Influence of a quality improvement intervention on rehabilitation outcomes of children (6-24 months) with acute malnutrition: a retrospective study in rural Angola.

BACKGROUND: Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. METHODS: Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6-24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. RESULTS: The intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil. CONCLUSIONS: The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.

Nutritional education during rehabilitation of children 6-24 months with acute malnutrition, under unavailability of therapeutic/supplementary foods: a retrospective study in rural Angola.

BACKGROUND: Dietary counseling can play an important role in managing child malnutrition but is often inadequate or absent. Moreover, little emphasis is given to the usefulness of local available foods in the rehabilitation of malnourished children. This study aimed to evaluate the adherence and effectiveness of nutritional education during rehabilitation of children (6-24 months) with acute malnutrition, in a setting of unavailability of therapeutic/supplementary foods. METHODS: Retrospective observational study on the adherence to dietary counseling and the impact on growth in children 6-24 months who were referred for acute malnutrition at the Catholic Mission Hospital of Chiulo (Angola) from August 2018 to January 2019. Main outcome measures were change in dietary habits and growth gain. RESULTS: Sixty-four out of 120 children returned at first follow-up visit (default rate 47%). A change in dietary habits was reported in 32/64 (50%) children. Changing dietary habits was associated with an improved change in weight gain (MD 9.3 g/kg/day, 95%CI 4.2 to 14.3; p = 0.0005) and in weight/height ratio (MD 1.1 SD, 95%CI 0.7 to 1.4; p < 0.0001). CONCLUSIONS: A change in dietary habits after discharge was noted in only half of the patients who returned at first follow up visit, but it provided some advantages in term of weight gain and weight/height ratio. Further studies are needed to identify children at risk of low adherence to follow-up visits and low compliance to the nutritional recommendations, in order to increase the effectiveness of rehabilitation programs.

Digital radiology to improve the quality of care in countries with limited resources: a feasibility study from Angola.

OBJECTIVE: Sub-standard quality in X-ray image acquisition and interpretation is common in low-resource countries, and can ultimately result in higher patient morbidity and mortality. This study aimed at evaluating; 1) feasibility of implementing a digital X-ray device in a second level hospital in Angola; 2) quality of digital X-ray images, when digital radiology was in the hands of local technicians; 3) feasibility of digital teleradiology and its potential impact on case management. METHODS: We developed and tested at the Hospital Divina Providencia (HDP) in Luanda, Angola, a digital X-ray device and a telemedicine network to acquire and print digital X-ray images and send them as DICOM files for remote consultation. RESULTS: 20,564 digital X-ray images were made at HDP from November 2010 to December 2012, with no major technical problems and no need for on-site supervision. Digital radiology largely improved the number of X-ray images of good and very good quality (100% of images with digital radiology, compared to 15% of screen-film images, p<0.0001). Teleradiology using digital images was used in 7.6% of paediatric cases, and provided, in these cases, an important contribution to case management. CONCLUSIONS: The implementation of a digital X-ray device is feasible in low resource settings with significant improvement in quality of X-ray images compared to standard screen film radiology.

Effectiveness of a prevention of mother-to-child HIV transmission programme in an urban hospital in Angola.

BACKGROUND: Antiretroviral therapy is effective in reducing rates of mother-to child transmission of HIV to low levels in resource-limited contexts but the applicability and efficacy of these programs in the field are scarcely known. In order to explore such issues, we performed a descriptive study on retrospective data from hospital records of HIV-infected pregnant women who accessed in 2007-2010 the Luanda Municipal Hospital service for prevention of mother-to-child transmission (PMTCT). The main outcome measure was infant survival and HIV transmission. Our aim was to evaluate PMTCT programme in a local hospital setting in Africa. RESULTS: Data for 104 pregnancies and 107 infants were analysed. Sixty-eight women (65.4%) had a first visit before or during pregnancy and received combination antiretroviral treatment (ART) in pregnancy. The remaining 36 women (34.6%) presented after delivery and received no ART during pregnancy. Across a median cohort follow-up time of 73 weeks, mortality among women with and without ART in pregnancy was 4.4% and 16.7%, respectively (death hazard ratio: 0.30, 95% CI 0.07-1.20, p = 0.089). The estimated rates of HIV transmission or death in the infants over a median follow up time of 74 weeks were 8.5% with maternal ART during pregnancy and 38.9% without maternal ART during pregnancy. Following adjustment for use of oral zidovudine in the newborn and exposure to maternal milk, no ART in pregnancy remained associated with a 5-fold higher infant risk of HIV transmission or death (adjusted odds ratio: 5.13, 95% CI: 1.31-20.15, p = 0.019). CONCLUSIONS: Among the women and infants adhering to the PMTCT programme, HIV transmission and mortality were low. However, many women presented too late for PMTCT, and about 20% of infants did not complete follow up. This suggests the need of targeted interventions that maintain the access of mothers and infants to prevention and care services for HIV.