasibility of implementing and sustaining the WHO guidelines for inpatient management of severe malnutrition in under-resourced rural South African hospitals, and to identify any constraints.

Intervention: Three 2-day training workshops were held in 1998 followed by monthly 1-day visits for 5 months, ending March 1999, in two rural district hospitals with limited resources in Eastern Cape Province, South Africa.

Methods: A 12-month observational study was conducted from April 2000-April 2001 in Mary Theresa and Sipetu hospitals, including 1011 child-hours of observation on the wards, medical record reviews, interviews with carers and staff, and inventories of essential supplies. All admissions (n=193) for severe malnutrition to the two hospitals were studied. The main outcomes were the extent to which the 10 steps for routine care of severely malnourished children were implemented, proficiency of performance, and constraining factors.

Results: Hospitals made the changes required in clinical and dietary management, but the tasks were not always performed fully or with sufficient care. Not implemented were play and stimulation and an effective system of follow-up. Constraints to optimal management were doctors's poor knowledge, nurses's inattentiveness, and insufficient interaction with carers. Underlying factors were inadequate undergraduate training, understaffing, high doctor turnover, and low morale.

Conclusions: Guidelines for severe malnutrition were largely feasible but training workshops were insufficient to achieve optimal management as staff turnover and an unsupportive health system eroded the gains made and doctors treated cases without having being trained. Medical and nursing curricula in Africa must include treatment of severe malnutrition.

Keywords: feasibility study, guideline adherence, hospital treatment., integrated management of childhood illness, malnutrition

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