Muzigaba Moise, Van Wyk Brian, Puoane Thandi
Faculty of Community and Health Sciences, School of Public Health, University of the Western Cape.
Afr J Prim Health Care Fam Med. 2018 Jan 30;10(1):e1-e8. doi: 10.4102/phcfm.v10i1.1547.
Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas.
To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa.
An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis.
Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians.
Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings.
尽管世界卫生组织（WHO）关于严重营养不良管理的指南在南非广泛实施，但在一些医院，尤其是农村地区，仍观察到5岁以下儿童的治疗效果不佳。
探讨南非两家地区医院医护人员对导致严重急性营养不良治疗效果不佳的上游和近端因素的看法。
进行了一项探索性描述性定性研究。使用基于在同一家医院进行的流行病学研究结果制定的访谈指导问题，与33名医院工作人员（高级临床和管理人员以及初级临床工作人员）进行了四次焦点小组讨论。使用框架分析法对定性数据进行分析。
大多数受访者认为，与入院时早期和高病死率相关的危重病与一系列因素有关，包括偏爱传统医学而非常规护理、家庭层面严重忽视儿童、在最初治疗点对严重营养不良的误诊、缺乏处理复杂病情的专业技能、医院病床短缺以及在患者未完全康复前的出院政策。大多数人认为WHO指南有效且相对易于实施，但对于病情危急入院的严重急性营养不良病例，这些指南并没有太大作用。病例管理不善与轮转临床医生培训缺乏连续性、治疗资源偶尔短缺、正常工作时间后人员配备不足以及一些临床医生无法直接控制的组织和全系统挑战有关。
本研究结果表明，在研究环境中，小儿严重急性营养不良的有效管理受到在卫生系统和社区不同层面表现出来的多种因素的影响。鼓励进行验证性研究以证实这些发现。
