Community Management of Acute Malnutrition (CMAM) is a community-based integrated approach to management of acute malnutrition. Retrospective and on the spot (present) assessment of performance of community management of acute malnutrition program was carried out in two Outpatient Therapeutic Programme (OTP) centers at Wagini and Batsari communities of Batsari local government area of Katsina state with the aim of assessing the performance of the programme in the locality. Access, coverage and other performance indicators of CMAM programme, biochemical and haematological parameters of 435 children with Severe Acute Malnutrition (SAM) and relapse rate among SAM children were among the indices assessed using standard methods. For the retrospective study, data already available at the OTP centers were collected and used while for the present study, severe acute malnourished children admitted into the OTP were monitored for 8 week period within which their anthropometric and biochemical data were collected. All the indices measured for the assessment of coverage: Point (95.66%), treatment (87.70%) and period (96.26%) were significantly (p < 0.05) higher than the 50% (rural coverage) and 70% urban coverage stipulated by the SPHERE standard and there was no significant difference (p > 0.05) in the coverage data between the retrospective study and present study. The performance indices: cure rate (93.19%), death rate (5.65%), default rate (13.27%) and non-recovery rate (3%) are classified as good performance when compared with SPHERE standard. There were also no significant differences (p > 0.05) among the performance indices in the retrospective and present study. There was also a notable steady improvement in the growth performance and recovery indices (MidUpper Arm Circumference Weight forheight and Oedema) among the SAM children admitted to the OTP Centers for the 8 week period. Similarly, significant (p < 0.05) improvements were recorded in the biochemical and haematological indices determined (Packedcellvolume, Haemoglobin concentrations, Serum albumin and glucose concentrations) in both study groups at the point of discharge and the average relapse rates determined for SAM children at both OTP centers was 10%. From these results, the CMAM programme in Batsari LGA of Katsina State is running well in alleviating the SAM burden in the coverage area.

1.1 Malnutrition
Malnutrition generally refers both to under nutrition and over nutrition. Many factors can cause malnutrition, most of which relate to poor diet or severe and repeated infections, particularly in underprivilegedpopulations. Inadequate diet and disease, in turn, are closely linked to the general standard of living, the environmental conditions and whether a population is able to meet its basic needs such as food, housing and health care (Elia, 2000).

Malnutrition is thus a health outcome as well as a risk factor for disease, exacerbated nutrition and can also increase the risk both of morbidity and mortality (Stratonet al.,2003). Although it is rarely the direct cause of death (except in extreme situations, such as famine), child malnutrition was associated with 54% of 10.8 million children deaths in developing countries in 2001 (WHO, 2001).

Nutritional status is clearly compromised by diseases with an environmental component, such as those carried by insect or protozoan vectors, or those caused by an environment deficient in micronutrients. The effects of adverse environmental conditions on nutritional status are even more pervasive. Environmental contamination e.g. destruction of ecosystems, loss of biodiversity, climate change, and effects of globalization have contributed to an increasing number of health hazards (Johns and eyzagurre, 2000). and all affect nutritional status. Overpopulation, too, resulting in a breakdown of the ecological balance in which the population may exceed the carrying capacity of the environment. This then undermines food production, which leads to inadequate food intake and/or the consumption of non-nutritious food, and thus to malnutrition. (Habitch, et al.,1974).

On the other hand, malnutrition itself can have far-reaching impacts on the environment, and can induce a cycle leading to additional health problems and deprivation. For example, malnutrition can create and perpetuate poverty, which triggers a cycle that hampers economic and social development, and contributes to unsustainable resource use and environmental degradation (WEHAB, 2002).

On prevalence of malnutrition in Nigeria, the nutritional status of children in Nigeria has gradually improved but slowly over the last decade. The proportion of children who are stunted declined from 41 percent in 2008 to 37 percent in 2013. However, the extent of wasting has worsened, indicating a more recent nutritional deficiency among children in the country. The northwest still remain at the top with regards to malnutrition, followed by the Northeast. Among the states in the Northwest, Kebbi state ranked the highest in prevalence rate of malnutrition (NDHS, 2013).

Severe acute malnutrition(SAM) is a condition characterised by bilateral pitting oedema, mid-upper arm circumference MUAC of <11 .5cm="" 2008="" 3z="" a="" acutely="" and="" another="" are="" arm="" as="" attained="" band="" based="" be="" between="" boards="" by="" charts="" child="" children.="" children="" circumference="" colour-coded="" compared="" considered="" crisis="" determine="" determined="" developed="" during="" expected="" falls="" five="" for="" found="" growth.="" has="" have="" health="" healthy="" height.="" height="" her="" his="" if="" information="" international="" is="" known="" malnourished.="" measurement="" measurements.="" measurements="" measuring="" mid-upper="" month="" muac="" nbsp="" normal="" nourished.="" nutritional="" of="" often="" on="" or="" organization="" range="" rather="" require="" s="" scales="" score="" simple="" since="" situations.="" six="" span="" standards="" status="" studies="" than="" that="" the="" they="" this="" thousands="" to="" used="" useful="" weighed="" weighing="" weight="" weights="" well="" wfh="" whether="" within="" world="" years="">age, a MUAC measurement of less 12.5cm but greater than or equal to 11.5cm indicate that a child is suffering from moderate acute malnutrition. If the MUAC measurement is under 11.5cm, however, the under-five child‟s life may be in danger as he or she is suffering from severe acute malnutrition, all children under five years old having MUAC less than 12.5cm i.e. moderate and severe malnutrition are refered to as having global acute malnutrition (GAM), (WHO, 2006)A third way of diagnosing acute malnutrition is by testing for the presence of oedema. Oedema affects a child‟s appearance giving him or her a puffy, swollen look in either lower limits and feet or face. It can be detected by small pits or indentations remaining in the child‟s lower ankles or feet, after pressing lightly with the thumbs. The presence of oedema in both feet and lower legs is always considered a sign of severe acute malnutrition (WHO, 2006).

Severe acute malnutrition has traditionally been managed in inpatient facilities. However, in several large scale humanitarian crises in the 1990‟s, it became evident that the traditional therapeutic feeding center (TFC) model of inpatient care was unable to provide an effective response. For example, during the farming in south Sudan in 1998, only small proportion of acutely malnourished people were treated in NGO-run TFC. Access was a considerable obstacle, and coverage was very limited. People who did reach the TFC were congregated together, exposing them to the risk of cross infection and additional security risk. Furthermore, the opportunity costs to the family of having to stay in the center were high. Caregivers, usually mothers, had to stay in center for several weeks leaving their other children and family members at home and rendering them unable to engage in daily activities.(CTC Manual, 2012) Community based management of acute malnutrition (CMAM) Programme was designed to address these limitations, its underlying aims are to maximize coverage and access, in practice, this means prioritizing providing care for the majority of the acutely malnourished children, This can only be done by providing treatment in people‟s homes. Community mobilization techniques are used to engage the affected population and maximize coverage. Where ever possible, the programme builds on local capacity and existing structures and systems, helping to equip communities to deal with future period of vulnerability (USAID, 1999).

The major challenge of management of SAM in Katsina state the funding. The other barriers are integration and ensuring the sustainability in the supply of Ready to use Therapeutic Foods (RUTF) Interestingly, the CMAM programme which is curative in nature has also not been well integrated with preventive care that focuses on working CMAM with Infant and young child feeding program, ( IYCF) and other protective interventions like cash transfer and income generation project to address the basic causes of malnutrition at house hold level (Katsina State Health Service Management Board,2015).

1.2 Statement of Problem
Silent emergency is already happening in the northern part of Nigeria regarding increase in number of children suffering from severe acute malnutrition (NDHS, 2013). There have also been difficulties especially among the rural dwellers in identifying the right food to eat at the right time. Globally, malnutrition as a public health problem worsens illness and weaken the immune system and about 50% of death of under-five is as a result of malnutrition.Twenty million children worldwide suffer acute malnutrition and one million die annually from severe acute malnutrition (NDHS, 2013).

1.3 Justification
CMAM started in 2009 in two Northern states of Kebbi and Gombe, with 30 Health Facilities that carried out CMAM services but later there was a rapid scale up to 633 in 2014 nationally. In all these facilities, regular assessment of their performance with regards to the CMAM has not been effectively done. Knowing what is responsible for the performance of the CMAM Programme will go a long way in helping to consolidate and expand the programme to other parts of Katsina State. This research is important to examine whether therapeutic diet consumed by children and management practices to reduce the burden of severe acute malnutrition is effective. Also pertinent is to observe whether there are nutritional changes in children with severe acute malnutrition under the Outpatient Therapeutic Programme (OTPs) selected. Similarly, knowledge of any correlation between therapeutic diet consumed and severe acute malnutrition management will enrich available data on CMAM in Nigeria.

1.4       Aim and Objectives
The aim of the study is to assess the performance of Community Management of Acute Malnutrition programme in the management of severe acute malnutrition in Batsari Local Government Area of Katsina State.

1.4.1    Specific Objectives
1. To determine the access and coverage of Community Management of Acute Malnutrition (CMAM)programme in Batsari Local Government Area of Katsina State.

2. To determine retrospective and present performance indicators of the CMAM programme in Batsari Local Government Area of Katsina State.

3. To determine growth recovery performance and biochemical indicators of group of severely malnourished (SAM) children admitted to the Outpatient Therapeutic Programme in (OTP) the month of October 2014.

4. To determine the rate of relapse among the admitted SAM children eight weeks post discharge from OTP.

1.5       Hypothesis (Null)
The  CMAM  programme  in  Batsari  Local  Government  Area  is  not  effective  in reducing the level of severe acute malnutrition in the area.

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