Mambulu-Chikankheni Faith Nankasa
Department of Curriculum and Teaching Studies (Human Ecology), Nalikule College of Education, Lilongwe, Malawi.
Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
PLOS Glob Public Health. 2023 Aug 18;3(8):e0002277. doi: 10.1371/journal.pgph.0002277. eCollection 2023.
Severe acute malnutrition (SAM) is associated with 30.9% of South Africa's audited under-five children deaths regardless of available guidelines to reduce SAM at each level of a three tyre referral system. Existing research has explored and offered solutions for SAM guidelines implementation at each referral system level, but their connectedness in continuation of care is under-explored. Therefore, I examined implementation of SAM guidelines and factors influencing implementation within subdistrict referral systems. An explanatory qualitative case study design was used. The study was conducted in two subdistricts involving two district hospitals; three community health centres, four clinics, and two emergency service stations. Between February to July 2016 and 2018, data were collected using 39 in-depth interviews with clinical, emergency service and administrative personnel; 40 reviews of records of children younger than five years; appraisals of nine facilities involved in referrals and observations. Thematic content analysis was used to analyse all data except records which were aggregated to elicit whether required SAM guidelines' steps were administered per case reviewed. Record reviews revealed SAM diagnosis discrepancies demonstrated by incomplete anthropometric assessments; non-compliance to SAM management guidelines was noted through skipping some critical steps including therapeutic feeding at clinic level. Record reviews further revealed variations of referral mechanisms across subdistricts, contradictory documentation within records, and restricted continuation of care. Interviews, observations and facility appraisals revealed that factors influencing these practices included inadequate clinical skills; inconsistent supervision and monitoring; unavailability of subdistrict specific referral policies and operational structures; and suboptimal national policies on therapeutic food. SAM diagnosis, management, and referrals within subdistrict health systems need to be strengthened to curb preventable child deaths. Implementation of SAM guidelines needs to be accompanied by job aids and supervision with standardised tools; subdistrict-specific referral policies and suboptimal national policies to ensure availability and accessibility of therapeutic foods.
严重急性营养不良（SAM）与南非经审计的五岁以下儿童死亡病例中的30.9%相关，尽管在三级转诊系统的每个层面都有减少SAM的现有指南。现有研究已探讨并提出了在每个转诊系统层面实施SAM指南的解决方案，但对其在持续护理中的关联性研究不足。因此，我研究了分区转诊系统内SAM指南的实施情况以及影响实施的因素。采用了解释性定性案例研究设计。该研究在两个分区进行，涉及两家区级医院、三个社区卫生中心、四个诊所和两个急救站。在2016年2月至7月以及2018年期间，通过对临床、急救服务和行政人员进行39次深入访谈、对40份五岁以下儿童记录进行审查、对参与转诊的九个机构进行评估以及观察等方式收集数据。除记录外，采用主题内容分析法对所有数据进行分析，记录被汇总以确定在每份审查病例中是否执行了所需的SAM指南步骤。记录审查显示，由于人体测量评估不完整，存在SAM诊断差异；在诊所层面，发现跳过包括治疗性喂养在内的一些关键步骤，不符合SAM管理指南。记录审查还揭示了各分区转诊机制的差异、记录中的矛盾文件以及护理连续性受限。访谈、观察和机构评估表明，影响这些做法的因素包括临床技能不足、监督和监测不一致、缺乏分区特定的转诊政策和运营结构以及国家治疗性食品政策欠佳。分区卫生系统内的SAM诊断、管理和转诊需要加强，以遏制可预防的儿童死亡。实施SAM指南需要辅以工作辅助工具和使用标准化工具进行监督；制定分区特定的转诊政策和优化国家政策，以确保治疗性食品的可获得性和可及性。
