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Peter R. Lamptey
Department of Community Health, University of Ghana Medical
School, Accra, Ghana
Cecilia Florencio
Department of Nutrition, University of the Philippines,
Quezon City, Philippines
Beatriz Picar
Community Intervention Programmes, Nutrition Center of the
Philippines, Manila, Philippines
INTRODUCTION - BACKGROUND OF THE STUDY
The Republic of the Philippines is an archipelago of 7,107 islands stretching about 1,760 km along the southeastern rim of Asia. Eleven of the islands account for 94 per cent of the total land area and population. The country is divided into 12 regions with a total population of 42 million (1975 estimate); the per capita GNP is US$340 (1).
Seventeen per cent of the population is under five years old and 3.5 per cent is over 65 years of age. The crude birth rate is 28.2 per 1,000, the crude death rate is 6.4 per 1,000, and the rate of natural increase is 2.2 (1). The infant mortality rate is 58.7 per 1,000 live births, and the 1-to-4-year-old mortality rate is estimated to be 9.3 per 1,000 (1).
TABLE 1. Results from Operation Timbang (OPT) by Regions,
July 1976
| Region | Percentage distribution by nutritional status | |||
| normal | first degree | second degree | third degree | |
| I. Ilocos | 22.0 | 47.0 | 25.3 | 5.7 |
| II. Cagayan | 23.3 | 47.4 | 23.7 | 5.6 |
| III. Central Luzon | 20.5 | 47.2 | 25.6 | 6.7 |
| IV. Southern Luzon | 22.5 | 46.9 | 24.3 | 4.9 |
| V. Bicol | 22.5 | 46.9 | 24.6 | 6.0 |
| VI. Western Visayas | 16.6 | 44.4 | 30.7 | 8.3 |
| VII. Central Visayas | 24.1 | 48.9 | 22.2 | 4.8 |
| VIII. Eastern Visayas | 17.9 | 45.8 | 28.4 | 7.9 |
| IX. Western Mindanao | 24.0 | 47.1 | 23.4 | 5.5 |
| X. Northern Mindanao | 24.9 | 46.9 | 23.0 | 5.0 |
| XI. Southern Mindanao | 26.3 | 48.8 | 21.1 | 3.8 |
| XII. Central Mindanao | 25.0 | 47.3 | 23.3 | 4.4 |
| Philippines | 22.1 | 47.3 | 24.8 | 5.8 |
Source: National Nutrition Council in co ordination with the National Economic Development Authority (NEDA).
TABLE 2. Comparison of
Nutriwards and Nutrihuts
| Nutriward | Nutrihut | |
| Facility | Part of a paediatric ward or ward of a hospital | One-room structure of nips and bamboo |
| Number of beds or huts | 5 - 20 | 3 - 5* |
| Affiliation | Provincial or regional hospital | Health centre or emergency hospital |
| Staff | Physician, nutrionist, nurses, and care-taker | Nurse or midwife, care-takers |
| Lodging facilities | For mother or care-taker only | For mother or care-taker and some siblings |
| Admission criteria | 3rd- or 2nd-degree PEM with complications** | 3rd- or 2nd-degree PEM with complications** |
| Discharge criteria | Substantial weight gain | Substantial weight gain |
| Follow-up | Yes | Yes |
| Community support | Minimal | Community provides additional huts |
| Other services | Nutrition education, education in sanitation and personal hygiene, family planning | Nutrition education, education in sanitation and personal hygiene, family planning |
* A nutrivillage usually has 10
to 15 units.
** Cases complications are first admitted to a paediatric ward
and returned to the nutriward or nutriward or nutrihut after
these have been treated.
In 1976 the Philippine Nutrition Program (PNP) conducted a nation-wide weight survey known as Operation Timbang (OPT) covering over 4 million children of preschool age. This survey showed that 24.8 per cent of preschoolers had second-degree malnutrition and 5.8 per cent had third-degree malnutrition according to the Gomez classification. There are, therefore, an estimated 2.9 million moderately and severely malnourished pre-schoolers in the Phillippines (2). Table 1 shows a breakdown of OPT results by regions.
The PNP has initiated several
programmes and projects aimed at improving the nutritional status
of the under nourished segments of the population. There are
about 24 government and private agencies and organizations
undertaking one or more nutrition-related activities in the
country. The elements of the PNP are:
- food assistance,
- nutrition information and education,
- health protection, and
- food production.
Health protection includes the treatment and rehabilitation of malnourished children and the education of the mothers of these children.
Clinical cases of protein-energy malnutrition (PEM) have traditionally been treated in hospitals. Recently, more non-hospital rehabilitation units have been established. In the Philippines, the hospital-based unit is known as a nutriward, and the rural health centre-affiliated unit as a nutrihut. A group of 10 to 15 nutrihuts is called a nutrivillage. Table 2 compares the two types of nutrition rehabilitation institutions. Seventy-eight nutriwards and 250 nutrihuts have been built to date (3).
LITERATURE REVIEW
The concept of nutrition rehabilitation was originally formulated by Bengoa (4), and has been developed and modified in various countries. Nutrition rehabilitation has been carried out in day-care centres, special rehabilitation centres, paediatric wards, special wards attached to hospitals, or in rural huts (5-7). The major objectives of these institutions are to rehabilitate the malnourished child and to provide nutrition information and education for the mother in an effort to prevent a relapse in the treated child and malnutrition in other siblings. In practice, however, these centres tend to concentrate mainly on the nutritional rehabilitation of the child. Jelliffe has recommended that nutrition rehabilitation centres be mother-oriented rather than child-oriented (8).
Hospital-based nutrition rehabilitation programmes generally are expensive and limited in the number of people they affect, and they tend to emphasize the curative and clinical rather than the preventive and rehabilitative aspects of PEM. They also have higher mortality rates because of an increase in cross-infections. On the other hand, non-hospital centres are less expensive and appear to have a much more permanent effect than does the medical rehabilitation of a child in hospital. Cook (9) has reviewed the literature to provide data on the prognosis of malnourished children treated under hospital and non-hospital conditions. He concluded that non-hospital treatment of PEM cases provides an estimated cure of 30 to 60 per cent compared to 0 to 10 per cent as a result of hospitalization.
In spite of the fact that a large number of nutrition rehabilitation units have been established in many parts of the world, there have been few systematic attempts to evaluate them (10).
The nutritional status of the child at discharge is a measure of the medical and dietary management of the malnourished child during confinement, and the performance of the child on follow-up is a measure of the success of the rehabilitation process and an indirect evaluation of the nutrition education of the mother. In this study, I will compare the hospital-based nutriwards to the health centre-based nutrihuts during confinement and follow-up.
HYPOTHESIS (NULL)
The main hypothesis to be tested
is that there is no difference in growth, as measured by changes
in the weight-for-age by sex of the standard, in malnourished
children rehabilitated in nutriwards and nutrihuts between:
- admission and discharge,
- discharge and follow-up,
- admission and follow-up.
The alternate hypotheses are:
- there is significant weight gain during confinement in a
nutriward or nutrihut;
- there is significant weight gain after discharge from a
nutriward or nutrihut.
METHODS
Region X was selected for the study on the basis of the following criteria: (i) adequacy of records, (ii) presence of nutrihuts that were functioning for the whole of 1978, (iii) security reasons, and (iv) accessibility of institutions. Five of the eight nutriwards in the region were selected because of their accessibility, the time constraint of the study, and for security reasons. Of the 24 nutrihuts in the region, 11 were functioning in 1978, and seven of these were included in the study (the other four were on islands off the mainland). The only nutrivillage in the region was included in the sample.
All cases of PEM admitted between 1 January and 31 December 1978 to the selected institutions were studied. From the records of ail admissions, the following information was collected for 397 cases in 13 institutions: age of child on admission, sex, diagnosis, duration of stay, outcome of stay (discharged rehabilitated, died, or self-discharged), and weight on admission and discharge. Complications on and during admission were to have been included; however, children with PEM and medical complications were invariably first admitted to the paediatric ward and then transferred to the nutriward or nutrihut after these complications had been treated.
Cases from four nutriwards and four nutrihuts were selected for follow-up (one of the nutrihuts turned out to be non-operational). An attempt to select cases randomly to be followed up proved futile, since a large proportion of the cases were difficult to find.
All 325 cases from the seven institutions were therefore included in this sample. Of these, 47 per cent (152) were followed up in their homes. The following information was collected for these cases:
- the child's age at interview (verified from birth certificates), weight at follow-up (measured to the nearest 0.1 kg using a local beam [OPT] scale), status (alive or dead), interval between discharge and follow-up, and any re-admissions since discharge:
- the mother's age, parity, number of living children, level of education, occupation, and monthly income;
- the father's level of education, occupation, and monthly income;
- younger and older siblings' age, weight, sex, and any previous admissions with PEM.
The major reasons we were unable to trace some of the discharged patients were: the patients' addressee were not always adequately recorded; some families had moved or were temporarily away; some patients were too far away, and others were inaccessible. Patients in the rural areas were generally easier to locate (even with the name of the village as the only address) than those in the municipalities and urban slums. Sixty-nine per cent of the nutrihut patients and 40 per cent of the nutriward patients were followed up.
The data were analysed using Minitab package programmes at the Computer Center at the University of the Philippines at Quezon City and BMDP programmes at the Massachusetts Institute of Technology, Cambridge. The percentage weight-for-age by sex was calculated using the fiftieth percentile of the WHO reference standards (11). Analysis of variance and the paired t test were used to test the equality of group means between continuous variables, and the chi square was used for discrete variables.
DEFINITION OF TERMS
The following terms were defined for the purpose of this study:
- rehabilitated children,
those discharged by the rehabilitation institution;
- self-discharged children, those who absconded or were
discharged against medical advice;
- relapse rate, the proportion of children whose
weight-for age at follow-up had fallen to the level of, or below,
their admission weight-for-age of the standard.
LIMITATIONS OF THE STUDY
During the course of the study a number of limitations were encountered. No attempt was made to validate or verify the records of the cases examined except for the ages of children, which we verified from birth certificates during follow-up in the homes; age records kept by the institutions were sometimes found to be faulty. Records in the nutriwards were generally satisfactory, but those in some of the nutrihuts were inadequate.
Another limitation was in the selection of the cases that were followed up. Random sampling of cases could not be done because some children's addresses were inadequate. This sub-sample may therefore not be entirely representative of cases admitted to the rehabilitation institutions.
Accurate comparison of the anthropometric data collected was made difficult because different scales were used by different staff with varying levels of training and weighing was carried out under differing conditions. There was also no regular standardization of weighing scales. The local scale used for follow-up had an estimated accuracy of only 0.1 to 0.2 kg (1).
The rather simplistic definition of the term "rehabilitated" was used because of the difficulty in ensuring standardized criteria for children discharged from all institutions. Children who were discharged by the care-taker or doctor in charge were regarded as rehabilitated as opposed to cases who left without the approval of the institution; such cases were labelled "self-discharged." The underlying assumption in the definition is that doctors or care-takers only discharged adequately rehabilitated patients.
The interpretations of the results of this study apply to the institutions in Region X and are not necessarily representative of such institutions throughout the country.
RESULTS
Distribution of Rehabilitation Institutions
The distribution of nutriwards and nutrihuts is shown in table 3. Five nutriwards in Agusan del Norte, Surigao del Norte, and Misamis Oriental were studied. The nutrihuts included the nutrivillage at Prosperidad (Agusan del Sur) and seven nutrihuts in Surigao del Norte. Most of the nutrihuts were associated with health centres, but some were affiliated with an emergency hospital or even a provincial hospital (table 4).
Distribution of Cases
Sixty-five per cent (258) of the cases were from nutriwards and the rest (139) were from nutrihuts (19.4 per cent) and the nutrivillage (15.6 per cent). Sixty-eight per cent of the nutriward patients came from the provincial capitals, with only 24 per cent from the rest of the province (8 per cent were from outside the province). In contrast, 12 per cent of the nutrihut patients came from the capital, and 88 per cent from the rest of the province.
TABLE 3. Provincial
Distribution of Nutriwards, Nutrihuts, and Nutrivillage - Region
X
| Province | Nutriwards | Nutrihuts | Nutrivillage |
| Agusan del Norte | 2 | 0 | 0 |
| Agusan del Sur | 0 | 0 | 1 |
| Bukidnon | 1 | 0 | 0 |
| Camiguin | 1 | 0 | 0 |
| Misamis Occidental | 1 | 0 | 0 |
| Misamis Oriental | 2 | 0 | 0 |
| Surigao del Norte | 1 | 22 | 0 |
| Totals | 8 | 22 | 1 |
TABLE 4. Capacity and Associated Institution of Nutrihuts
| Nutrihut | Number of huts | Type of associated institution |
| 1. Prosperidad* | 12 | Provincial hospital |
| 2. Placer | 4 | Emergency hospital |
| 3. Guigaguit | 3 | Health centre |
| 4. Mainit | 5 | Health centre |
| 5. Sison | 3 | Health centre |
| 6. Bacuag | 3 | Health centre |
| 7. Marimono | 3 | Health centre |
| 8. Tagana-an | 3 | Health centre |
| Total huts | 36 |
* Nutrivillage
TABLE 5. Distribution of Ages
of Children on Admission, by Diagnosis
| Diagnosis | Percentages by age ranges(in months) | |||
| 0 - 12 | 13 - 24 | Over 24 | Total | |
| Marasmus | 34.3 | 32.1 | 33.4 | 100 |
| Kwashiorkor | 21.3 | 27.9 | 50.8 | 100 |
| Marasmic-Kwashiorkor | 16.3 | 25.6 | 58.2 | 100 |
| Total | 30.0 | 30.5 | 39.5 | 100 |
N = 397
Characteristics of the Cases on Admission
The mean age of the children on admission was 28.6 months (SD 22.6), with 60 per cent below 24 months and 12 per cent over 60 months. Most of the cases (72.5 per cent) were diagnosed as marasmus and the rest as Kwashiorkor (16.4 per cent) and marasmic-kwashiorkor (11.1 per cent). Table 5 shows the distribution of age on admission by diagnosis. Most of the children with marasmus (66.4 per cent) were less than 24 months old, whereas most of the Kwashiorkor and marasmic-kwashiorkor cases were over 24 months old. There were no differences between patients of nutriwards or nutrihuts in terms of age on admission, severity, or type of malnutrition exhibited.
TABLE 6. Duration of Stay by
Diagnosis
| Diagnosis | Percentage by duration of stay(in weeks) | |||
| 0 - 5 | 6 - 12 | 13 or more | Total | |
| Marasmus | 63.8 | 25.3 | 10.9 | 100 |
| Kwashiorkor | 80.7 | 14.5 | 4.8 | 100 |
| Marasmic-Kwashiorkor | 67.4 | 27.9 | 4.7 | 100 |
| Total | 67.1 | 23.8 | 9.1 | 100 |
N = 397
TABLE 7. Changes in
Weight-for-Age during Confinement and at Follow-up
| Percentage of cases with change in weight-for-age relative to WHO reference standards | ||||
| Loss | No change | Gain | Total | |
| Between admission and discharge | 11.5 | 12.2 | 76.3 | 100 |
| Between discharge and follow-up | 33.3 | 7.4 | 59.3 | 100 |
| Between admission and follow-up | 20.5 | 2.7 | 76.8 | 100 |
The mean duration of stay was 5.5 weeks (SD 6.2). Patients in the
nutriwards stayed for an average of 3.8 weeks, and in the
nutrihuts for 8.6 weeks (p <0.001). Marasmic children, on
average, stayed for a longer period than did those with
Kwashiorkor (p = 0.05). Table 6 shows the distribution of
duration of stay by diagnosis. The mean weight-for-age on
admission was 57.1 per cent, and on discharge, 64.3 per cent,
representing a mean weight gain of 7.2 per cent of the standard
weight (p < 0.001), with 23 per cent of cases (table 7) having
lost or registered no weight gain during confinement. The mean
rate of weight gain during confinement was 200 grams per week.
There was no significant difference between patients in
nutriwards (231 grams per week) and nutrihuts (162 grams per
week) - p = 0.11. Third-degree cases (less than 60 per cent of
expected weight-for-age) on average stayed longer and gained more
weight (p = 0.03) than second-degree cases weighing 60 to 74 per
cent of expected weight-for age on admission. However, the rate
of weight gain was not significantly different between the two
groups. There were no significant differences in the rate of
weight gain and the absolute weight increase during confinement
between cases of kwashiorkor and marasmus. There was fair
correlation between weight gain during confinement and duration
of confinement (r= 0.36).
Twenty-two per cent of the children were discharged against medical advice from nutriwards, 7.4 per cent from nutrihuts, and 35.1 per cent from the nutrivillage.
The overall mortality rate during confinement was 6.8 percent, and the specific case-fatality rates were: marasmus, 5.1 per cent; kwashiorkor, 9.7 per cent; and marasmickwashiorkor, 16.3 per cent. Overall mortality rate was highest in nutriwards - 8.4 per cent - followed by 6.7 per cent in the nutrivillage and 2.7 per cent in nutrihuts.
Characteristics of the Cases Followed Up
Table 8 compares the characteristics of cases that were followed up and those which were not. The only significant differences were in the duration of confinement (p = 0.008) and admission weight-for-age (p = 0.03).
The mean interval between discharge and follow-up was 8.7 months (SD 4.8). Table 9 shows the distribution of cases by interval between discharge and follow-up. The mean weight-for-age at follow-up was 68.3 per cent (SD 10.3), with a mean weight gain of 4.0 percentage points (p < 0.001) between discharge and follow-up. However, 33 per cent (table 7) of the children had fallen below their discharge percentage weights of the standard. The rest (67 per cent) had either maintained their discharge percentage or gained. The mean rate of weight gain after discharge was 190 grams per month, compared to 200 grams per week while in confinement.
TABLE 8. Comparison of Cases
Followed Up with Those Not Followed Up
| Variable | Not followed up | Followed up | P value |
| Mean age at admission (months) | 29.3 | 27.4 | 0.41 |
| Mean weight-for-age at admission* | 60.0 | 57.1 | 0.03 |
| Mean weight-for-age at discharge* | 65.3 | 64.3 | 0.46 |
| Mean duration of confinement (weeks) | 4.6 | 6.9 | 0.0008 |
| Mean gain in weight-for-age during confinement (% points) | 5.4 | 7.0 | 0.10 |
| Rate of weight gain (grams per week) | 209 | 200 | 0.81 |
| N | 245 | 152 |
* Percentage of WHO reference standards (11).
TABLE 9. Relation of Weight
Gain to Interval between Discharge and Follow-up
| Interval(months) | Number of cases | Percentage of cases | Mean weight- for-age-at admission* | Mean weight- for-age at follow-up* | Mean gain in weight-for-age(% points) |
| 6 or less | 55 | 36.4 | 61.2 | 65.0 | 3.8 |
| 7 - 12 | 56 | 37.1 | 65.2 | 70.2 | 5.0 |
| 13 - 18 | 40 | 26.5 | 66.9 | 69.3 | 2.4 |
| Total | 151 | 100.0 | 64.3 | 68.3 | 4.0 |
Mean interval between discharge
and follow-up was 8.7 months.
* Percentage of WHO reference standards (11).
TABLE 10. Comparison of
Patients of Nutriwards and Nutrihuts (Cases followed up in their
homes)
| Variable | Nutriward | Nutrihut | P value |
| Mean age at admission (months) | 23.7 | 32.5 | 0.01 |
| Mean weight-for-age at admission* | 55.7 | 59.0 | 0.09 |
| Mean weight-for-age at discharge* | 62.9 | 66.1 | 0.12 |
| Mean duration of confinement (weeks) | 4.7 | 9.8 | 0.0001 |
| Mean weight-for-age at follow-up* | 68.9 | 67.8 | 0.57 |
| Mean interval between discharge and follow-up (months) | 8.9 | 8.4 | 0.49 |
| Self-discharge rate (%) | 21.6 | 23.4 | |
| Mortality during confinement (%) | 8.4 | 4.3 | |
| Mortality after discharge (%) | 20.0 | 1.7 | |
| N | 88 | 64 |
* Percentage of WHO reference standards.
Children admitted with third-degree PEM gained an average of 4.5 percentage points after discharge, while those with second-degree malnutrition gained only 1.8 percentage points. Cases admitted with third-degree PEM therefore gained an average of 13.8 points between admission and follow-up, and those with second-degree PEM gained 6.3 percentage points. Ironically, seven children who were admitted with first-degree malnutrition gained 4.1 points during confinement but lost 8.7 percentage points after discharge (a net loss of 4.6 percentage points between admission and follow-up). The mean weight gain between admission and follow-up was 9.7 per cent (p < 0.001) of the standard weight. The relapse rate at follow-up was 23 per cent.
The overall mortality rate after discharge was 12.4 per cent, with patients of nutriwards having a mortality rate twelve times that of patients treated in nutrihuts (table 10). The mortality rate of nutriward patients who absconded was 31.6 per cent, compared to 16.7 per cent of cases discharged rehabilitated. There were no significant differences in mortality after discharge between cases of marasmus and kwashiorkor. Children discharged with weight-for-age below 60 per cent had a discharge mortality rate 3.5 times higher than those with weight above 60 per cent (p = 0.01). In contrast, there was no such association between the weight-for-age on admission and discharge mortality. There was a fair degree of correlation between weight gain after discharge and admission weight-for-age (r = 0.4), and between weight gain after discharge and discharge weight-for-age (r = 0.5).
Siblings
The mean percentage weight-for-age of the immediate younger and older siblings of the rehabilitated child was 84 per cent and 77 per cent respectively. Seventeen per cent of the younger siblings and 14 per cent of the older ones had been admitted with PEM in the past.
Parents
The mean age of the mothers was 31.3 years (SD 7.2). The average parity was 5.7 (SD 3.2), and average number of living children was 4.9. Forty-six per cent of these mothers had had at least six years of education. The mothers of children admitted to nutriwards were better educated (p = 0.01), had lower parity (p = 0.02), and had fewer living children (p = 0.0û3) than the mothers of nutrihut patients. The average monthly income of the fathers was 213 pesos (US$30), and of working mothers, 163 pesos (US$23). There was no association between follow-up weight-for-age and parents' income, education of mother, or number of living children.