Factors associated with defaulting in MSF ambulatory programme

Summary of meeting abstract¹

Children participate in the obligatory 'appetite' taste for RUTF

Since Médecins Sans Frontières (MSF) changed its treatment approach from centre-based to 'ambulatory' therapeutic feeding programmes (ATFP), a considerable number of programmes have experienced high defaulter rates. In 2006, 15 (68%) of the 22 MSF Holland ambulatory programmes had a defaulter rate of > 15%, three ATFPs (14%) had a defaulter rate of 10- 15%, and only four (18%) had a defaulter rate of < 10%. As a result, MSF conducted a study to identify key factors underlying defaulting.

Quantitative and qualitative data on defaulting was collected in programmes in south Sudan, Darfur, Myanmar, Ivory Coast and Ethiopia. Defaulting children were defined as missing a follow-up appointment more than twice. Semi-structured and indepth interviews were conducted with caretakers of enrolled children in south Sudan and Darfur about personal or community attitudes to ambulatory therapeutic care programmes and barriers to participation. Defaulters were not interviewed due to time, transport and security constraints. Further information was gathered through observations of programmes and from programme reports. Statistical analysis was performed on data from registration books and patient files to examine characteristics of defaulters. This involved analysis of timing of defaulting, gender and distance to programme.

The results demonstrated no significant difference in age, gender or weight for height on admission between cured children and defaulting children. In south Sudan, Darfur and Myanmar, 55%, 44% and 62% of patients defaulted immediately after admission or the first follow-up visit.

Comparison between programmes in South Sudan showed that average length of stay before defaulting was related to the type of care the child received. In-patients averaged 48 days before defaulting, children who spent the first week in day-care averaged 12 days, and out-patients averaged 6 days. Programme default rates were related to intensity of outreach work; programmes with well-established outreach (Ivory Coast, Darfur and Myanmar) had default rates of <10% while those without outreach (south Sudan and Ethiopia) had default rates >30%.

Distance to ambulatory therapeutic care programmes was not related to defaulting, except for people living very far away (e.g. two days walk away). In Darfur, patients who travelled 8 hours by donkey were twice as likely to default compared to people living relatively nearby (p=0.001). Caretakers' appreciation of the programme was high but their understanding of malnutrition, target weight and treatment duration was poor. Community attitudes to ATFP were not a barrier to participation.

Conclusions

Around half the defaulters left the programme soon after joining. This appears to be associated with poor communication with caretakers, unreliability of centre opening hours and food availability. There is a need for a more patient-centred approach to ensure caretakers are informed of the aim of the treatment, exit criteria, expected duration and number of visits, and are motivated to continue follow-up visits. Outreach workers have a vital role to play in this. Programme planners should ensure reliability of programme services, such as standard opening hours, continuous availability of food and the use of standard ATFP patient files to reduce defaulting.

¹Van der Velden. E and van der Kam. S (2008). Key factors underlying defaulting in MSF ambulatory therapeutic feeding programmes. MSF Scientific Day Report. 'Research shaping the way we work'. 5th June 2008. http://www.msf.org.uk/scientificday.event