Bangwe Home Based Care Project in Malawi

Summary of published research¹

WFP warehouse in Malawi

The Bangwe project is a joint home based care (HBC) project run by the Salvation Army and the Department of Community Health, College of Medicine, University of Malawi. While providing a standard HBC service to a township of 40,000 adjacent to the city of Blantyre, data have been collected since January 2003 on health problems of patients, their response to treatment and their nutritional status. Antiretroviral (ARV) drugs have not been given during the study period.

Following a recommendation from the National AIDS Commission (NAC) that the project should assess the use of supplementary feeding to HBC patients, WFP began providing food in July 2003. Nutritional assessments were carried out at the time of initial assessment of the patient, and in June 2003, November 2003 and July 2004 on the members of the household of each patient.

Inclusion criteria

Inclusion criteria were adult patients (over 15 years of age) with chronic disease of more than one month and in need of home based care. The group of patients who were enrolled between January and June 2003, and their families, did not receive food in the first period of their home based care. They, and all subsequent patients, received the basic food package from July 2003 to July 2004. The effect of the food was measured by the difference in nutritional status of each patient, comparing the Body Mass Index (BMI)² at the latest survey assessment with the original BMI, expressed as the rate of change per 100 days.

The WFP supplement was targeted at households taking care of orphans and those with someone requiring HBC. Monthly rations were 50 kg of maize, 5 kg of beans and 7.5 kg of Likuni Phala (a Malawian fortified blended food). Four litres of oil were given to half of the households selected on a random basis.

The study was divided into three periods (January 2003 to July 2003, August 2003 to November 2003 when the second nutritional survey was implemented, and mid November 2003 to July 2004, when the third nutritional survey occurred). Results were analysed using SPSS.

Results

Between January 2003 and July 2004, 360 patients were enrolled, of whom 59% were women. It appears that half of the chronically sick in the study area were enrolled at the time. The mean age of men was 33.4 years and of women 30.9 years. Over the course of the study, over half of the patients (56%, 199/360) died. There was no apparent difference in case severity of patients enrolled in the different periods of the study based on symptoms of fever, cough, lower limb pain and thrush. The majority of patients presented in an advanced stage of disease, with 70% in stage 4.

Change in BMI

The mean BMI at presentation was 18.5. Half of the patients were malnourished, with a BMI less than 18.5 on enrolment, and one quarter were severely malnourished (BMI=16). The nutritional status of the group presenting before July 2003 was similar to that of the group who presented during the second and third periods. During the first period, when none of those enrolled received food, nutritional status remained constant. By the second survey, the mean BMI of those still alive rose by 0.49 per 100 days, and by 0.46 per 100 days by the time of the third survey. These increases were not statistically significant. For the small group of patients (n=22) who survived through all surveys, there was an increase in the rate of change of BMI between the pre-food and the first post food period, but not with the third study period. The addition of oil to the food package had no effect on nutritional status, as measured by change in BMI per 100 days.

Survival

One third of patients died within four months of being first seen, while half of those enrolled survived 14 months. There was no difference in the survival patterns of those who did not initially receive food compared to those who received food from the start. Survival was better in those allocated to receive oil and those who actually received oil compared to those who did not. Oil seems to have an effect, but only for those who survived six months from the time of initial assessment. The results show no statistically significant difference between the groups before and after food distribution, although there is a suggestion of improved survival in clinical stage 4 patients post food distribution.

Household nutrition

Households of patients enrolled between January and June 2003 (and measured in July 2003) were compared to households of patients measured in late July 2004. Some of the families of patients measured in July 2003 who survived a year were also measured in 2004, and so were included in both groups. Mean BMI fell between the two measurement dates, despite food supplementation from July 2003. This pattern of a lower mean BMI of household members persists when those surveyed in 2003 are excluded from the 2004 group, and for different age groups.

Discussion and conclusions

An observational study of this sort is difficult to interpret and there is much room for bias if similar groups are not compared. Using discriminant analysis of the presence and severity of presenting symptoms, the 'before' and 'after' food groups had similar mixes of case severity and comparable BMIs. The main difference between the groups was the preponderance of females in the 'before' food group. It may be that males tend not to seek HBC until it is known that food is available. However, the severity of disease of those presenting when food was being distributed does not seem to differ from those presenting before the food handouts started. Overall, it appears that the two groups, at first presentation, are comparable.

In this study, food supplementation seems to have no effect on survival, but does affect the nutritional status of those home based care patients who survived to one of the follow up weighing surveys. The result is not surprising, considering the late stage of disease in many presenting patients. Another possible reason for the absence of effect on survival could be that little food reaches the terminally ill, due to problems of distribution in an urban area of Malawi - families may have no one to carry food home from the distribution point and many neighbours are hungry. Oil, it was observed, may have an effect on those patients who survive six months. This may be because it is a concentrated form of energy or because it is a saleable commodity and money realised may be used to purchase essential commodities.

The food supplement did not help maintain the BMI in household members of HBC patients. The reduction in BMI of household members may be attributable to the socio-economic catastrophe of loss of income and increase in expenditure, due to chronic ill health of one or two adults in the family. The longer the adult remains alive and ill, the longer the loss of earnings, drain on resources and ensuing poverty. This may account for the reduction in BMI in households of people living with HIV/AIDS, some of whose patients have survived for 12 months or more. Arguably, the situation may have been worse without the provision of food.

¹An assessment of food supplementation to chronically sick patients receiving home based care in Bangwe, Malawi: a descriptive study. C Bowie, L Alinafe, R Marsh, H Misiri, P Cleary, C Bowie. Nutrition Journal 2005, 4:12 doi:10.1186/1475-2891-4-12 http://www.nutritionj.com/con tent/4/1/12

²BMI calculated as weight (kg) divided by height in metres squared