Quantitative and qualitative analysis of CTC programme coverage

Summary of published research¹

A study has recently been published on determinants of community-based therapeutic care (CTC) coverage based on collaborative work between Valid International and Concern Worldwide as part of the CTC Research and Development Project. It draws lessons from 12 different CTC programmes across Africa, implemented 2003 to 2006.

The study set out to assess the most common barriers to access and their relative impact on programme coverage, using a retrospective analysis of quantitative and qualitative data. Quantitative data were collected from questionnaires implemented as part of centric systematic area sample (CSAS) coverage surveys. These were completed by all caregivers of malnourished children found within the target area who were not enrolled in the relevant components of the local CTC programme. A total of 1,696 caregivers were surveyed. The reasons for non-attendance were analysed to establish their frequency and their modality. Qualitative data from socio-cultural assessments conducted in the first four to eight weeks of programme implementation in the 12 programmes and prior to CSAS surveys were also analysed. These surveys were carried out to identify local perceptions of malnutrition, barriers to access to programmes and health seeking behaviour. Data were collected using semi-structured interviews, and focus group discussions with key informants and groups in the targeted communities. The results of the CSAS survey questionnaires and the sociocultural assessments were compared to pinpoint concordance and discordance in their identification of barriers within the same programme.

On average, previous rejection accounted for 38.5% of cases of non-attendance. While these were the result of direct prior experience of the programme, rejection was found also to have indirect consequences for attendance. Rejection of a 'known child' (in the family or community for example) was found to contribute to nonattendance in four of the 12 programmes surveyed. Its significance was less than direct rejection, but on average, 'rejection of known child' was found to be responsible for 4.8% of cases of non-attendance. The use of different anthropometric standards for screening and admission was a major cause of the problem. Children who were rejected at programme sites following referral from the community often did not return for subsequent screening or admission - even when their condition had deteriorated or they had been referred again. The authors argue that the standardisation of referral and admission criteria through the use of single method that ensures that all of those referred are admitted to the programme, is an essential step towards reducing the negative feedback associated with rejected referrals. They also advocate that mid-upper arm circumference (MUAC) criterion could be used for both assessment referral and admission.

The study also found that on average, lack of awareness of the existence of the CTC programme was responsible for 6.7% of nonenrolled cases. Misinformation and confusion also play a part. In areas with a high concentration of non-governmental organisations (NGOs) and humanitarian programmes, confusion about the different operating programmes can influence programme coverage negatively. High programme uptake depends on the degree of awareness of malnutrition as a condition that can be treated successfully, and the availability of treatment at low cost to the beneficiary household. The study found that, on average, 18.8% of malnourished children not in the programme had not been identified as malnourished by their primary caregivers. CTC programmes have traditionally addressed this 'recognition gap' through community sensitisation. Adequate resources must therefore be devoted to community sensitisation.

Distance to sites was found to be the primary barrier to access for 10.8% of severely malnourished cases not enrolled in CTC programmes. The site selection process should make use of socio-cultural assessments for the identification of local variables that define accessibility in its broadest sense. Such variables can include the appropriateness of the existing health infrastructure, the hidden costs of travelling, security and perceptions of acceptable distance.

Integrated CTC interventions often aim to support existing primary health care systems but these may not always be accessible to all groups in the community. For the nomadic populations of the Somali region of Ethiopia, for instance, fixed health structures were found to be unsuitable even in times of food insecurity. Socio-cultural assessments helped to pinpoint locations without any physical infrastructure but with a strong socio-economic significance. Security also plays a role in local perceptions of distance, as a factor that can facilitate or hinder access to the programme. During a socio-cultural assessment in the south Wollo CTC programme, for instance, caregivers and community leaders highlighted the issue of security when travelling to and from the sites. Further dialogue with these groups allowed the CTC programme to ascertain local solutions to the problem, such as travelling in groups or whenever possible, being in the company of husbands or other men from home communities.

Identification of the 'hidden costs' of travelling is another important element of ensuring the optimal selection of sites. Transport costs, for example, are notable variables that influence people's perception of distance. There is no universal definition of acceptable distance, and perceptions of acceptable distance vary from community to community. In south Wollo, caregivers often travelled for upwards of 12 hours on return trips to the distribution sites. By comparison, caregivers in the CTC programmes in Aceh Province in Indonesia considered much shorter treks of around 30 minutes to be too demanding.

The results of this study show how previous rejection, distances to sites and awareness of the programme are commonly associated with failure to achieve high coverage. These three issues combined were responsible for almost 75% of cases of non-attendance. The authors suggest that all CTC programmes must address these issues proactively and rigorously. The study also demonstrates that socio-cultural assessments and CSAS survey questionnaires are useful, complementary tools for distinguishing barriers to access. Each method offers insights for CTC programme implementers. Sociocultural assessments are capable of spotting early potential barriers and should be conducted in the early phase of programme implementation. The strength of CSAS survey questionnaires, meanwhile, lies in their ability to identify barriers that have developed since the start of the programme. These surveys therefore need to occur later in the programme cycle but with enough time to transform the results into concrete steps to overcome any identified barriers to access.

¹Guerrero. S, Myatt. M and Collins. S (2010). Determinants of coverage in Community based Therapeutic Care programmes: Towards a joint quantitative and qualitative analysis. Disasters, vol 34 (2), pp 571-585