A critical appraisal of guidelines used for management of severe acute malnutrition in South Africa's referral system.

BACKGROUND: Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents (global and national) that guide the country's SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country's lower level and referral healthcare system under-explored. METHODS: To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines (global and national) and conducted complementary expert interviews (n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country's referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents' development process. RESULTS: None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines' formulation processes to be unclear and stakeholder involvement in the process to be minimal. CONCLUSION: In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines.

Factors influencing the implementation of severe acute malnutrition guidelines within the healthcare referral systems of rural subdistricts in North West Province, South Africa.

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.