Improving defaulter rates in Ambulatory Feeding

Programs

Ellen van der Velden (Investigator)

Saskia van der Kam

June 2008

Background High defaulter rates in ATFP

Default rates MSF-OCA 2006

19%

14%67%

< 10%

10%-15%

>15%

n=22 programs

Objectives

• Identify key factors modifiable by MSF

that would decrease defaulting in

ambulatory feeding programs (ATFP)

Methods

• Analysis of available quantitative program data

• Analysis of qualitative information from interviews and observation

(all under program field conditions)

MethodsCountry Regular

program report

Patient data

analysis

Beneficiary interviews

Observation & staff

interviews

Quantitative Qualitative

South Sudan + + 9 +Darfur + + 6 +Burma + + +Ivory Coast + - +

Ethiopia + - -• Some defaulter interviews in South Sudan Plus

Results Quantitative methods

• Defaulters do not differ from non-defaulters in terms of

• Age• Gender• Weight on admission• Height on admission

• Irregular attendance not associated with defaulting

• Defaulting occurred regardless of last recorded W/H status

Timing of defaulting

Weeks in program before being cured or defaulting Feina Darfur 2006

0

5

10

15

20

25

30

0 2 4 6 8 10 12 14 16 18 20weeks

% c

ure

d/d

efa

ult Defaulters

Cured

%

Defaulting after 1st and 2nd visit

% of all defaulters

Darfur 45 %

South Sudan 55 %

Burma 62 %

OutreachCountry Outreach Default

rates

Darfur (Feina)

1 person who could contact everybody

< 10%

Myanmar 11 local ORWs, 3 per site

< 10%

Ivory coast Standard visit 1st week

< 10%

South Sudan

Absent 30-50 %

Ethiopia (Abdurraffi)

Volunteers for health education; 1 day/week,

> 20 %

Behaviour analysed from three perspectives

1. Personal perception of likely consequences

(Behaviour belief)

2. Social norms (Normative belief)

3. Personal perception of ability to act (Control belief)

Qualitative methods

Result Personal and Social Beliefs

• Caretakers perceived their child was sick, not malnourished

• Caretakers lacked an understanding of the purpose of the nutritional program

• Social beliefs/norms have a limited impact on defaulting rates

Results Control Beliefs

Security

• Insecurity related to traveling was identified as a barrier

• Influence of insecurity not measurable

Costs

• Direct costs (money) seen as low

• Indirect costs are considerable(e.g. long waiting time, travel time, opportunity costs)

Distance as barrier to completion of treatment

Distance in "donkey hours" Feina Darfur 2006

0%

20%

40%

60%

80%

100%

Defaulters Cured

>8 hours

4-8 hours

<4 hours

% Cured/defaulter

Limitations of study

• Conducted under field conditions while providing technical support to programs

• Limited access to beneficiary perspectives

Conclusion

Many obstacles identified are modifiable

• Mother’s understanding of program aims

• Geographical access

• Patient waiting times and clinic opening

• Food stock ruptures

Recommendations

• Improve MSF- caretaker communication (personal and community level)

• Outreach indispensable for retention and tracing

• Decentralization to increase access

• Efficient patient flow

Acknowledgements

• Field teams and beneficiary participants

in the 5 programs

• Royal Tropical Institute (KIT),

Amsterdam