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Improved care and survival in severe malnutrition through eLearning
  1. Sunhea Choi1,
  2. Ho Ming Yuen2,
  3. Reginald Annan3,
  4. Michele Monroy-Valle4,
  5. Trevor Pickup2,
  6. Nana Esi Linda Aduku3,
  7. Andy Pulman2,
  8. Carmen Elisa Portillo Sermeño5,
  9. Alan A Jackson6,
  10. Ann Ashworth7
  1. 1 Human Development and Health, University of Southampton, Southampton, UK
  2. 2 Faculty of Medicine, University of Southampton, Southampton, UK
  3. 3 Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
  4. 4 Facultad de Ciencias de la Salud, Universidad Rafael Landivar, Guatemala City, Guatemala
  5. 5 Department of Nutrition and Diets, Hospital Nacional General “Dr. Juan José Fernandez” Zacamil, San Salvador, El Salvador
  6. 6 National Institutes for Health Research Biomedical Research Centre, University of Southampton, Southampton, UK
  7. 7 Department of Population Health, London School of Hygiene Tropical Medicine, London, UK
  1. Correspondence to Dr Sunhea Choi, Human Development and Health, University of Southampton, Southampton SO16 6YD, UK; s.choi{at}


Background Scaling up improved management of severe acute malnutrition (SAM) has been identified as the nutrition intervention with the greatest potential to reduce child mortality but it requires improved operational capacity.

Objective To investigate whether an eLearning course, which can be used at scale in resource-poor countries, leads to improved diagnosis, clinical management and survival of children with SAM.

Design A 2-year preintervention and postintervention study between January 2015 and February 2017.

Setting Eleven healthcare facilities: nine in Ghana, one in Guatemala, and one in El Salvador.

Intervention Scenario-based eLearning course ‘Caring for infants and young children with severe malnutrition’.

Main outcome measures Identification of children with SAM, quality of care, case-fatality rate.

Methods Medical record reviews of children aged 0–60 months attending eleven hospitals between August 2014 and July 2016, observations in paediatric wards, and interviews with senior hospital personnel.

Results Postintervention there was a significant improvement in the identification of SAM: more children had the requisite anthropometric data (34.9% (1300/3723) vs 15.9% (629/3953)) and more were correctly diagnosed (58.5% (460/786) vs 47.1% (209/444)). Improvements were observed in almost all aspects of the WHO ‘Ten Steps’ of case-management, and case-fatality fell from 5.8% (26/449) to 1.9% (14/745) (Post-pre difference=−3.9%, 95% CI −6.6 to −1.7, p<0.001).

Conclusions High quality, interactive eLearning can be an effective intervention in scaling up capacity building of health professionals to manage SAM effectively, leading to a reduction in mortality.

  • severe acute malnutrition
  • capacity building
  • eLearning
  • WHO ten steps

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  • Contributors SC and TP conceived and designed the study, and HMY, RA, MM-V and AA contributed to the study design. RA and MM-V identified the study sites and obtained permission for the study in Ghana and Latin America. SC, AP, RA and MM-V coordinated the study and supervised the research teams in the United Kingdom, Ghana and Latin America, and RA, NELA, MM-V and CEPS carried out research activities in Ghana and Latin America. SC, AA, HMY and TP led the analysis and interpretation of the data with HMY leading statistical analysis and AP and SC qualitative data analysis, and RA, NELA, MM-V, CEPS and AAJ contributed to the interpretation of the results. SC, HMY and AA led the preparation of the manuscript. TP, AP, RA, NELA, MM-V and AAJ supported the preparation and later critically reviewed the manuscript. All authors participated in the final approval of the manuscript. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This study was supported by the UK Department for International Development Nutrition Embedding Evaluation Program (grant number: DFI.1836-554999-1.GRT). All members of the study team are independent from the funder.

  • Competing interests None declared.

  • Ethics approval This study was reviewed and approved by the ethics committees of the University of Southampton Faculty of Medicine, United Kingdom (Ethics ID:12872); Komfo Anokye Teaching Hospital and Kwame Nkrumah University of Science and Technology, Ghana (ID:CHRPE/AP/041/15); the Universidad Rafael Landívar, Guatemala (ID:FCSS 76/2015); and Hospital Universitario San Vicente de Paul, Colombia (ID:CHRPE/AP/041/15).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Full datasets are available from the corresponding author ( Informed consent was obtained from participants and institutions for data sharing.

  • Collaborators Andrew Penn; Carmen Isabel Velásquez Monzón; Samuel Kyei-Boateng; Sally Hickman.

  • Patient consent for publication Not required.

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