Barriers, facilitators and effect of using locally formulated therapeutic foods on treatment success among children admitted with Severe Acute Malnutrition in Uganda : a mixed method study

Abstract

Background: Severe Acute Malnutrition (SAM), defined as severe wasting or nutritional oedema, remains a major cause of child mortality in Uganda. Frequent stockouts of commercial therapeutic foods (CTFs) in inpatient therapeutic care (ITC) facilities have necessitated reliance on locally formulated therapeutic foods (LTFs). However, evidence on their effect on treatment success, as well as the barriers and facilitators influencing their use, remains limited. Objective: To investigate the association between treating SAM with LTFs versus CTFs on SAM in Uganda. The barriers and facilitators influencing the use of LTFs by health workers were also explored. Methods: A retrospective cohort study was conducted by extracting data from the integrated nutria tion register (INR) of children who received LTFs and CTFs during the stockout of CTFs (January to September 2023) and no stockout of CTFs (October 2023 to June 2024), respectively, across 22 health facilities in Uganda. The association between receiving LTFs versus CTFs and treatment success was tested by modified Poisson regression analysis using STATA 15 to report adjusted risk ratios (aRR) at 95% confidence interval (CI). In addition, in-depth interviews (IDIs) were conducted with 22 purposively selected ITC in-charges to explore facilitators and barriers to the use of LTFs. Data generated from IDI was analyzed using themes. Results: Of the 340 children, 48.5% received LTFs during the stockout periods. Treatment success rates were 80.3% and 71.3% for commercial and locally formulated therapies, respectively, with no statistically significant differences observed (p=0.08). Multivariable analysis identified nutrition status on admission, SAM with oedema (+) aRR1.14 (95%Cl:1.02-1.27, P=0.02), and Weight-for-Height Z-score above -2 standard deviations [aRR 1.13, 95%CI: 1.06-1.10, P<0.001] were likely to achieve treatment success. In contrast, defaulters from ITC were less likely to achieve treatment success, aRR 0.28 (95%CI:0.15-0.55, P<0.001). Qualitative findings showed that affordability, accessibility, cultural acceptability, perceived effectiveness, and caregiver empowerment facilitated LTF use, while labor-intensive preparation, spoilage risks, and added financial burden on facilities were key barriers. Conclusion: Use of locally LTFs during the stockout period of CTFs has an equal potential as CTFs to treat SAM among children in Uganda. Health facility administrators need to support and address facilitators and barriers perceived by ITC health workers to effectively use LTFs, respectively