International Journal for Quality in Health Care 16:31-40 (2004)
© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Improving the hospital management of malnourished children by participatory research
1 School of Public Health, University of the Western Cape, Bellville,
2 Medical Research Council, Tygerberg,
4 Initiative for Sub-District Support, Health Systems Trust, Cape Town, South Africa,
3 London School of Hygiene and Tropical Medicine, London, UK
Objective. To improve the clinical management of severely malnourished children in rural hospitals in South Africa.
Study design. A pre- and post-intervention descriptive study in three stages: assessment of the clinical management of severely malnourished children, planning and implementing an action plan to improve quality of care, and monitoring and evaluating targeted activities. A participatory approach was used to involve district and hospital nutrition teams in all stages of the research.
Setting. Two rural first-referral level hospitals (Mary Theresa and Sipetu) in Mount Frere District, Eastern Cape Province.
Main measures. A retrospective record review of all admissions for severe malnutrition to obtain patient characteristics and case fatality rates, a detailed review of randomly selected cases to illustrate general case management, structured observations in the paediatric wards to assess adequacy of resources for care of malnourished children, and in-depth interviews and focus group discussions with nursing and medical staff to identify barriers to improved quality of care.
Results. Before the study, case fatality rates were 50% and 28% in Mary Theresa and Sipetu hospitals, respectively. Information from case studies, observations, interviews, and focus group discussions revealed many inadequacies in knowledge, resources, and practices. The hospital nutrition team developed and implemented an action plan to improve the quality of care and developed tools for monitoring its implementation and evaluating its impact. In the 12-month period immediately after implementation, case fatality rates fell by 
25% in both hospitals.
Conclusion. Participatory research led to the formation of a hospital nutrition team, which identified shortcomings in the clinical management of severely malnourished children and took action to improve quality of care. These actions were associated with a reduction in case fatality rates.
Keywords: case fatality rates, in-patient treatment, malnourished children, malnutrition, participatory research, quality of care
Accepted for publication July 31, 2003.
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