A mixed methods feasibility study of the Kusamala Program at a nutritional rehabilitation unit in Malawi

Allison I Daniel, Meta van den Heuvel, Melissa Gladstone, Mike Bwanali, Wieger Voskuijl, Celine Bourdon, Isabel Potani, Sara Fernandes, Jenala Njirammadzi, Robert H J Bandsma, Allison I Daniel, Meta van den Heuvel, Melissa Gladstone, Mike Bwanali, Wieger Voskuijl, Celine Bourdon, Isabel Potani, Sara Fernandes, Jenala Njirammadzi, Robert H J Bandsma

Abstract

Background: Children admitted to nutritional rehabilitation units (NRUs) for inpatient treatment of severe acute malnutrition (SAM) are at high risk of poor developmental and nutritional outcomes. The Kusamala Program is an interactive hospital-based counseling program for primary caregivers of children with SAM that integrates three modules: nutrition and feeding; water, sanitation, and hygiene (WASH); and psychosocial stimulation. This mixed methods feasibility study aimed to evaluate the implementation of the Kusamala Program in an NRU setting and developmental outcomes in children with SAM 6 months after inpatient treatment.

Methods: An internal pilot trial including the first 30 children and their primary caregivers enrolled to a cluster-randomized controlled trial of the Kusamala Program was performed. Barriers and enablers were identified in a qualitative study with a focus group discussion (FGD) and in-depth interviews (IDIs) with 12 hospital staff members, including five NRU nurses who deliver the Kusamala Program.

Results: Results demonstrated high participant engagement (100%) and adherence (87%) of primary caregivers to the Kusamala Program. Potential barriers to implementation identified through the qualitative study were caregivers' perceived value of the program, prioritization of other ward activities, and shortages of staff. On the other hand, enablers to implementation were engaging other staff members, motivation and work ethic, and refresher training.

Conclusions: This mixed methods study demonstrates the feasibility of implementing the Kusamala Program in a real NRU setting. The full cluster-randomized controlled trial will be completed to evaluate the effectiveness of the Kusamala Program.

Trial registration: ClinicalTrials.gov, NCT03072433. Registered on 7 March 2017-retrospectively registered.

Keywords: Child development; Integrated interventions; Nutrition; Psychosocial stimulation; Severe acute malnutrition; WASH.

Conflict of interest statement

Ethics approval for this study was obtained from the College of Medicine Research and Ethics Committee (P.04/16/1930) in Blantyre, Malawi, and the Research Ethics Board (1000053578) at the Hospital for Sick Children in Toronto, Canada. Consent was requested of all participants in the study; primary caregivers were asked to provide consent on behalf of themselves and their children.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Modified version of CONSORT 2010 flow diagram of participants in the internal pilot trial
Fig. 2
Fig. 2
Boxplot of MDAT z-scores for gross motor, fine motor, language, and social domains in children with SAM at discharge and follow-up. Pooled MDAT z-scores for children in intervention and comparison arms. Excluding children with known neurodisabilities. MDAT Malawi Developmental Assessment Tool, SAM severe acute malnutrition

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