Severe acute malnutrition (SAM) affects approximately 14·3 million under-five children globally(1). This serious form of undernutrition, defined as a mid-upper arm circumference < 11·5 cm or a weight-for-height Z-score < − 3 with or without oedema, is attributable to numerous life-threatening conditions during the early years of life(2–Reference Dailey-Chwalibóg, Freemark and Muehlbauer4). The condition is often multifactorial and characterised by a number of clinical manifestations including muscle wasting and nutritional oedema(Reference Karunaratne, Sturgeon and Patel3). SAM was also found to be associated with co-infections, inflammation and enteropathy(Reference Karunaratne, Sturgeon and Patel3). This deadly form of acute malnutrition may result in deceleration of immune functions, increased risk of infectious diseases and ultimately accelerates mortality, particularly in under-five children(Reference Alam, Larbi and Pawelec5). SAM is considered to be one of the leading causes of childhood deaths in hospital settings(Reference Gera6). The ongoing pandemic of COVID-19 further deteriorated the condition causing an increased rate of morbidity and mortality in severely malnourished children warranting immediate attention and utmost care to reduce the deaths from SAM in young children. However, the lack of effective healthcare services is a serious concern for the management of SAM in resource limited settings(Reference Puett and Guerrero7). The WHO has developed guidelines for inpatient management of children with SAM in order to reduce the unfavourable outcomes as well as mortality(Reference Ashworth, Khanum and Jackson8). The mortality from severe malnutrition can be reduced substantially if the management guidelines are precisely followed by the healthcare providers(Reference Nduhukire, Atwine and Rachel9,Reference Ashworth, Huttly and Khanum10) .
Due to inappropriate application of these guidelines, the mortality from severe wasting remains persistently high in many low- and middle-income countries(Reference Hossain, Huq and Ahmed11). SAM accounts for approximately one to two million under-five child deaths/year globally(Reference Bhutta, Ahmed and Black12,Reference Collins, Dent and Binns13) . The number of severely wasted children is considerably high in South Asian countries, including Bangladesh(1). As per Bangladesh Demographic and Health Survey 2017–2018, the prevalence of SAM was estimated 2 % among children aged 6–59 months which accounts for more than 0·3 million under-five children(1,14) . The country has adopted national guidelines for successful management of childhood SAM to avert its adverse consequences(15,16) . However, the outcome of inpatient care for children with SAM is not yet up to the mark(Reference Hossain, Huq and Ahmed11,Reference Munirul Islam, Arafat and Connell17) . There may have potential barriers within the health systems, both on demand and supply sides, which are primarily responsible for such undesirable outcomes in relation to facility-based management of SAM in children. Evidence suggests that facility-based management of SAM can be affected by multiple factors(Reference Jacobs, Ir and Bigdeli18–Reference Peters, Garg and Bloom20). Besides, the readiness of a facility to deliver standard healthcare services in order to manage critically ill patients with SAM is also crucial to ensure proper facility-based management(Reference Raven, Hofman and Adegoke21,Reference Ameh, Msuya and Hofman22) . To that end, it is imperative to assess the readiness in management of childhood SAM in the public healthcare facilities of Bangladesh. In addition, identification of potential barriers would help to design effective policies to ensure appropriate inpatient management of children with SAM. Therefore, we sought to assess readiness of the facilities and identify barriers to the facility-based management of childhood SAM in public healthcare settings in Bangladesh.
Methods
Study design
A qualitative study was done to assess the facility readiness as well as different perspectives on barriers and challenges to the facility-based management of children with SAM. Data were collected using in-depth interviews (IDI), key informant interviews, exit interviews and a pre-tested observation tool. IDI were conducted among doctors and nurses who were directly involved in the inpatient management of children with SAM, KII were conducted among key personnel who were considered as experts in the facility-based management of SAM and EI were conducted among caregivers of the patients with SAM. The interview guidelines and observation checklist were prepared based on the national guidelines and findings from previous studies. We did pre-test the interview guidelines after interviewing ten participants (six for IDI, two for key informant interviews, two for exit interviews) in a tertiary care hospital. The observation checklist was also pre-tested in the paediatric ward and nutrition rehabilitation unit of a tertiary care hospital. Results from IDI and KII were recorded and analysed to identify the barriers from the perspective of supply side. Information from EI were audiotaped and analysed to point out the barriers from demand side. The observation checklist was developed and pre-tested with the purpose of methodological triangulation of data obtained by different techniques.
Study settings and participants
The study locations as well as the respondents for IDI and KII were selected purposively. First, two administrative divisions of Bangladesh were selected based on the prevalence of wasting: Rangpur (with lowest prevalence, 7·3 %) and Sylhet (with highest prevalence, 10·4 %)(14). Subsequently, one tertiary care teaching facility and two district hospitals were chosen from each division. The teaching hospitals were Sylhet MAG Osmani Medical College and Hospital (SOMCH) and Rangpur Medical College and Hospital (RMCH). These two institutions are the largest and oldest healthcare facility in Sylhet and Rangpur divisions. There are fully functional SAM units or paediatric wards to provide inpatient services to the children with SAM. Moreover, these are the hospitals with highest number of under-five children admissions in the past year in their respective divisions.
For the district hospital, we did select Habiganj District Hospital and Moulvibazar District Hospital from the Sylhet division and Thakurgaon District Hospital and Kurigram District Hospital from the Rangpur division. All these facilities had highest number of under-five children admissions in the previous years compared with other district hospitals in their respective divisions(23). Additionally, there present functional SAM wards to provide management to undernourished children as per the national guidelines. Overall, two tertiary care teaching facilities and four secondary care district hospitals were selected where severely malnourished children get admitted for inpatient care according to the national guidelines(16).
Finally, healthcare providers, both doctors and nurses posted in paediatric wards, were selected from the chosen healthcare facilities as the respondents for IDI. We did only interview doctors and nurses for IDI if they were directly involved in the facility-based management of children with SAM. The key informants were nominated based on their position as well as expertise on the facility-based management of SAM. Professors, Head of the Departments or Hospital Supervisors were primarily considered for key informant interviews. In addition, we interviewed Line Director and Program Manager of National Nutrition Services as key informants as National Nutrition Services is the public authority to launch and oversee nutrition programmes in the country. Exit interviews (exit interviews) were done with the caregivers of hospitalised children with SAM. We found only four hospitalised children with SAM during our visit to the selected hospitals. Therefore, the number of EI was four.
Definition and components of facility readiness
Facility readiness was defined as the overall capacity of the facility to deliver optimum healthcare services to the children with SAM(24). It was measured by the availability of tracer items in six domains: (1) instruments for SAM identification; (2) documents related to management of SAM; (3) necessary medical equipment and devices; (4) diagnostic facilities and essential medicines; (5) amenities to maintain standard sanitation and hygiene practices and (6) overall structure and condition of the ward(24,Reference Ssempiira, Kasirye and Kissa25) .
Data collection
The qualitative data collection was carried out between September 2020 and January 2021. Overall, twenty-six IDI, thirteen KII and four EI were conducted until the saturation of data. In addition, 28 h of observation was done in each of the selected hospitals to monitor ward infrastructure, facility preparedness and SAM management practices by the healthcare professionals. Observation data were collected between 8 am to 10 pm for two consecutive days. In Bangladesh, hospital duties are divided into three shifts: morning (8 am to 3 pm), evening (3 pm to 10 pm) and night (10 pm to 8 am). The observation data were collected in morning and evening shifts of the hospital duties. We primarily investigated facility-based SAM management barriers and barriers from the supply side through IDI. We also explored facility related barriers, challenges related to possible solutions and recommendations by KII and demand side barriers and challenges through EI. The interviews as well as observation were facilitated by the study investigators.
Data analysis
All the interviews were conducted by trained and experienced interviewers and recorded accordingly in Bengali language. The interview team consists of physicians and anthropologists who received training regarding inpatient management of SAM and have experience of conducting qualitative interviews in the hospital settings. The audio recordings were transcribed manually in Bengali. Transcribed data were described and analysed using qualitative content analysis method(Reference Krippendorff26). Subsequently, a research team with expertise in treating children with SAM, public health and anthropology conducted thematic analysis by manual coding where each theme portrayed barriers from either supply or demand sides. A combined theoretical and inductive coding approach was used by the members where they each went through all of the transcripts and generated codes. Potential codes and themes were reviewed and revised among all the members until agreement was reached. Finally, the relevant quotes were translated to English from Bengali. The investigators translated the quotes by themselves. However, there was no standard protocol that has been followed for translation. Observation data collected from the facilities during the study were analysed based on the WHO manual on Service Availability and Readiness Assessment (SARA Tool)(24). Two physicians and one anthropologist collected the observation data using a pre-tested semi-structured observation checklist. They observed the paediatric wards including SAM corners and their associated parts. SAM corner is a separate space within the paediatric ward dedicated only for the children diagnosed with SAM. Such corners are established in all the facilities where inpatient management of children with SAM are regulated. The observation was done for 28 h in two consecutive days including the morning and evening shifts extending from 8 am to 10 pm. The night shift was excluded because most of the management is usually covered within morning and evening shifts. Under ‘broad spectrum antibiotics’, we searched for at least one of these three injectable drugs; ampicillin, gentamycin and/or ceftriaxone to be available during our visit to the wards. In ‘essential micronutrients’ category, we checked for Zn, multivitamins, folic acid, vitamin A, potassium and magnesium supplementation collectively. We have recorded it as ‘absent’ if any of these was found missing in the selected facilities. With regard to ‘laboratory investigation facilities’, we looked at whether routine blood examinations including complete blood count, serum electrolytes and blood cultures were carried out in the facilities. No radiological or sonographic investigations were included in our observation checklist. Facilities that did not fulfill all the criteria to be deemed prepared were defined as ‘not ready’ and vice versa.
Reliability and validity
In this study, we interviewed the participants until data saturation to ensure the reliability of information regarding barriers and challenges to the facility-based management of childhood SAM. Different methods can be used in qualitative research to ensure data validity and reliability. Among them triangulation (triangulation among different interview and observation tools, methods and researchers), member checking and peer debriefing are prominent(Reference Lincoln and Guba27). In our study, we have triangulated our data with different research findings. Data from interviews and observations were also triangulated in our analysis. In addition, peer debriefing was done regularly to ensure data reliability and saturation. Internal validity was ascertained by triangulating themes among interviews with different types of respondents (i.e. healthcare providers, subject experts and caregivers of the children) and observation of facility readiness as well as management practices. Validity of the findings was reinforced by the application of qualitative methods and reporting the perceptions as stated by the respondents in their own words.
Results
Participant characteristics
A total of forty-three participants were interviewed (twenty-one doctors, eighteen nurses and four caregivers) from six hospitals. The socio-demographic characteristics of the interviewees attended IDI and key informant interviews are reported in Table 1. A majority of the participants were aged between 31 and 40 years. Among the IDI participants, seven (26·9 %) received training on facility-based management of SAM. Out of the four respondents of exit interviews, three were female.
Summary of socio-demographic features of participants
NNS, national nutrition services; SAM, severe acute malnutrition.
Facility readiness for management of children with severe acute malnutrition
A total of 168 h of observation was conducted in the selected hospitals during the project period. Anthropometric tools, for instance, length board and mid-upper arm circumference tape, were unavailable in three (50 %) out of six facilities. However, paediatric weighing scales were present in all the selected facilities. Glucometer, an important tool to assess hypoglycaemia, was not available in two out of six hospitals. Posters on nutrition education were present in four facilities. However, the national guidelines for facility-based management of SAM were found only in two of the selected hospitals. Sitting or sleeping arrangements for the caregivers were not present in any of the chosen hospitals. The caregivers and attendants took rest on the same bed that the children were kept on or lay down on the floor. In addition, the general condition and cleanliness of the wards and toilets were found below standard that means these were not properly cleaned. Moreover, the sanitary conditions were found unhygienic. In each facility, caregivers had to buy drinking water from outside due to lack of drinkable water sources in the hospitals. Essential laboratory investigation facilities were available only in one hospital. Moreover, supplies of essential equipment, medicines and foods were not available in some of the selected hospitals. Only two of the selected hospitals had stock of essential micronutrients, while ReSoMal was not present in any of the facilities. Findings on readiness of facilities and availability of essential equipment to ensure treatment services are described in Table 2. All the facilities were seemed to be ‘not ready’ as none of them could fulfill the required criteria to be deemed as ready for providing effective services to children with SAM.
Facility readiness for management of children with SAM based on data obtained from observation
SAM, severe acute malnutrition; MUAC, mid-upper arm circumference; ReSoMal, rehydration solution for malnutrition; IPS, instant power supply.
Barriers to the facility-based management of childhood severe acute malnutrition
A total of forty-three interviews were conducted in the selected facilities that assisted us in identifying the barriers to the facility-based management of SAM in public healthcare settings. Barriers related to health system, hospital settings and demand side were detected after analysis of the interview findings. Table 3 describes the specific barriers under each domain with significant quotes from the respondents.
Barriers to the facility-based management of childhood SAM
Health system barriers
A number of health system-related barriers were identified in this study that are highlighted with quotes in Table 3. Insufficient manpower resulting in increased workload, lack of training, rapid turnover of healthcare staff and healthcare professionals’ lack of adherence to the guideline suggestions were found as key challenges in ensuring the proper management of SAM. The quotes from the study respondents clearly emphasised on requirement of training for healthcare providers. We found that only seven out of twenty-six26 IDI participants had received training on inpatient management of SAM. Lack of adequate manpower in the wards was an important barrier recalled in several interviews. Our observation also supports the shortage of service providers in the selected facilities. We observed that healthcare providers rely more on their own judgement rather than the protocol outlined in the national guidelines. As reported in Table 3, a healthcare provider stated that he administers dexamethasone in children with hypothermia. However, prescribing steroids to such patients is not recommended in the management guidelines. We found only four out of twelve nurses (33·3 %) who were aware of the national guidelines as well as the steps to manage children with SAM. This can be considered as a potential barrier from the service delivery side. In addition, rapid turnover of staff was found as another obstacle in managing severely malnourished children. Rapid turnover denotes to frequent posting of healthcare staff from one facility to other facilities. A number of interviewees stated that such turnover initiate difficulties in the management of children with SAM because it takes time to make the new staff oriented with the guidelines for facility-based management of SAM.
Facility-related barriers
Facility-related barriers were identified by analysing the interviews and triangulating the interview findings with observation data. The unavailability of functional anthropometry tools was one of the major facility-related barriers. Length boards and mid-upper arm circumference tapes were found only in three of the six selected hospitals. Although weighing machines were available in all the selected facilities, the scales were not readily available in the paediatric wards. Some of the respondents mentioned that sometimes they face difficulties to measure weight due to inadequacy of the weighing scales in the wards. Nevertheless, they never calculate Z scores as length is not measured regularly in the wards. In that case, SAM identification is done based on the visual inspection of muscle wasting or oedema. Inadequacy of medicines, insufficient treatment supplies and unavailability of resources for laboratory investigations were also detected as major obstacles from the interviews. These findings remain analogous when triangulated with inspection data. We observed that attendants had to buy medicines and supplies due to unavailability of these items in the hospitals. We also observed similar findings in terms of laboratory investigations. Besides, unavailability of the national guidelines in the paediatric wards, difficulties in managing foods for admitted children and insufficient space and beds in the SAM corner were found as barriers from the supply side affecting the inpatient care.
Demand-side barriers
Important themes that emerged to identify barriers from the service recipient side were increased number of attendants affecting services, the financial crisis of parents, insufficient knowledge of the caregivers regarding malnutrition and proper feeding practices and their reluctance to complete the treatment regimen. Apart from these, parents not seeking early help was also recognised as a barrier from the demand side. From a quote related to an increased number of attendants in the ward (Table 3), it is conspicuous that the service providers were discontented regarding the issue. It was affecting service delivery severely. In addition, a large number of attendants were not wearing masks putting the healthcare providers at risk of being infected with SARS-CoV-2. According to the quote in Table 3, the lack of knowledge of caregivers regarding malnutrition affected the child’s recovery. Incompletion of treatment at the hospitals was also a serious issue that was raised by the interviewees.
Exit interviews were conducted to discover potential barriers that are being faced by the caregivers in the process of receiving treatment services. They received basic information about nutrition and food preparation techniques from the healthcare providers upon admission to the hospitals. Dissatisfaction regarding general conditions and cleanliness of the paediatric wards was one of the main concerns raised by the caregivers. Although the caregivers were referred multiple times from one facility to another, they were not disappointed with such process. Concerns of extra expenditure were raised by the caregivers during the interview. However, apart from the barriers, we have identified a number of positive notations in this study. The findings are mutual trust among the healthcare professionals, sufficiently good level of communications between the service providers and a positive doctor–patient relationship. Fulfillment of treatment was also acknowledged by the caregivers interviewed in this study.
Discussion
The national guidelines for facility-based management of SAM have been introduced to ensure proper inpatient therapeutic care of severely malnourished children(16). However, the results of this study indicate that even after more than a decade of adopting the guidelines the facilities are not yet completely prepared to deliver services to the children with SAM at an optimum level. It also suggests that recommendations of national guidelines are not maintained as intended in the facilities. This finding is consistent with previous studies demonstrating poor quality of child care in public hospitals of the country(Reference Hoque, Rahman and Billah28). A recent study in Bangladesh exhibited that preparedness was poor for management of sick under-five children in primary health care facilities(Reference Billah, Saha and Khan29). The unpreparedness of facilities for the management of SAM underscores not only building up the community-based management of acute malnutrition programme but also improvement in inpatient management of SAM(Reference Ireen, Raihan and Choudhury30). The study respondents also emphasised reinforcing the community-based management of acute malnutrition programme in the community. Implementation of growth monitoring and promotion activities and identification of children with acute malnutrition in the community using mid-upper arm circumference screening may help to improve nutritional outcomes in young children(Reference Liu, Long and Garner31). In addition, effective counseling, appropriate social safety net programme and provision of therapeutic food on a targeted basis in community level would help to reduce hospitalisation as well as adverse consequences of acute malnutrition in children(Reference Engidaw and Gebremariam32). However, the facility-based services are still important for detection and management of SAM in under-five children(Reference Morán, Alé and Charle33). Thus, efforts need to be taken to improve quality of services in the hospital settings. The WHO has emphasised on infrastructural development, supply of essential drugs and equipment, skilled health workforce and guideline-based management for improving the quality of care in the facilities(34,35) . To that end, provision of essential medicines, a stock of necessary equipment and supplies, development of existing infrastructure and appropriate training of healthcare staff may help to overcome the gaps in relation to facility preparedness(Reference Billah, Saha and Khan29,Reference Tamang, Simkhada and Bissell36) .
We have identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, insufficient training of the service providers and lack of adherence to the management protocol as recommended in the guidelines. Bangladesh is in a critical stage for lack of trained health workforce including doctors and nurses(Reference Joarder, Tune and Nuruzzaman37,Reference Islam and Biswas38) . Shortage of skilled service providers and rapid turnover of healthcare staff immensely affect the quality of care(Reference Ameh, Msuya and Hofman39). It also results in high workload pressure of existing staff in the facilities. Increased workload of health workforce has already been reported in the government hospitals of Bangladesh(Reference Joarder, Tune and Nuruzzaman37). Hence, it is recommended by the WHO to increase proportion of healthcare staff and adopt flexible health workforce planning to reduce the workload of physicians and nurses in the public healthcare facilities(35). We have reported a low coverage for training of the healthcare providers on the facility-based management of SAM. Perhaps, inadequate fund and opportunities for skill enhancement in remote areas are primarily responsible for this problem. It is also possible that most of the healthcare staff missed the training programme due to rapid turnover. In addition, insufficient training programmes during the period of COVID-19 pandemic can be another possible cause for lack of training. Further studies are required to elucidate the reasons for inadequate training of healthcare professionals. However, the inadequate training could be a probable reason for lack of adherence to the management protocol as recommended in the national guidelines. Earlier works showed that supervised training improves perception as well as adherence to any standard protocols or guidelines(Reference Bailey, Blake and Schriver40–Reference Hoque, Arifeen and Rahman42). The WHO has also endorsed for investment in skill development of healthcare providers in order to improve the quality of hospital services(43). Appropriate training with regulated supervision may improve the quality of care and ensure adherence of the healthcare providers to the management guidelines(Reference Hoque, Rahman and Billah28).
The facility barriers observed in this study are unavailability of necessary medical supplies, required equipment and essential medicines in the facilities, insufficient space and beds in the SAM corner, unavailability of resources for laboratory investigations and difficulties in managing food for admitted children. Presence of functional anthropometric tools is essential for screening of undernutrition and regular assessment of nutritional status of the sick children(Reference Billah, Saha and Khan29). Lack of anthropometric apparatus in the hospital settings may lead to inaccurate diagnosis of children with undernutrition and thwart the appropriate management of malnutrition(Reference Arifeen, Bryce and Gouws44). Misdiagnosis of SAM in the facilities may also deprive the malnourished children from receiving specialised care designed for this vulnerable group of patients(Reference Trehan and Manary45). Unavailability was also reported for glucometer, thermometer, paediatric sphygmomanometer and necessary medical supplies. Children with SAM are prone to develop hypoglycaemia that may further increase the risk of mortality among critically ill children(Reference Egi, Bellomo and Stachowski46). It is, therefore, imperative to monitor blood glucose level of severely malnourished child at a regular interval. Glucometer is a widely used point-of-care-testing device for bedside monitoring of blood glucose levels(Reference Sengupta, Handoo and Haq47). However, we found that two of the hospitals did not have a glucometer in the paediatric ward. Lack of glucometer in the hospitals is a potential barrier to ascertain the protocol-based management. Supply of glucose to treat hypoglycaemia is similarly important. It was discovered from the interviews and observations that supply of glucose was scarce in the facilities. Similar pattern was identified for essential medicines including broad-spectrum antibiotics, micronutrient supplements, ReSoMal, F-75 and F-100.
The national guidelines suggest immediate administration of broad-spectrum antibiotics to the hospitalised children with SAM(16). In addition, correction of micronutrient deficiency in children with SAM is recommended as it reduces the risk of diarrhoea, respiratory infections and ocular manifestations(Reference Ejaz and Latif48,Reference Bhutta49) . It is also evident that administration of micronutrient supplements contributes to better health outcome in malnourished children(Reference Bhutta49). ReSoMal is the first choice of fluid to correct dehydration in severely malnourished children(16). However, we observed no supply of ReSoMal in all the selected facilities. Instead, glucose-based oral saline was used for the management of dehydration in the hospitals. Oral saline is high in Na that may cause sodium-overload in severely malnourished children(Reference Houston, Gibb and Maitland50). Most of the physicians interviewed in this study recommended a constant supply of ReSoMal, F-75 and F-100 in the paediatric units. F-75 and F-100 are important therapeutic products which are developed for management of malnourished children. In our study, we found that half of the facilities (n 3) did not have the supply of F-75 and F-100. Insufficient supply of medicines and foods in the public facilities results in out-of-pocket payment of caregivers owing to purchasing the products from outside sources(Reference Tahsina, Ali and Hoque51). Hence, there remains a chance of missed dosage of medicines for children from poor families. Continuous supply of required drugs at the facilities could reduce the cost of caregivers and ensure the proper treatment of children with SAM in the facilities.
Although we have observed growth charts and record keeping register books in all the selected facilities, the printed version of the guidelines for facility-based management of SAM was unavailable in four of the hospitals. A study conducted in India showed that absence of institutional guidelines for clinical management led to confusion and different treatment practices among the healthcare professionals(Reference Barua, Mundle and Bracken52). We also observed lack of adherence of healthcare providers towards management protocol as recommended in the guidelines. In Bangladesh, the National Nutrition Services has been implemented to strengthen the infrastructure of public healthcare facilities for management of malnourished children(Reference Billah, Saha and Khan29). Nevertheless, we observed infrastructural inadequacy with insufficient space and limited beds for children with SAM in the facilities. Increasing number of beds and spacious corners dedicated for children with SAM could play an important role in improving the outcome of facility-based management of SAM. In addition, special attention needs to be given on cleanliness of the wards, supply of adequate drinking water and arrangement of resting place for caregivers.
In our assessment, caregivers’ reluctance to complete the treatment regimen and their insufficient knowledge regarding malnutrition as well as proper feeding were the principal contextual barriers. In addition, increased number of attendants affecting services and poverty of parents were identified as key factors in hindering the facility-based management of SAM. Well-constructed counselling sessions by trained and efficient healthcare providers would improve the knowledge of the caregivers. They should also be motivated to translate the acquired knowledge into actions. Prior evidence suggests that caregivers may not adopt the practices even after education sessions by healthcare staff in the facilities(Reference Chaturvedi, Patwari and Soni53). Therefore, multiple sessions on nutrition and health education using behaviour change and communication materials are recommended to overcome this issue. Regulatory measures should be taken to control the number of attendants in the wards. Increasing supply of medicines and ensuring the laboratory investigations in the facilities could address the issue of poverty to some extent.
Strengths and limitations
To the best of our knowledge, this is the first study to evaluate the readiness of public healthcare facilities and investigate the barriers to the facility-based management of severely malnourished children in Bangladesh. The strength of the study includes inclusion of six public healthcare settings from two administrative divisions of the country. In addition, interview of healthcare providers and subject experts enables us to excavate several structural barriers through the application of qualitative methodology. Triangulation of interview findings with data obtained from observation was also strengthened our results. However, there are several limitations as well. Lack of generalisability and cross-sectional nature of the study may have limited the robustness of the findings. Nevertheless, saturated themes emerged from the interviews. Moreover, we could interview only four caregivers in this study which restricted us to evaluate the barriers from the perspective of demand side. Radiology and sonography were not included in the observation checklist which is another limitation of the study.
Conclusions
Our findings suggest that facilities were not completely ready to deliver inpatient services to the children with SAM. A number of health system and facility-related barriers were identified which are curbing the facility-based management of severely malnourished children. Recruitment of skilled healthcare providers, proper on job training and adequate supply of necessary logistics may alleviate these challenges. Besides, proper functioning of SAM corners, arrangement of resources for laboratory investigations and allocation of dedicated staff for management of SAM would improve the management. Proper counselling of caregivers may reduce the obstacles from demand side. Trained healthcare staff to be assigned for the purpose of multiple counselling sessions. In addition, strengthening of community-based management of acute malnutrition programme, implementation of growth monitoring and promotion and recruitment of field level staffs are recommended to avert the unfavorable consequences of acute malnutrition in children. Moreover, there needs policy efforts to develop feasible interventions in order to reduce the barriers and ensure preparedness of the facilities for effective service delivery.
Acknowledgements
Acknowledgements: We thank the interviewees and all staff members of the study who were involved in data collection. This study was funded by core donors who provide unrestricted support to icddr,b for its operations and research. Current donors providing unrestricted support include the Governments of Bangladesh, Canada, Sweden and the UK. We gratefully acknowledge our core donors for their support and commitment to icddr,b’s research efforts. Financial support: This study was funded by the core donors of icddr,b under the Rainy Day Grant Fund Policy for Young Scientists (grant number BCXXXXX). Authorship: S.M.F., M.R.I., M.J.R. and T.A. formulated the research questions and designed the study. S.M.F., M.R.I., M.J.R. and N.M.A. carried out the study. S.M.F., M.R.I. and N.M.A. collected and analysed the data. S.M.F., M.R.I. and M.G.R. interpreted the results and wrote the manuscript. M.G.R., N.M.A., M.M.I.B. and T.A. critically reviewed and edited the manuscript. All the author(s) read and approved the final manuscript for submission. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Institutional Review Board of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh. Written informed consent was obtained from all the participants and from the Director or Superintendent of the hospitals to observe SAM management practice in the respective healthcare facilities.
Conflicts of interest:
There are no conflicts of interest.
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