There is limited evidence on facilitators and barriers to treatment approaches for malnutrition in infants <6 months. WHO recommends an inpatient approach [5], but in practice both inpatient and outpatient care are being applied, as seen in the two clinics where this study was conducted. Treatment choices vary, depending on the perspectives of health care workers and mothers of malnourished infants. This qualitative study, using both IDIs and FGDs, revealed some of those perspectives. The key factors access, quality of care, and community engagement framed 9 facilitators and barriers presented by health workers and mothers. In Fig. 3 some of the main facilitators for each treatment approach are listed.
Key factor 1: Access: distance
Distance was frequently mentioned as an access barrier. This is understandable given that health services offering care for malnourished young infants are scarce in Senegal. Because treatment is generally intensive and long, there is a risk for loss to follow-up when health services are too far from home. A rooming-in service is one solution, but if women can choose they would rather have an outpatient service close to their home.
Key factor 1: Access: cost
Cost for care of a malnourished infant is another barrier to care in Senegal. Most mothers seek care at a clinic because they think their child needs a milk supplement and infant formulas sold at the shops become too expensive. The lack of an affordable milk supplement at primary care level forms a current access barrier. In Senegal, the milk supplement F-100 is provided for free by the government but exclusively in inpatient services. Nevertheless, care in hospitals is generally perceived by patients to be more expensive. Keru Yakaar is one of the few clinics that offer infant formula for a low price.
Key factor 1: Access: perception of healthcare
The lack of trust in a health service appeared to be of great importance and other barriers seemed easier to overcome. Building a reputation of trust often starts at entry level. Guerrero found that lack of good reception or earlier experience of rejection at a health service was one of the main barriers to access to outpatient nutrition programs [23]. Inpatient care was perceived by mothers in this study to be only for children who were seriously ill. When inpatient care is the only available option, mothers wait until the situation is serious before seeking care [24]. Outpatient services as first point of care, with possible referral, could remove this barrier. When \provided at a primary care level, a nutrition program could be embedded in the existing health care, as are prenatal care and vaccinations, thus generating trust.
Key factor 2: Quality of care: re-lactation technique
An effective re-lactation technique is essential for giving good quality care. The SS method is the recommended inpatient re-lactation method for malnourished infants in the WHO protocol [5]. Field reports show good results, but say that this method requires intensive guidance of both mothers and medical staff [25, 26]. The cup and spoon-feeding method has the advantage that it can be used in the outpatient setting. This current study shows good feedback on this method. It is mentioned as an option in the new WHO guideline on breastfeeding support in health facilities [27]. In refeeding the infants, mother-child attachment is an important aspect, which is often underestimated in nutritional care [8]. The MAMI project concluded that children and young infants receiving stimulation during treatment for severe malnutrition have significantly superior intellectual development than the control group [8]. Rooming in is a WHO recommended solution [27]. Home-based treatment would be naturally beneficial regarding mother-child attachment.
Key factor 2: Quality of care: medical care
Good quality medical care in an outpatient nutrition program for young infants is thought to be ensured, if treatment protocols are followed and an appropriate referral system is in place. Following the WHO guideline [5], acute malnutrition among infants <6 months can be treated in an outpatient setting, but infants with complications or underlying illnesses need to be referred to hospitals. A few health workers in this study suggested that nutritional treatment could happen in an outpatient program, while simultaneously treating some underlying illnesses during paediatric appointments at a hospital.
Key factor 2: Quality of care: health education
Educating mothers on nutrition and health is a facilitator for good quality care, but often insufficient due to time constraints and a lack of home visits. Especially breastfeeding counselling appeared to be a huge need that could often not be met in a clinical setting. This weakness is reflected in the health workers’ concern about the infants still needing milk supplement at discharge. Breastfeeding counselling can be done in outpatient settings [28]. Aidam et al. studied a healthy population and found a 100% increase in the rate of exclusive breastfeeding by a combination of educational sessions during regular prenatal visits and home visits [29]. This could be applied and evaluated in the Senegalese context.
Key factor 3: Community engagement: health seeking behaviour
In Senegal, family members like the grandmother are involved in recognizing the problem of malnutrition, and influence the type of care to be sought. Religious leaders have a strong influence on health seeking behaviour, especially concerning new-borns. Fathers or other male household members are the decision makers for the financial aspect of care. Because outpatient care is physically closer to those key community figures, seeking care will be facilitated by communication and interaction with them. Guerrero describes success of a community based nutrition program as partly defined by how well it is known in the community [23]. Good treatment outcomes will result in a clinic’s good reputation, which could lead others to seek help earlier.
Key factor 3: Community engagement: peer influence
The negative influence of peers was mentioned more frequently in this study than the possible benefits. Misconceptions about breastfeeding, for example, were said to influence a mother and child in treatment; inpatient care would allow the mother to be more detached from the community to learn new feeding practices. Ashworth underscores this by showing that hospital based care showed less risk of relapse [30]. On the other hand, outpatient care has the potential of favouring community involvement when mothers become initiators of change in their community by sharing new feeding practices with neighbours and peers. A study in Bangladesh showed the importance of peer support in breastfeeding counselling. A series of counselling visits to healthy mothers with their new-born babies dramatically improved exclusive breastfeeding rates [31]. Active involvement of the community is currently lacking in both clinics, which is a weakness.
Key factor 3: Community engagement: domestic tasks, employment
Domestic tasks form a main barrier for either treatment model. Mothers frequently refused treatment or defaulted because of domestic tasks. Often it was not the mother making this decision, but the husband or the community as a whole. Outpatient care was most preferred by mothers allowing them to continue their domestic, or paid work while going for regular visits. Health workers were concerned that mothers would easily be distracted by domestic work when treating them at home. Inpatient treatment allows the mother to fully focus on the treatment without interruptions.
Limitations
This study has several limitations. Only mothers were interviewed, while male care givers perspectives could further enrich the findings. Another limitation was the fact that the translator during FGD was a nurse at the nutrition department She knew some of the participating mothers in this clinic, which could have influenced participants’ responses, not wanting to hurt the feelings of their treating nurse. On the other hand, our experience with patients had shown us that questions from strangers raised suspicions. As a health worker herself, the translator was able to create an atmosphere of trust and free exchange. The women were invited to speak out of their experiences, tell their stories, and not criticise the health care as such. Her role was seen more as facilitating rather than a limiting because of the nature of the discussion. Applicability is an issue, this is a study conducted in urban Senegal, while health workers and mothers opinions might be different in rural setting or in neighbouring countries. The 9 factors are very general though and can probably still be transformed into recommendations in a different setting.