Qualitative review of an alternative treatment of SAM in Myanmar

By Naomi Cosgrove, Jane Earland, Philip James, Aurélie Rozet, Mathias Grossiord and Cecile Salpeteur

Naomi Cosgrove has over 13 years of experience in the food industry. in addition to experience in the humanitarian sector, including a local Mental Health & Development NGO in Sri Lanka and as a Food Security, Livelihood & Hygiene Advisor in Northern Argentina. This research project was completed as part of her Masters in Human Nutrition.

Jane Earland is a registered Dietitian and Public Health Nutritionist and works in nutrition and research at the Universities of Liverpool and Sheffield. Her background includes nutrition education and training in Papua New Guinea for 11 years, Field Director for Save the Children and short term work in Indonesia, Malaysia and Papua New Guinea.

Aurélie Rozet is a nurse trained in nutrition and has been working with ACF since 2006 in Asia in particular. She was a Nutrition Programme Manager in Myanmar at the time of the programme evaluated in this article and now supports theACF France Nutrition team in Paris.

Mathias Grossiord is a Public Health Nutritionist (MSc) and was a Nutrition Programme Manager in Myanmar at the time of the programme evaluated in this article. He is now Nutrition Programme Manager for ACF in India.

Phil James was a Masters student with LSHTM in 2010 analysing the performances of the alternative treatment of SAM in Myanmar and is now Emergency Nutrition Coordinator for ACF UK. He is preparing a scientific article with ACF on this MSc thesis.

Cecile Salpeteur is a public health nutritionist and is ACF HQ Operational Nutrition Research Facilitator and HIV focal point. She has six years ACF field experience in implementing a wide range of nutrition and food security programmes.

Children attending a stabilisation centre

In 2009, Action Contre la Faim (ACF) treated an estimated 18,000 children under five years for severe acute malnutrition (SAM) in Maungdaw and Buthidaung Townships and Sittwe, Rakhine state, western Myanmar. This followed a change of protocol in January 2009 where the identification of malnourished children was switched from being based on National Centre for Health Statistics (NCHS) standards to the 2006 WHO International Child Growth Standards (ICGS)^1,2. As a result of this change, the number of children falling into the category of severe malnutrition increased dramatically (a multiplication factor of 5.6) so that there was an increased amount of product required to treat these children. In addition, in April 2009, there were complications with the import of the ready to use therapeutic food (RUTF) (Plumpy’Nut©). This meant that there was insufficient stock to cover the case load of SAM affected children until the end of the year and ACF had to identify a solution to the problem³.

Modified treatment protocol

ACF decided to modify the treatment protocol and introduced a second phase of treatment, once the child had improved from a severe to a moderate (MAM) stage of malnutrition (see Figure 1 for existing and modified treatment protocols). Eligible children for this ‘Alternative Treatment’ were uncomplicated MAM cases, without oedema, above six months of age and with increasing weight. The intake of RUTF for this second phase was reduced from two or three sachets per child per day (depending on body weight as defined in the usual protocol) to only one sachet and hence a reduction in kilocalories. This reduction ranged from 116% (< one year old) to 62% (> four years old) of the child’s daily energy needs, based on an average requirement of an adequately nourished child within that age category⁴. As a result, ACF staff advised caregivers to make up the energy requirements of the child with food available at home⁵.

This Alternative Treatment was implemented from July 2009 to January 2010 and the data were collected, analysed and compared to the same period the year before. Despite the reduced ration using the Alternative Treatment, the performance of the programme was found to be as good and in some instances, better than when the Standard Protocol was used in 2008. However there were limitations to comparing these two data periods, mainly due to the different standards being used (NCHS in 2008 versus WHO in 2009). Nevertheless, results of the Alternative Treatment greatly exceeded the international Sphere Standards.

Paediatricians and scientists who developed the normal treatment protocol for SAM were aware that that the quantity of RUTF sachets given to children was rounded up to the higher figure and maintained throughout the treatment until complete recovery, in order to simplify implementation by health personnel. However, the nutritional needs of the child for catch up growth are expected to decrease as his/her nutritional status improves. Thus the quantities administered in the latter stages of treatment are not fully justified from a nutritional perspective⁶.

Rationale for proposed study

As the key drivers behind this successful programme outcome were not fully understood, ACF wanted to carry out further study.

Aims & objectives

The overall aim of this study was to identify the factors that contributed to the success of the Alternative Treatment. The objectives were:

1. To identify all factors associated with success of the intervention, as well as areas for improvement in the Myanmar programme using the Alternative Treatment.
2. To develop a feasibility grid system for identifying another country with these optimum conditions for further testing of the Alternative Treatment.

Methods

See Figure 2 for a summary of the eight stage study design used in this research project and described in more detail here.

1. A literature review was conducted to identify new innovative tools and methods for qualitatively evaluating programmes and the factors that may influence the success of feeding programmes. This was used to inform the development of the interview guide and analysis⁷.
2. ACF documents and reviews were collected and reviewed that included capitalisation reports from the relevant field Programme Managers during 2009 and ACF Country Operational Strategy Reports (2009 and 2011) from ACF HQ Paris. Notes were taken from these documents to inform the questions for the interview guide. This information was also used to validate the data gathered from the interviews at a later stage, i.e. a triangulation approach⁸.
3. Using information gathered from steps one and two, the interview guide with key questions was developed as a tool for conducting the interviews. These questions needed to be open ended to ensure accurate, non-biased answers. Probes and follow up questions were added where necessary, to ensure the question was fully answered. Seven key areas were identified as areas to explore in the interview. Questions were developed for each and were incorporated into the interview guide. These areas were:
   • General introduction and context of Myanmar.
   • Opinions and descriptions of the Nutrition Programme
   • Management Style
   • Training and Capacity Building
   • Community Involvement
   • Other ACF programmes
   • Other international non-governmental organisations (INGOs) working in the area.
4. In-depth interviews were conducted, lasting up to an hour, with key informants across a range of professional disciplines to obtain an accurate and balanced perspective of the programme, processes and relationships. Where possible, the interviews were held face-to-face - this was not always possible due to logistics and therefore several were done through Skype. Key people interviewed included the Nutrition Advisor in ACF Paris HQ, regional and local Nutrition Managers, the local Human Resources Manager for the programme, the Head of Base (logistics and administration) and local Programme Managers in other ACF programmes.
5. A Pattern, Theme and Content Analysis method was used to analyse the data collected. The analysis consisted of identifying core consistencies and meanings from the material and interviews. Patterns and themes were searched for across all information provided (both interview transcripts and notes from the relevant documents) and re-occurring words and texts were identified, including their frequency and the context in which they were used⁹. Data were presented in the form of quotations with sufficient context to ensure that they could be interpreted.
6. The early findings were discussed in a workshop which included two highly valued individuals who had a great deal of field experience. The five key questions which were debated in the workshop were:
   • How solid, coherent and consistent is the evidence in support of the findings?
   • To what extent and in what ways do the findings increase and deepen understanding of the situation/ success of the Alternative Treatment for SAM?
   • How do these qualitative factors complement the quantitative outcomes and help to explain the success of the programme?
   • To what extent are the findings consistent with other knowledge?
   • To what extent are the findings useful for use in other programmes globally?
     The initial findings were also sent to two of the interviewees to get reactions and additional comments.
7. A one page success factor matrix was developed and discussed in the workshop. The aim of this matrix was to visually represent the findings and correlate them with the quantitative outcomes.
8. A simple, one page feasibility grid was also developed and discussed in the workshop. This involved creating a series of questions and a scoring system. The aim of this grid is to identify another country with optimum conditions for further testing the Alternative Treatment.

Results

The fourteen factors that were consistently identified as key contributors to the success of the Alternative Treatment are summarised in Figure 3. Eight areas of improvement were also identified and are summarised in Figure 4.

BNF: Beneficiary
These success factors were then placed at the relevant levels in terms of local context, community involvement, the Nutrition Programme, the mother/caregiver and the BNF/child.

* Quantitative outcomes were measured from admission to discharge.
* The remaining % of children: 6.71% had an unknown outcome, 0.07% transferred due to medical complications and 0.91% were non responders
* Children spent a median of 14 days on phase 1 and 21 days on phase 2 of the Alternative Treatment

Discussion

The discussion below focuses on the key outcomes including the Success Matrix and the Feasibility Grid and also raises additional findings and considerations from the research.

The Success Matrix

The Success Matrix was developed to build a picture of the data as a whole to aid systematic analysis and link the qualitative findings to the quantitative outcomes (see Figure 5).

The Feasibility Grid

The Feasibility Grid needed to be in a spreadsheet form that could be used for identifying other countries that also have optimum conditions for further testing the Alternative Treatment. Input and feedback was given by all those people that would be using it to ensure it was user-friendly and relevant.

The grid was developed as a series of questions to be answered by Country Nutrition Co-ordinators for each country being considered for replicating the Alternative Treatment. There is a simple scoring system. If the answer is yes to a question, 1 point is given and if no, 0 points are given. This enables each country to be ranked, in order to identify the optimum country for further testing the alternative protocol. All questions were given the same weighting although weighting might be considered in future versions of the grid. The country that scores the highest points is the recommended country.

The grid could potentially be adapted and used for on-going programmes in the future, including as an annual quality check. A portion of the spreadsheet is shown in Table 1. The full spreadsheet is available on request from the author.

Discussion on what makes a good quality programme

Responses were not consistent to the interview question on what makes a good quality programme. However there were several recurring themes, including good programme management, staff training, educating the caregiver on the causes of malnutrition and caring for the child, and having a preventative strategy in place. The review of published papers on programme effectiveness indicated that there has been very little discussion at an international level on programme quality and the impact this has on the outcomes. There appears to be an emphasis on quantitative outcomes and limited understanding of the factors which contributed to these outcomes, i.e. the ‘how’ and ‘why’ questions, which are typically addressed through qualitative research. This suggests a need for a clear definition and set of guidelines regarding programme quality, as well as more published studies examining the qualitative aspects of humanitarian programmes globally.

Cost saving of using less RUTF versus additional time and resource needs

Although there were some cost savings in using the Alternative Treatment in terms of product, the research shows that more time and resource are required by the staff and management to ensure successful implementation. Although the amount of additional time and resources to implement the alternative protocol in the Myanmar programme are believed to be relatively low due in part to exceptional management and highly competent, well trained staff, this will not always be the case going forward in other missions and countries.

Ideal setting in Myanmar

There are a number of reasons as to why this was an ideal setting for testing the Alternative Treatment. These included absence of natural disaster during 2009, home feeding being part of the treatment, and existence of well trained and experienced staff. However it is important to consider that if any of these factors were to change, the outcomes could be very different. It is also worth noting that ACF had complete control of the programme and did not depend on the government and local amenities for any aspect of programming. This will not always be the case, especially as a key objective for many INGOs today is to empower local governments so that they can implement nutritional services.

Sustainability of the programme

Some of the constraints to sustainability include the high turnover of local medical staff, the high cost of the RUTF product (over 50% of total programme costs)¹⁰ and the need to import product. Insufficient government involvement in the programme also impedes sustainability. This suggests the urgent need for strategic review. Despite high levels of community awareness, there appears to be no improvement in overall malnutrition rates in the intervention area of ACF in Myanmar since the programme began in 2003 and children continue to be admitted.

Conclusions

The aim and objectives of this study were successfully achieved using both review of documents and in-depth interviews. The study has shown the importance of combining qualitative and quantitative research to give a comprehensive picture and meaning to the figures. This combined learning has led to a deeper understanding of the Alternative Treatment.

The results from this research project have given invaluable insights into the Alternative Treatment of SAM. The findings confirm that it is not only the high quality of RUTF itself which is necessary for success, but a large number of quality considerations some of which may be specific to the local context in Myanmar. It is a combination of all of these factors that resulted in the quantitative outcomes far exceeding the Sphere Standards and it is these factors which need to be considered before the Alternative Treatment is replicated globally.

This research project indicates that there needs to be a stronger emphasis on nutrition programme design. Key design issues and factors include careful planning, existence of well trained staff and community mobilisation.

The findings have also shown that the current programme is not sustainable in Myanmar and that future strategies must address this challenge.

For more information, contact; Cécile Salpéteur, email: csalpeteur@actioncontrelafaim.org

¹NCHS. (2011). National Centre for Health Statistics. Retrieved 28.04.11, 2011

²WHO. (2011). World Health Organisation. Retrieved 28.04.11, 2011

³ACF (2009). ECHO Report - Integrated Approach to malnutrition through nutrition, health and care practices.

⁴FAO, WHO, UNU Human energy requirements: Report of a Joint FAO/WHO/UNU Expert Consultation. FAO: Rome, 2004

⁵James, P. (2010). Evaluation of an Alternative Protocol for the Treatment of Severe Acute Malnutrition, implemented by ACF Myanmar from July 2009 to January 2010 Masters in Nutrition, London School of Hygiene and Tropical Medicine. Also see Footnote 3.

⁶Golden, M. (2011). RUTF Sell - Prevention and Treatment of Severe Acute Malnutrition Forum Area. http://www.en-net.org.uk/question/362.aspx also Footnote 4.

⁷Literature review: Dersham, L. (2011). Design, Monitoring and Evaluation - Save the Children. Retrieved 05.05.11. Draper, A. and J. A. Swift (2011). Qualitative research in nutrition and dietetics: data collection issues. J Hum Nutr Diet 24(1): 3-12. Green, J. and N. Thorogood (2009). Analysing Qualitative Data. Qualitative methods for Health Research. D. Silverman, SAGE publications Ltd: 195-228. Patton, M. Q. (2002). Qualitative Research & Evaluation Methods, Sage Publications Ltd. . Pilnick, A. and J. A. Swift (2011). Qualitative research in nutrition and dietetics: assessing quality. J Hum Nutr Diet 24(3): 209-214.

⁸Green, J. and N. Thorogood (2009). Analysing Qualitative Data. Qualitative methods for Health Research. D. Silverman, SAGE publications Ltd: 195-228

⁹Patton, M. Q. (2002). Qualitative Research & Evaluation Methods, Sage Publications Ltd.

¹⁰James, P. (2010). See footnote 5.