الفهرس 
INTRODUCTION and Aim of the present studyOnly 14 pages are availabe for public view
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Abstract
Childhood malnutrition is a significant global public health concern and one of the main public health challenges in the 21st century despite numerous advances and improvements in child health care. Each year approximately 2.3 million deaths among children between 6-59 months in developing countries are associated with acute malnutrition. Severe acute malnutrition (SAM) is a serious public health problem in Yemen; it remains a significant challenge to child survival and development where it is associated with a high risk of morbidity and mortality.
Outpatient therapeutic programme (OTP) is one dimension of the CMAM that provides screening, diagnostic and treatment services for uncomplicated SAM children 6–59 months of age, by providing home-based treatment as Ready-to-use Therapeutic Food (RUTF) and routine medical treatment.
The study was carried out to investigate the performance of SAM outpatient therapeutic programme among children aged 6-59 months in Al-Hodeidah city, Yemen with the following specific objectives:
1. To assess the performance of severe acute malnutrition outpatient therapeutic programme in terms of the following outcomes: cure, defaulter, non response, medical transfer and death.
2. To identify the determinants of the following outcomes: recovery, defaulter and non response.
3. To assess the knowledge of severe acute malnutrition children’s mothers regarding complementary foods and breastfeeding practices.
The study was carried out among newly enrolled SAM children aged 6 to 59 months and their mothers to OTP in Al-Hodeidah city districts, Yemen using a longitudinal prospective approach. A total sample of 140 SAM children with their mothers selected from primary health care centers and governmental hospitals’ outpatient clinics was included in the study.
Al-Hodeidah city is divided into 3 districts: Al Hali district (with 6 subdistricts), Al Hawak district (with 5 subdistricts) and Al Mina district (with 3 subdistricts). One OTP clinic was randomly selected from each subdistrict, totaling 14 OTP clinics. The predetermine SAM children sample (140) was distributed equally on the 14 selected clinics and taken consecutively to fulfill the required sample. All mothers of the children sample were included in the study.
Data collection was done in two phases:
• Phase I for measurement of all SAM children enrolled in the programme and assessment of knowledge of their mothers.
• Phase II for follow up of SAM children 2 and 4 months later to assess the performance of the programme.
Data were collected using a structured interviewing questionnaire with the mother and the follow up card of SAM children at time of the entry in the programme and 2,4 months later. The data included: socio-demographic data, anthropometric measurements for weight, height and MUAC, housing conditions, sanitation and waste disposal, number of family members, previous medical conditions of SAM children, vaccination status, breastfeeding and feeding practices, medical complications of children, routine medications, location of health service and RUTF (packaging, flavor and taste). In addition to the knowledge data of mothers regarding complementary food and breastfeeding practices.
The study revealed the following main results:
The median age of SAM children was 13 (6-59) months. More than half of SAM children (53.6%) were females.
The median age of mothers was 30 (17-43) years old. More than half of mothers (52.9%) were in the age 25 to less than 35 years. About 39% of mothers were illiterate, and the majority of them (95.7%) were housewives.
More than half of SAM children’s families (58.6%) lived in a permanent house, and more than half of them (59.3%) had low income. The number of family members ranged between 3 and 15 persons, and the median was 6 persons.
The majority of SAM children’s families (82.8%) used public pipes as a source of drinking water, and the majority of them (92.9%) did not use any method to treat drinking water.
More than two thirds of SAM children’s families had sewerage system with toilet facilities, and 47.1% of them used rubbish drums for garbage disposal.
Nearly half of SAM children (49.3%) had diarrhea, 45.7% had upper respiratory infection, and 60% of SAM children had experienced fever during the 2 weeks preceding enrollment in the program.
The majority of SAM children (92.1%) had full vaccination coverage. Among SAM children more than 9 months 87.4% received measles vaccination.
Less than two thirds of SAM children (62.1%) were exclusively breastfed from birth to six months. The majority of SAM children (85.7%) were breastfed 6- 9 months, and the same proportion of them received semi-solid complementary food in this age.
Among the age group 2-5 years, the majority of SAM children (96.4%) had three main meals with their families; among them 85.7% got extra meals
Reducing the size and number of meals due to scarce resources, reducing spending on education and health to provide food and sleeping hungry due to insufficient food were prevalent among 32%, 21.4%, 18.6% and 15.7% of the study sample respectively.
More than three quarters of SAM children’s mothers (80.8%) had a good level of knowledge regarding breastfeeding, complementary food and hygiene. There was no statistically significant association between mothers’ knowledge level about breastfeeding, complementary food and hygiene and cure rate (MCP = 0.136 (p>0.05)).
The median weight, height and MUAC of children after treatment was 6.9 (3.7-15) kg, 70.1 (56-106.8) cm and 11.9 (8.9-15.3) cm compared to 6 (3.1-13) kg, 68 (50-106) cm and 11.2 (8.2-13.7) cm before treatment respectively. There is a highly statistically significant increase in median child weight, height and MUAC after treatment (p < 0.0001).
About 61% of children had severe degree of SAM based on MUAC, only 13.6% remained in severe degree of SAM after treatment. This difference in percentage of severity degree of SAM based on MUAC before and after treatment was statistically significant (p < 0.0001).
The majority of children (87.9%) had severe degree of SAM based on WHZ, only 12.1% remained in a severe degree of SAM after treatment. This difference in percentage of severity degree of SAM based on WHZ before and after treatment was statistically significant (x2mcnemar= 103.18, p < 0.0001)
SAM children suffered from diarrhea, cough (RTI), loss of appetite and vomiting during treatment representing 31.4%, 21.4%, 7.1 and 5.7% of the total sample respectively.
The majority of SAM children (91.4%) used antibiotic as amoxicillin on the first visit, more than half of them (51.4%) used anthelminthic medications on the second visit of treatment, while 30% used folic acid. Only 6.4% of SAM children used antimalarial medications.
The overall cure rate of SAM children in OTP was 82.2%.
The non-responder, default, transfer and death rates were 10%, 6.4%, 1.4% and 0% respectively.
The median length of stay in the programme was 7 weeks (2-16 weeks).
The average weight gain of SAM children was 3.31±2.43 g/kg/day for length of stay.
There was no statistically significant association between socio-demographic characteristics of SAM children parents and the cure rate (p>0.05).
Increasing number of family members elevates risk of non-cure as risk in family with 6-8 members or more than 8 members is 1.31 and 3.42 times the risk in smaller family respectively.
The risk of non-cure rate is reduced by 68% with introducing semisolid complementary food for child aged 6-9 months. While continuous breastfeeding of child aged 9-24 months reduced risk by 70%.
The risk of non-cure with reduction of child meal number due to scarce resources is 2.44 times higher than non-reduction. Moreover, the risk is 2.52 times higher when child slept hungry because of insufficient food.
The risk among those experienced diarrhea is 2.36 times compared to those without diarrhea. There was no statistically significant association between other medical conditions identified during treatment (such as vomiting, cough or loss of appetite) and cure rate (p>0.05).
History of used anthelminthic medications on the second visit reduced risk of non-cure rate by 56% versus non-use.
History of used folic acid on the first visit reduced risk of non-cure rate by 68% versus non-use.
The risk of non-cure was 3.25 times among those reported unsafe road compared to those with safe road.
The risk of non-cure was 3.38 times among those with a waiting time half an hour or more compared to those with less than half an hour.
There was no statistically significant association between any marked change in packaging, flavor, taste, texture or side effects of RUTF with cure rate (p>0.05).
Child acceptance of RUTF taste reduces risk on non-cure rate by 78%.
Good and medium child appetite during treatment decreased risk of non-cure rate by 69, 67% respectively.
Mothers’ compliance to feeding their children RUTF reduces risk of non-cure rate by 78%.
Mother’s belief of gaining weight by treatment reduces risk of non-cure rate by 75%.
Absence of family support had a risk of non-cure rate 3.37 times compared to those with good family support (95% CI= 1.67, 6.79).
6.2 Conclusion:
According to the results of this study, the following can be concluded:
The OTP is a considered successful programme in treating SAM children aged 6-59 months in Al-Hodeidah city, Yemen as the estimated performance indicators (cure, default and death rates) are consistent with the acceptable international sphere standards.
The proportion of cured SAM children increased with decrease in mothers’ age, and with increasing level of mothers’ education.
The majority of SAM children’s families used public pipes as a source of drinking water and the majority of them did not use any method to treat drinking water, while more than two thirds of SAM children’s families had sewerage system with toilet facilities.
The majority of SAM children had full vaccination coverage.
More than one third of SAM children were non-exclusively breastfed from birth to six months.
Most of mothers were compliant in feeding their child with RUTF and also had positive belief about the effect of RUTF regarding weight gain.
Introducing only semi-solid complementary food for SAM children aged 6- 9 months, food security, using anthelminthic and folic acid medications during treatment, level of road safety, waiting time to get the service, acceptable RUTF taste, good child’s appetite, level of mother’s compliance and level of family support, higher family income were statistically significantly positively associated with the cure rate.
Higher number of family members, diarrhea during treatment were negatively correlated with the cure rate and the results were statistically significant.
The majority of SAM children’s mothers had good level of knowledge regarding breastfeeding, complementary food and hygiene, but that was not statistically significantly associated with the cure rate.