Implication of Cholera Exposure on Incidence, Time to Recovery, and Continuum of Care for Severe Acute Malnutrition among Children in Ethiopia: A Mixed Methods Study

Abstract

This research highlights the relationship between infection and malnutrition, specifically examining how cholera exposure contributes to the development of severe acute malnutrition (SAM) in children under fifteen years. It reveals how cholera impacts both the incidence and recovery of SAM, emphasizing the need for continuous nutritional healthcare during outbreaks to prevent severe acute malnutrition. Addressing a gap in previous studies, this research project includes older children, providing a more comprehensive view of SAM. Key determinants such as cholera exposure, inadequate meal frequency and diversity, poor sanitation, economic hardship, and limited healthcare access are analyzed to show how these factors intensify cholera’s effect on malnutrition. Findings underscore the importance of integrated health strategies that address infections and malnutrition. This dissertation offers evidence-based insights for developing targeted interventions, especially in Ethiopia, to reduce SAM incidence, improve the continuum of nutritional care during and after emergencies, and accelerate recovery among cholera-exposed children. Here are the summarized details. The first chapter of this dissertation serves as a comprehensive introduction to acute malnutrition and the burden of Cholera, emphasizing their interconnection. It begins by defining cholera and SAM, exploring common drivers and consequences of both conditions. The chapter presents an overview of cholera and SAM's global, regional, and national status, highlighting their prevalence and public health impacts. It further addresses the determinants contributing to SAM, providing insights into socio-economic, nutritional, and health-related factors. Additionally, the chapter outlines strategies and approaches implemented to mitigate the burden of malnutrition and promote healthier outcomes while also identifying gaps and areas that previous studies may have overlooked regarding the interaction between SAM and cholera. The second chapter outlines the general methods employed in this study. It provides an overview of the study design, period, setting, and population. In addition, the chapter describes the inclusion and exclusion criteria used to select participants, the sampling strategy, and the sample size calculations to ensure statistical power. Furthermore, it elaborates on the data collection methods and procedures, the specific tools or instruments used to collect data, data management procedures, 1 including data entry, storage, and quality control measures, information on statistical tests, software packages, or analytical techniques employed to examine the study variables and assess the outcomes of interest. Additionally, it covers the study variables of interest, explaining the key measures or indicators used to assess the outcomes under investigation. Ethical considerations are emphasized in this chapter, highlighting the steps taken to ensure the protection of participants' rights and well-being. In the third chapter, the systematic review of the global magnitude of SAM among children with cholera is presented. This systematic review and meta-analysis focused on children under fifteen, utilizing a comprehensive search of databases including PubMed, Scopus, CINAHL, and Cochrane Library. Two independent reviewers performed full-text evaluations and critical appraisals using the JBI tool, resolving disagreements through discussion. From an initial 8,731 articles published between 1912 and 2023, 38 were reviewed, leading to the inclusion of six studies. The findings indicated that acute malnutrition among children with cholera ranged from 8% to 41%, with a pooled SAM prevalence of 21.18% and no significant heterogeneity among studies. While all studies focused on children under five, only one examined those under nine, highlighting a research gap for older children. The review identified the absence of malnutrition screening for children aged five to fourteen, and underscored driving factors of malnutrition, including diarrheal diseases, poor sanitation, inadequate feeding practices, and low family income, alongside unsafe water and poor hygiene exacerbating cholera spread. The findings underline the need for updated treatment guidelines and comprehensive food and nutrition policies to effectively prevent malnutrition and improve health outcomes for vulnerable children, especially those affected by cholera. In the fourth chapter, the qualitative study on mothers’ experiences within the continuum of care for children suffering from acute malnutrition and cholera is presented. Using a phenomenological approach, the study engaged ten participants to explore their lived experiences. Findings indicate that factors such as poverty, poor feeding practices, supply interruptions, and the exclusion of children aged five and older from malnutrition screenings significantly hinder early detection and treatment of malnutrition. Additionally, mothers and caregivers reported that a lack of support for 2 them from health facilities during their stay at the health facility for their children's treatment often forced them to discontinue SAM care, with complications. This lapse adversely affects the continuum of care and exacerbates malnutrition prevention and treatment efforts. To address these critical gaps, the study recommends strengthening emergency nutrition programs within the healthcare system and revising food and nutrition policy to better incorporate emergency nutrition strategies, with a strong emphasis on all children under fifteen years old. In chapter five, the incidence of SAM among children exposed and unexposed to cholera, involving 550 participants, is presented. The overall incidence of SAM was found to be 40.7%, with 25.8% in the cholera-unexposed group and 55.6% in the cholera-exposed group. Key findings indicate that cholera-exposed children had 1.56 times higher probability of risk [Adjusted Hazard Ratio (AHR): 1.56, CI: 1.15-2.12] to develop SAM compared to their unexposed counterparts. Additionally, children under five years old had 1.67 times higher probability of risk [AHR: 1.67, 95% CI: 1.24-2.25] to experience SAM than those aged five to fourteen. The study also revealed that children whose parents lacked nutritional knowledge had 1.65 times higher probability of risk [AHR: 1.65, 95% CI: 1.25-2.18] to suffer from SAM than those whose parents were well informed. Furthermore, children with poor dietary diversity practices had almost twice high probability of risk [AHR: 1.83, 95% CI: 1.23-2.70] to develop SAM compared to those with good practices. The risk of SAM was more than doubled [AHR: 2.33, 95% CI: 1.52-3.56] among children who did not complete oral cholera vaccination (OCV) compared to those who did. Additionally, children from households that did not treat water safely had 1.61 times higher probability [AHR: 1.61, 95% CI: 1.21-2.14] to be at risk of SAM. The study identifies several determinants that significantly increase the risk of SAM, including cholera exposure, inadequate dietary diversity, younger age, inadequate water treatment practices, insufficient parental nutritional knowledge, and incomplete cholera vaccination. Collaborative efforts among policymakers, partners, and healthcare providers are essential to address these challenges. Strategies should focus on enhancing nutritional education for parents, improving dietary diversity, ensuring access to clean water, and increasing vaccination coverage. By fostering collaboration and implementing targeted interventions, the incidence of SAM in children can be effectively 3 reduced, ultimately improving health outcomes and resilience in vulnerable children affected by cholera. Chapter Six addresses the recovery time from SAM and its determinants among children exposed and unexposed to cholera. This study utilized a prospective cohort design, tracking the time to recovery for 224 children with SAM. The findings revealed that nearly 80% of participants recovered, with a recovery rate of 40 per 1,000 person-week observations and a median recovery time of 21 days [Inter Quartile Range: 14-28 days]. Key determinants influencing recovery included food insecurity, meal frequency, and parental attitudes toward children's dietary habits. Specifically, children from food-insecure families had a 39% lower probability of achieving rapid recovery than those from food-secure households. Children who consumed three or more meals daily had a 1.61 times higher probability of a faster rate of recovery than those who ate less frequently. Moreover, children from families with positive attitudes towards nutrition had a 2.23 times lower probability of rapid recovery from acute malnutrition. The study also identified cholera exposure as a significant factor, with cholera-exposed children having a 54% lower rate of recovery from SAM than their unexposed counterparts. To improve recovery times and outcomes for children suffering from SAM, especially in the context of cholera exposure, the study recommends developing interventions that address food insecurity, meal frequency, and nutritional attitudes. Chapter seven presents the general discussion and implications of the findings for children affected with cholera, conclusions, and recommendations for further research.