This study investigated the challenges and motivation in accessing CMAM, the challenges CMAM workers face in implementing CMAM in the rural communities, the level of community involvement in CMAM, as well as CMAM beneficiaries‟ perspective on how access to CMAM can be improved. 3 CMAM centres formed part of the study. Mothers and Community Health Volunteers (CHVs) at the various centres were selected by convenience. Consequently, spouses (fathers) of these mothers formed part of the study. The assemblymen for the communities in which the centres are situated, and the CMAM implementers at the selected centres also formed part of the study. The study employed in-depth interviews and used semi-structured interviews to obtain qualitative data from the study participants. Questionnaires were used to obtain quantitative data on beneficiaries‟ demographics. Descriptive statistics such as frequencies and percentages were used to analyze demographic characteristics of beneficiaries and the results presented in tables, while the spider gram framework and thematic analysis was used to analyze the level of community participation. Through a process of reading and familiarization with the data, data collected was grouped into codes, basic themes and global themes. Challenges and motivation in accessing CMAM, challenges in CMAM implementation, as well as beneficiaries‟ perspective of how to improve access to CMAM were analyzed based on these themes. Results from the study showed that majority 83.6% of the beneficiaries had no basic education, agriculture was the dominant occupation, and 21.8% of the beneficiaries did not have a source of income. The study also revealed that the level of involvement of beneficiaries in designing and implementing CMAM was very low (had a score of 1 in all the spider gram indicators). For mothers, challenges in accessing CMAM included geographic accessibility, delay at the CMAM centre, social events, cultural/social barriers and as well as no money for transportation and food when there is a delay at the centre. Challenges to implementation of CMAM in the district included poor logistics in the form of shortages of plumpy nut, problem transporting plumpy nut to the various CMAM centres, few teaching and learning materials for educating mothers, illiteracy/ poor enlightenment of the community, no incentives for Community Health Volunteers (CHVs), and ridiculing of CHVs by the communities. Lastly, gaining a source of income, receiving money from the government, provision of accessible drinking water, increasing rationing quantity, constant reminders from husbands and household members to attend CMAM and help with means of transport were the various ways beneficiaries thought access to CMAM can be improved. The study recommends improving community involvement in CMAM through involving traditional, religious, and opinion leaders as well as other interest groups in the decision making activities of CMAM. Decentralization is recommended to provide CMAM in more communities, good drinking water should be provided by the government for the communities in the district, Ghana health Service should create a well-structured delivery system for the CMAM programme and CHVs should be motivated with incentives such as means of transport/transport allowances.


1.1 Background
1.2 Problem Statement
1.3 Research Questions
1.4 Main Research Objective
1.4.1 Specific Research Objectives
1.5 Justification

2.1 Conceptual Framework of the Study
2.2 Malnutrition Effects: Globally and Locally
2.3 Health Inequalities
2.4 Community-based Management of Acute Malnutrition
2.4.1 Components of CMAM Community Outreach Outpatient Care for Children 6-59 Months Inpatient Care for Children 0-59 Months Supplementary Feeding of Children 6-59 Months
2.5 Access to Healthcare Programmes
2.6 Challenges in Accessing Rural Healthcare Programmes
2.6.1 Geographical Accessibility to Healthcare Programmes
2.6.2 Availability of Healthcare Programmes
2.6.3 Affordability of Healthcare Programmes
2.6.4 Acceptability of Healthcare Programmes
2.7 Community Participation in Health Programmes
2.7.1 Challenges in Defining Community Participation
2.7.2 Process Indicators of the Spider-Gram Framework

3.1 Study Design
3.2 Description of the Study Area
3.3 Study Population/ Target Groups
3.4 Sampling Technique
3.5 Data Collection
3.6 Data Analysis

4.1 Characteristics of Beneficiaries (Mothers and Fathers) of CMAM
4.1.1 Age Distribution of Respondents
4.1.2 Educational Level of Respondents
4.1.3 Source of Respondents‟ Income
4.1.4 Number of Respondents‟ Children Under Five Years
4.2 Level of Respondents‟ Participation in CMAM
4.3 Beneficiaries‟  Challenges  to  Accessibility  and  Motivation  to  Access CMAM Centre
4.3.1 Mothers‟ Challenges in Accessing CMAM
4.3.2 Mothers‟ Motivation to Access CMAM
4.3.3 Fathers‟ Challenges in Aiding Spouses Access the CMAM Centre
4.3.4 Fathers‟ Motivation to Aid Spouses Access the CMAM Centre
4.4 Challenges to Implementation
4.5 Beneficiaries‟ Suggestions for Improving Access to CMAM

5.1 Introduction
5.2 Summary and Conclusions
5.3 Recommendations

1.1 Background 
The term malnutrition generally refers both to under-nutrition and over-nutrition, where under-nutrition means a deficiency of one or more essential nutrients and over-nutrition means excessive intake of food nutrients, especially in unbalanced proportions. Malnutrition is as a result of many factors, most of which relate to poor diet or severe and repeated infections, particularly in children and underprivileged populations (Blossner et al., 2005). Worldwide, ten and a half million children of age under-five die of malnutrition every year, with 98% of these deaths reported to occur in developing countries (UNICEF, 2007). Malnutrition is a major public health and development concern especially in sub-Saharan Africa, and has foregoing health and socioeconomic impacts on development. The prevalence of malnutrition among the group of under-five is rated at 40% in sub Saharan Africa (UNICEF, 2012). United Nations (2000) identified sub-Saharan Africa as the only region in the world where the number of child deaths is increasing as a result of malnutrition.

Programmes such as the Millennium Development Goals (MDGs) adopted under-fives' nutritional status as indicators for evaluating progress. This shows the measure of importance attached to child nutrition (UN Millennium Project, 2006). Increased morbidity and mortality, very slow mental development, poor school performance and reduced intellectual achievement are some of the repercussions that children who are malnourished tend to experience (Pelletier and Frongillo, 1995). Significant functional impairment in adult life, reduced work capacity, and consequently poor economic productivity are some of the negative factors associated with malnutrition especially in the early stages of childhood (Delpeuch et al., 2000).

The three main forms of malnutrition identified in Ghana by Ghana Health Service (2007) are Protein Energy Malnutrition (PEM), Mineral Deficiency Malnutrition (MDM) or a combination of both. It has the characteristics of stunting (chronic under nutrition), underweight (acute under-nutrition) and wasting (weight loss). Insufficient food intake and infirmities are the basic causes of malnutrition. Political, economic, socio-cultural, physical environment, household food insecurity, public health problems and social care of the environment are other underlying factors that contribute to malnutrition of children under-five (Muhammed and Naleena, 2012).

Over the past ten years, there has been a universal initiative to move from facility-based treatment approaches to malnutrition, to a decentralized community based approach. This move is founded on proof that substantial limitations on coverage and access to treatment of Severe Acute Malnutrition (SAM) cases were compounded by limitations to health facilities. For large numbers of children with SAM to be well treated and catered for in their communities instead of being admitted to therapeutic feeding centres, the Community-based Management of Acute Malnutrition (CMAM) initiative was approved (Tekeste et al., 2013). By providing treatment at many decentralized sites instead of a few centrally located inpatient facilities, CMAM aims to reach the maximum number of children with acute malnutrition thereby ensuring more coverage and access to nutrition healthcare (Ghana Health Service, 2010).

In 2007, WHO and UNICEF introduced the community based management of acute malnutrition (CMAM) programme in a bid to manage cases of severe malnutrition recorded at the community level (WHO/WFP/UNICEF/UNSCN, 2007). Evolving from the Community-based therapeutic care (CTC), CMAM consists of four main parts which are: outpatient care for the management of SAM without medical complications, inpatient care for the management of SAM with medical complications, management of moderate acute malnutrition (MAM) and community outreach (Ghana Health Service, 2010).

The success of health programmes depends very much on the extent to which the community participates, particularly with regard to needs assessment, leadership, resource mobilisation, management and organisation (Rifkin et al., 1988). A primary health care intervention like CMAM would tremendously be effective if there are high levels of participation from the community in decision making and implementing the health programme. Therefore, knowing the extent of community participation in CMAM, and constraints to the community‟s access to the programme is very useful to health planners or health managers.

1.2 Problem Statement
The importance of good nutrition cannot be over-emphasized; especially so in young children (under-five years). Good nutrition ensures the proper growth of children and reduces their susceptibility to infections and illnesses. Proper organ formation and function, a strong immune system, and neurological and cognitive development of children are all very dependent on good nutrition (Black et al., 2008). Over the years, management of SAM has been undertaken in inpatient facilities in hospitals and Nutrition Rehabilitation Centres (NRCs) attached to health facilities (Ghana Health Service, 2010). It is against this background that the Ghana Health Service (GHS) adopted the CMAM approaches to facilitate the management of SAM beyond inpatient care. The approach is rooted in the public health principles of expanded coverage and access, timeliness and appropriate care (Ghana Health Service, 2010).

CMAM was introduced to the northern parts of Ghana in 2010 and still works towards the improvement of nutrition in children under 5 years. Despite the efforts of CMAM in battling malnutrition for six years now by improving access and coverage to treatment, malnutrition still rises steadily. There is a trend of continued high prevalence of severe stunting, wasting, and under-weight forms of malnutrition in the Northern Region (Ghana Statistical Service, 2004; WFP and VAM Food Security Analysis, 2012; GSS et al., 2015).

The poor performance of CMAM in the Northern Region may be due to constraints within the programme in terms of poor planning, insufficient funds and poor implementation, amongst others. It may also be due to barriers the community or beneficiaries face in accessing the programme, such as the affordability of the programme, and the level of community involvement in the programme amongst others. Therefore, the study seeks to assess the reasons behind the poor performance of CMAM in curbing the prevalence of malnutrition in the district.

As a result of malnutrition, these children have weaker immune systems and are thus more susceptible to infections and illnesses, especially malaria (UNICEF, 2013b). The educational attainment of these children is also appreciably jeopardized. Child stunting impacts brain development and impair motor skills. These effects in terms of delayed motor and cognitive development are largely irreversible. Stunted children also become less educated adults, thus making malnutrition a long-term and intergenerational problem (Galler and Barret, 2001; UNICEF, 2006).

Neglecting the issue of malnutrition is tantamount to disregarding the vicious cycle of poor health, lower learning capacity, decreased physical activity and lower work performance or productivity that is locked in malnutrition. This cycle not only threatens health and survival, but also has the capacity to erode the foundation of economic growth, people‟s strength and energy, and adversely tamper with initiative, creative and analytical capacity (Horton et al., 2009). The study therefore seeks to assess the challenges to accessing and implementing CMAM in the Tolon District.

1.3 Research Questions
The aforementioned raise the following questions:

1.      What is the level of community participation in CMAM in the Tolon District?
2.      What are the challenges to accessing CMAM in the Tolon District?
3.      What are the challenges to implementing CMAM in the Tolon district?
4.      How do beneficiaries think their access to CMAM can be improved?

1.4 Main Research Objective
·      To investigate the level of participation, and assess the challenges to access and implementation of CMAM in the Tolon District.

1.4.1 Specific Research Objectives
1.      To investigate the level of community participation in CMAM in the Tolon District
2.      To assess the challenges to accessing CMAM in the Tolon District
3.      To assess the challenges to implementation of CMAM in the Tolon District
4.      To investigate beneficiaries‟ perspective on how access to CMAM can be improved

1.5 Justification
According to Black et al., (2008), malnutrition is a serious problem because it causes the deaths of 3.5 million children under 5 years old per year in the world. Malnutrition is responsible for majority of child deaths in the world, especially so in sub-Saharan Africa (SSA). In early childhood, sufficient and nutritious food intake is vital to ensure a strong immune system, healthy growth, neurological and cognitive development, and proper organ formation and function. To think critically, learn new skills and contribute to their communities, a well-nourished population is needed. A well-nourished population also ensures economic growth and human development. Child malnutrition contributes to poverty through impeding individuals‟ ability to lead productive lives and also impairs cognitive development and function (Black et al., 2008).

CMAM is a new intervention which aids in controlling and curing malnutrition and which is being scaled up by organizations such as UNICEF, WHO, and the Ghana Health Service. It is necessary to carry out this study to understand the reasons behind the poor performance of CMAM in eradicating malnutrition in the District. It will also inform government, policy makers and necessary organizations on the challenges to accessibility and implementation of CMAM in the District, as well as what can be done to improve involvement in the upscale of CMAM. This will aid in management and policy making decisions in effective battling of malnutrition in the Tolon District.

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Item Type: Ghanaian Topic  |  Size: 90 pages  |  Chapters: 1-5
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