Coverage Assessment for Community-Based Management of Acute Malnutrition In Rural and Urban Ghana: A Comparative Cross-Sectional Study
Authors: Apenkwa Joana , Amponsah Samuel Kofi , Sam Newton K. , Osei-Antwi Reuben , Nakua Emmanuel , Edusei Anthony K. , Otupiri Easmon 
Published: February 2022

Abstract
Background: Ghana for years has implemented the Community-based Management of Acute Malnutrition (CMAM) to reduce malnutrition in children. However, the prevalence of malnutrition remains high. This study aimed to determine CMAM coverage levels in the Ahafo Ano South (AAS), a rural district and Kumasi Subin sub-metropolis (KSSM), an urban district. Methods: The study was a cross-sectional comparative study with a mixed-methods approach. In all, 497 mothers/caregivers and children under-five were surveyed using a quantitative approach while qualitative methods were used to study 25 service providers and 40 mothers/ caregivers who did not participate in the quantitative survey. Four types of coverage indicators were assessed: point coverage (defined as the number of Severe Acute Malnutrition cases [SAM] in treatment divided by total number of Severe Acute Malnutrition cases in the study district), geographical coverage (defined as total number of health facilities delivering treatment for SAM divided by total number of healthcare facilities in the study district), treatment coverage (defined as children with SAM receiving therapeutic care divided by total number of SAM children in the study district) and programme coverage (defined as number of SAM cases in the CMAM programme ÷ Number of SAM cases that should be in the programme). The qualitative approach was used to support the assessment of the coverage indicators. Data were analyzed using STATA version 14, and Atlas.ti, version 7.5 for the quantitative and qualitative data respectively.Results: Geographically, only 6% of the facilities in the urban communities were participating in the CMAM programme as against 29% of rural district facilities. The districts had point coverage of 41% and 10% for the urban and rural districts respectively. The urban setting recorded a SAM prevalence of 52% as against 36% in the rural setting. The proportion of SAM children enrolled in CMAM was higher in KSSM as compared to AAS; 41% and 33% respectively. In both districts, the most likely factors to attract mothers/caregivers to utilize the CMAM services were: ‘free services’ and ‘a cured child.’ The qualitative approach showed that coverage improvement in both districts is hampered by distance, transportation cost, lack of trained personnel in the communities for community mobilization home visits and insufficient feeds. Conclusion: To improve CMAM coverage, there is the need to train health workers to embark on aggressive health education strategies to encourage mothers/caregivers of malnourished children to utilize CMAM while ensuring that services reach those who need them. Trial registration: This study is approved and registered with The Kwame Nkrumah University of Science and Technology Committee on Human Research, Ethics and Publications (CHRPE/AP/314/15). Participants were made to sign/thumb print to approve of their consent or otherwise to the study. Only participants who consented were involved in this study.