Ethiopian Children Missing Out on Nutrition Treatment Program: A Simple Spatial Survey Method (S3M II)

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In Ethiopia, SAM continues to affect a substantial proportion of children under five, with persistent challenges in treatment coverage, especially in rural areas. We aimed to evaluate the coverage of SAM treatment and the availability of nutrition interventions using the Simple Spatial Survey Method (S3M II) while identifying the challenges encountered in accessing treatment. Methods The study was conducted in rural Ethiopia, specifically in Babile Woreda, East Hararghe Zone, using a community-based S3M II design. Data collection took place in October 2023 A total of 5,023 households were surveyed, reaching 7,203 children aged 6–59 months from Vv enumeration area. The survey assessed socio-demographic characteristics, nutritional status, challenges in treatment, and participation in nutrition programs. The data was analyzed using STATA Software. Results The prevalence of SAM among the surveyed children was about 1.6%, with 67% not enrolled in any nutritional program. Additionally, about 4.6% of children were identified with Moderate Acute Malnutrition (MAM), with 78% not receiving any program interventions. Key barriers to program participation included lack of awareness about available treatments (25%) and stock unavailability (22.4%)at health facilities. During the assessment, we found few number of households (3.2%) having a health card provided by health facilities, and also a small percentage of children(2.7%) had their Mid-Upper Arm Circumference (MUAC) measured within the previous month from the month of assessment. Conclusions This study highlights significant gaps in the coverage of SAM treatment and the critical need for improved implementation of programs in Ethiopia. The findings also underscore the importance of monitoring the effectiveness of existing program interventions. Severe Acute Malnutrition (SAM) Nutritional status Ethiopia Treatment coverage Nutrition interventions Simple Spatial Survey Method (S3M II) Figures Figure 1 Figure 2 Figure 3 Figure 4 Background SAM is a significant public health challenge worldwide, particularly in developing countries [ 1 , 2 , 3 ]. SAM is a severe condition characterized by extreme wasting or weight loss due to prolonged inadequate nutrition [ 3 ]. In 2022, an estimated 45 million children under five suffered from wasting, a severe form of malnutrition, with the number of children experiencing severe wasting rising alarmingly in the 15 most affected countries due to global food and nutrition crises. The majority of these cases were reported in South Asia and sub-Saharan Africa. SAM significantly increases the risk of death, accounting for about one in five deaths in this age group [ 4 ]. Additionally, in 2022, Stunting affected an estimated 22.3% or 148.1 million children under 5 globally in 2022. Children with SAM are 11.6 times more likely to die than those not affected [ 5 ] . The main causes of SAM include poverty, inadequate access to safe drinking water, poor sanitation, inadequate breastfeeding practices, and insufficient food intake. Factors such as climate change, conflict, and displacement also significantly contribute to the prevalence of SAM [ 5 ]. SAM treatment is typically administered either in inpatient units or through outpatient therapeutic feeding programs (OTP), which are part of community-based management of acute malnutrition (CMAM) for children with uncomplicated SAM [ 6 ]. OTP services include the diagnosis and provision of ready-to-use therapeutic foods (RUTF) for two months, along with supplementation of medications like amoxicillin, folic acid, vitamin A, measles vaccination, and deworming. The Sustainable Development Goals (SDGs) and the World Health Assembly have set targets to reduce the proportion of children suffering from wasting to less than 5% by 2025 and less than 3% by 2030. However, the situation remains dire, as children with severe wasting are 11 times more likely to die from common childhood illnesses compared to well-nourished children [ 1 ]. The number of children suffering from wasting has risen significantly due to factors such as conflict, COVID-19, and climate change, all contributing to global food insecurity. Undernutrition is a major public health problem in Ethiopia, particularly among children. According to the UNICEF report released in February 2022, there has been a concerning surge in Severe Acute Malnutrition cases in regions affected by both drought and conflict. [ 4 ]. The recent national food and nutrition survey also revealed that in Ethiopia, 39% of children are stunted and 11% are wasted. The Oromia region has one of the highest stunting rates at 41% and wasting rates at 9% [ 7 ]. Babile woreda, situated within one of these impacted areas, is grappling with alarmingly high levels of Severe Acute Malnutrition and Moderate Acute Malnutrition among its children, a substantial proportion of whom are not receiving the necessary treatment. These rates are among the highest in the world, leading to severe long-term health and developmental consequences [ 8 , 9 ]. Several factors contribute to malnutrition in Ethiopia, including poverty, food insecurity, poor hygiene and sanitation, and limited access to healthcare and education. Natural disasters such as droughts and flooding further exacerbate food insecurity and malnutrition [ 10 ]. To address this issue, the Ethiopian government and its partners have implemented a variety of nutrition programs [ 11 ]. Selective-entry programs such as Community-based Management of Acute Malnutrition (CMAM) and Targeted Supplementary Feeding Programs (TSFP) target children who are already malnourished or at risk of malnutrition. CMAM focuses on identifying and treating SAM in children under five years old through community-based management, while TSFP provides supplementary feeding to moderately malnourished children. In addition, universal programs like the Expanded Program on Immunization (EPI), Growth Monitoring and Promotion (GMP), General Food Distribution (GFD), and blanket Supplementary Feeding Programs (SFP) aim to address malnutrition on a wider scale across Ethiopia. EPI provides vaccines to prevent childhood illnesses, GMP monitors the growth of children under five and promotes healthy nutrition practices, GFD provides food assistance to vulnerable households and blanket SFP targets entire populations in regions with high malnutrition rates [ 11 , 12 ]. This study aims to assess the coverage of SAM treatment and other direct nutrition interventions, identifying barriers and facilitators to coverage in the East Hararghe Zone, specifically in Babile Woreda. Methods and Materials Study Area The study was conducted in Babile Woreda in the East Hararghe zone. The Ethiopia Statistical Service Services provided PDF maps of the Babile district shown below. We followed two-step sampling procedures. Step 1: Door-to-door assessment of children 6-59 months old from 30 evenly spatially distributed primary sampling units (PSUs) Enumeration areas from Babile Woreda, East Hararghe were selected. Only households with children were included. Step 2: MUAC and bipedal edema to identify SAM children. Caregivers asked about their knowledge of the CMAM program. Caregivers asked about Vitamin-A supplementation, GMP, Iron-Folic Acid supplementation during their last or current pregnancy, and Infant and Young Child Feeding counseling. Study Design A community-based survey was conducted in October 2023 as a baseline study. The study design involved a two-stage evaluation approach. The first utilized a wide-area coverage assessment called the Simple Spatial Survey Method (S3M). This was conducted at baseline to identify geographic program units with high coverage of IMAM and related nutrition interventions and those with low coverage. S3M II is a valuable tool for assessing malnutrition in Ethiopia, a country that faces significant challenges in terms of nutrition. The S3M II method, developed by the World Health Organization (WHO) and UNICEF, offers a simple, cost-effective, and reliable way to collect data on malnutrition rates in different areas of the country[13]. The S3M II method involves taking anthropometric measurements of children under 5 years old in households of a given area. The data is then analyzed to determine the prevalence of malnutrition in that area. This information is crucial for planning and implementing effective nutrition programs, as it allows policymakers and health workers to identify areas with high levels of malnutrition and target interventions accordingly [13]. Several studies have shown that the S3M II method is effective in identifying areas with high rates of malnutrition. Recent studies conducted in South Sudan and Liberia are two specific instances that serve as examples of the S3M II method applied in least-developed countries. The study conducted in South Sudan found that the S3M II method was able to accurately identify areas with high rates of acute malnutrition and that these areas were associated with poor food security, poor access to health services, and a high burden of infectious diseases [14]. The study conducted in Liberia with a similar study method indicated that Program coverage such as IFA supplementation, IYCF counseling, and vitamin A supplementation have performed fairly well. Further, the majority of women and children targeted by these programs are knowledgeable about the program and are beneficiaries of the program. In Ethiopia, where resources for nutrition programs are limited, the S3M II method may be proven to be a valuable tool for prioritizing interventions and ensuring that resources are used effectively. Overall, the S3M II method is a simple yet powerful tool for addressing malnutrition in Ethiopia. By providing accurate data on malnutrition rates in different areas of the country, the method helps ensure that limited resources are used effectively and that nutrition programs are targeted where they are most needed. The second adopted the more targeted Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) investigations. Sampling techniques Data collection team members participated in a five-day training program, which included field-based piloting of the data collection process. Although the data collectors were professionals, refresher training sessions on MUAC measurement were conducted. Under-five children not included in the study were used for MUAC training and standardization. Feedback was provided to teams on their MUAC measurements, and corrective actions, including additional training, were implemented to ensure accurate and precise measurements. Seven teams, each consisting of two members, visited allocated households in the 30 PSUs of the study area. If a household had at least one child aged 6–59 months, the primary caregiver was asked to provide verbal assent for the child’s participation. The team explained the MUAC measurements, the purpose of the survey, and the approximate time required (10 minutes) to complete the survey. Upon receiving consent, MUAC measurements were taken for each child. Two supervisors oversaw the data collection teams to ensure adherence to protocols. During the survey, a systematically selected subset of every 10th household with children aged 6–23 months was invited to answer additional questions about specific interventions. These surveys took approximately 20–25 minutes, following the assent or consent process. Inclusion and exclusion criteria Eligible population groups of the survey were: 1) mothers having under-five children; and 2) children 6-59 months. The survey included population groups with children under the age of 5 residing in the study area who gave consent and participated in interviews. We excluded households without children under the age of five or with children older than 59 months or less than six months. Additionally, households that did not provide consent were excluded from the study. Data management and data analysis Data were collected using an electronic data entry system via the ODK application, running on the Android® operating system for mobile devices. The study instrument was pre-encoded into the electronic system and hosted on EPHI’s remote cloud server. Each data collection team was equipped with Android® devices configured to receive the electronic data form. Measurements and responses were recorded on mobile devices and transmitted to the server whenever a mobile or Wi-Fi signal was available. Appropriate data validation mechanisms were implemented in the field. Study supervisors conducted spot checks to ensure enumerators performed measurements correctly, administered the survey instrument appropriately, and entered data accurately. Updates and feedback were communicated to the study team to address and rectify any data collection issues promptly. The digital data form was designed to replicate the paper-based forms and sampling design described in the survey. Once data were cleaned and processed, analysis was conducted using Stata 16. Descriptive analyses were performed on the collected observations. An automatic reporting format, including figures and tables, was generated to summarize the findings. Result Socio-demographic characteristics The total number of households reached was 5023, with nine mothers refusing. The majority of mothers were in the age group of 20–29 (55%), with a significant percentage having only one child (61%). Antenatal care utilization for the first child was reported by 74% of the mothers. Only 3% reported that they have a health card for their children on hand. The number of children we approached for the study was 7203, with 54.1% of them falling within the age range of 6 months to 24 months, and an almost equal distribution between males (49.7%) and females (50.4%). Table 1: Sociodemographic characteristics of study participants Characteristics n % Mother’s Age N (5014) Don’t know 23 0.5 15-19 393 7.8 20-29 2746 55.0 30-39 1621 32.0 40-49 223 4.5 Age (7203) 6mo-24mo 3307 45.9 25mo-59mo 3895 54.1 Sex of children Male 3627 50.4 Female 3576 49.6 A significant portion (55.0%) indicate having had a health card for their babies but it is not currently available or has been lost. Additionally, a small number of participants (191) report having their MUAC measured within the last month. Table 2: Health-seeking behavior and awareness of study participants Category Frequency (n) Percentage (%) Have a health card (N=7203) Yes (and available) 229 3.2 Yes (but not available/lost) 3958 55.0 No (never had one) 2980 41.4 Don't know/Not sure 36 0.5 Aware of treatments (N=342) Yes 262 76.6 No 80 23.4 MUAC measured last month (N=7203) Don’t know/not sure 14 0.2 Yes 191 2.7 No 6998 97.2 In this study, the prevalence of SAM among children aged 6-59 months was found to be 1.6%, with a total of 113 children identified. Of these children, 67.3% (n=76) were not enrolled in any nutritional program. For MAM, the prevalence was 4.6%, with 328 children affected. Among these children, 78.0% (n=256) were not receiving any program interventions. Table 3: Nutritional status of study participants Category n Percentage Children with SAM (N=7203) 113 1.6 Not enrolled in any nutritional program (N=113) 76 67.3 Children with MAM N=7203) 328 4.6 Not receiving any program interventions (N=328) 256 78.0 Several barriers to program participation were identified for both SAM and MAM cases. For SAM, out of 76 children not enrolled in any nutritional program, the most common barriers included a lack of awareness about treatments in place (25%) and facilities being out of stock (22.4%). Similarly, for MAM, for the 256 children not receiving program interventions, the primary barriers were facilities being out of stock (25%), and lack of awareness (23%). One of the additional assessments conducted in every 10th household focused on Vitamin A supplementation coverage. Among the 463 participants identified, 256 reported that their children had received Vitamin A supplementation, resulting in a coverage rate of 57.2%. Discussion This study highlights the ongoing challenges in addressing Severe Acute Malnutrition in Ethiopia, particularly in a selected rural woreda. Despite efforts by the Ethiopian government and international organizations to combat malnutrition, the findings indicate significant gaps in treatment coverage and participation in nutrition programs. Before the implementation of OTP in Ethiopia, children with SAM were treated in inpatient units, which presented several limitations, including limited coverage, high costs, cross-infections, and high mortality rates [ 15 , 16 ]. Due to these challenges, OTP was endorsed as part of the healthcare system in 2005 after pilot testing in 2000. The timely identification and effective management of SAM are critical elements in contemporary medical practice, helping reduce the number of children requiring hospital admission for treatment [ 17 ]. Additionally, community-based management facilitates the early detection and prompt recovery of children with SAM. Providing treatment through OTP centers also reduces costs compared to inpatient programs [ 18 , 19 ]. Despite notable progress in reducing SAM rates in Ethiopia through community-based management programs, the overall coverage of treatment and access to services remains low. Interventions aimed at mitigating SAM include improving maternal nutrition, promoting exclusive breastfeeding, and strengthening healthcare systems. In this study, the prevalence of SAM among children aged 6–59 months was 1.6%, while the prevalence of Moderate Acute Malnutrition was 4.6%, with the majority of affected children (67.3% for SAM and 78% for MAM) not enrolled in nutritional programs. These findings align with previous research showing low coverage and participation in SAM treatment programs in Ethiopia and other low-income countries. For example, a study reported that SAM children's access to treatment remains limited due to barriers such as stock shortages and inadequate healthcare infrastructure.[ 15 ]. One key barrier identified is the lack of awareness about available treatments for malnutrition. Communities often fail to recognize the symptoms or are unaware of accessible treatment options, such as ready-to-use therapeutic foods or community-based management programs, delaying intervention and exacerbating the risk of complications. Efforts to enhance targeted communication and awareness campaigns are crucial to educate caregivers about the importance of early identification and care-seeking behaviors. [ 19 ] . Another significant barrier is the unavailability of treatment stock, which caregivers frequently cited as a reason for not enrolling their children in programs. This issue is common in other low-resource settings, where supply chain disruptions often hinder the consistent availability of therapeutic foods. [ 17 ]. Additionally, caregivers often fail to seek treatment because they do not perceive their child as being sick, underscoring the need for robust community engagement and health education initiatives. Community-based approaches, such as the Community-based Management of Acute Malnutrition, have proven effective in improving awareness and early detection of malnutrition, leading to better health outcomes. [ 16 , 19 ] . This study also found that routine nutritional monitoring, such as MUAC assessments, is inadequate. Regular monitoring is critical for the early detection and management of malnutrition, but implementation remains inconsistent. [ 21 ]. Furthermore, 78% of children with MAM did not receive any program interventions. If left untreated, moderate malnutrition can progress to severe forms, increasing the risk of morbidity and mortality.[ 15 ] . Ethiopia's unique challenges, such as a large rural population, limited healthcare infrastructure, and frequent natural disasters, exacerbate food insecurity and malnutrition. [ 22 ]. However, the successful implementation of community-based programs, like the Integrated Management of Acute Malnutrition in Malawi, demonstrates that significant progress is possible with appropriate strategies and resources. These strategies include community engagement, decentralization of services, capacity building, simplified treatment protocols, integration with health initiatives, robust monitoring, adequate funding, policy support, and awareness campaigns. [ 18 ] . The coverage of Vitamin A supplementation in this study was found to be 57.2%. This result is comparable to findings in other low- and middle-income countries, where Vitamin A supplementation coverage often remains inadequate despite its critical role in preventing childhood morbidity and mortality. According to the World Health Organization, Vitamin A supplementation is essential for reducing child mortality and promoting immunity. Barriers to full coverage include logistical challenges, lack of awareness, and inadequate distribution systems [ 23 ]. These factors highlight the need for strengthened distribution systems and increased community education to ensure that all children receive this essential micronutrient. In addition, programmers could consider aligning the provision of Vitamin A supplementation with vaccination programs, as both national and our data indicate good coverage of vaccination in Ethiopia. In conclusion, while progress has been made in addressing SAM in Ethiopia, this study highlights the need for expanded program coverage and improved effectiveness. Addressing barriers such as treatment awareness, supply chain management, and community education is essential. Future research should evaluate the impact of targeted interventions and explore innovative solutions to overcome these challenges. Strengths and limitations of the study This study's strengths include its use of the S3M II, which provides a cost-effective and reliable means of assessing malnutrition rates across different regions, thereby enabling targeted interventions. The focus on Babile Woreda, a high-risk area for SAM, offers valuable insights into local challenges and gaps in nutrition programs, making the findings highly relevant for addressing specific regional needs. The practical recommendations provided are grounded in the study’s results, aiming to improve the coverage and effectiveness of nutrition programs. However, there are limitations to consider. The focus on Babile Woreda means that the findings may not be fully generalizable to other areas with different socio-economic and environmental conditions. Furthermore, the study primarily examines existing nutrition programs and does not extensively address other potential factors influencing malnutrition, such as socioeconomic conditions or climate change impacts. Acknowledging these strengths and limitations provides a nuanced understanding of the study’s context and implications. Conclusion This study highlights the urgent public health challenge of SAM in Ethiopia, particularly in Babile Woreda, where high rates of SAM and MAM conditions persist. Contributing factors such as drought, conflict, and inadequate healthcare infrastructure exacerbate the problem, despite the presence of nutrition programs like CMAM and OTP. The S3M II has been instrumental in identifying high-risk areas, yet there are significant gaps in treatment coverage and program effectiveness. To address these issues, it is crucial to enhance the accessibility and coverage of nutrition programs, particularly in drought and conflict-affected regions. Strengthening healthcare infrastructure, addressing the underlying causes of malnutrition such as poverty and food insecurity, and improving monitoring and evaluation processes are essential. Additionally, promoting community engagement and education on nutrition can support effective interventions and foster better health outcomes. By implementing these recommendations, stakeholders can make meaningful progress in reducing SAM rates and improving child health in Ethiopia. Declarations Ethics approval and consent to participate The study was approved by the EPHI ethical review board (EPHI-IRB-524-2023). All methods were performed according to the relevant guidelines and regulations. Written informed consent was obtained from the mothers of under-five children involved in the study. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Clinical trial number Not applicable Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This project /research was funded by the generous support of Irish Aid. The funders had no direct input in the design, analysis, or interpretation of the study, and the opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the funding organizations. The Power of Nutrition team provided technical support in designing the program, played a program management role, and participated in key activities such as data collectors training, field visits for supportive supervision during the survey and participation in Dissemination activities. Authors' contributions ATB, MT: contributed significantly to the conception, design and data acquisition of the paper. ATB, KTR, IM, AM, SY, BT, JM, AW, MT: contributed significantly to design, data collection, analysis, interpretation, and drafting of the article. ATB, KTR, IM, AM, SY, BT, JM, AW, GT and MT: critically revised the paper for important intellectual content, gave final approval to the version to be published. All authors have agreed to be accountable for all aspects of the work. Acknowledgment We would like to extend our gratitude to the Babile Woreda Health Office and its staff, the non-governmental organizations operating in Babile Woreda, the quality control team, data collectors, and all the study participants in Babile Woreda. References Moyer JD, Bohl DK, Petry C, Scott A, Solórzano JR, Kuhn R. The persistent global burden of severe acute malnutrition: Cross-country estimates, models and forecasts. Glob Transitions . 2020 Jan 1;2:167-79. Ahmed AT, Abas AH, Elmi A, Omer A. Determinants of severe acute malnutrition among children aged 6-36 months in Kalafo district (riverine context) of Ethiopia. Sci Rep . 2022 Dec 1;12(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35338207/ Zhang X, Tang M, Zhang Q, Zhang KP, Guo ZQ, Xu HX, et al. The GLIM criteria as an effective tool for nutrition assessment and survival prediction in older adult cancer patients. Clin Nutr . 2021 Mar 1;40(3):1224-32. Available from: https://pubmed.ncbi.nlm.nih.gov/32826109/ UNICEF. Nutrition, for every child. 2024. Available from: [https://www.unicef.org/reports/nutrition-strategy-2020-2030] Joint child malnutrition estimates (JME) (UNICEF-WHO-WB). Available from: https://www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb Alflah YM, Alrashidi MA. Management and preventive strategies of uncomplicated severe acute malnutrition among children. 2023. National Food and Nutrition Strategy Baseline Survey - Key Findings Preliminary Report - Ethiopia | ReliefWeb . Available from: https://reliefweb.int/report/ethiopia/national-food-and-nutrition-strategy-baseline-survey-key-findings-preliminary-report. CSA/Ethiopia CSA-, ICF. Ethiopia Demographic and Health Survey 2016. 2017 Available from: https://www.dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm The State of the World’s Children 2023 | UNICEF. Available from: https://www.unicef.org/reports/state-worlds-children-2023 Belay DG, Chilot D, Alem AZ, Aragaw FM, Asratie MH. Spatial distribution and associated factors of severe malnutrition among under-five children in Ethiopia: further analysis of 2019 mini EDHS. BMC Public Health . 2023 Dec 1;23(1):1-13. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15639-2 Global Nutrition Report: Shining a light to spur action on nutrition - World | ReliefWeb. Available from: https://reliefweb.int/report/world/2018-global-nutrition-report-shining-light-spur-action-nutrition Ministry of Health F, Health Department F. National Strategy for Infant and Young Child Feeding - Ethiopia - Federal Ministry of Health, Family Health Department. 2004. The Global Hunger Index. Global Hunger Index 2022: Nigeria. Glob Hunger Index Annu Rep . 2021 Oct. Available from: www.globalhungerindex.org Abu-Manga M, Al-Jawaldeh A, Baseer Qureshi A, Elmunier Ali AM, Pizzol D, Dureab F. Nutrition assessment of under-five children in Sudan: Tracking the achievement of the global nutrition targets. 2021; Available from: https://doi.org/10.3390/children8050363 Olofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, Fawzi WW, et al. Associations of suboptimal growth with all-cause and cause-specific mortality in children under five years: A pooled analysis of ten prospective studies. PLoS One . 2013 May 29 ;8(5):e64636. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064636 Golden MH, Grellety Y. Integrated Management of Acute Malnutrition (IMAM) Generic Protocol ENGLISH version 6.6.2. Available from: https://www.researchgate.net/publication/292131715_Golden_MH_Grellety_Y_Integrated_Management_of_Acute_Malnutrition_IMAM_Generic_Protocol_ENGLISH_version_662#fullTextFileContent Bhutta ZA, Berkley JA, Bandsma RHJ, Kerac M, Trehan I, Briend A. Severe childhood malnutrition. Nat Rev Dis Prim . 2017 Sep 6;3(1). Available from: https://pubmed.ncbi.nlm.nih.gov/28933421/ Bachmann MO. Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model. Cost Eff Resour Alloc . 2009 Jan 15;7:2. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2630929/ Tekeste A, Wondafrash M, Azene G, Deribe K. Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia. Cost Eff Resour Alloc . 2012 Mar 19 ;10(1):1-10. Available from: https://resource-allocation.biomedcentral.com/articles/10.1186/1478-7547-10-4 Malnutrition. Available from: https://www.who.int/health-topics/malnutrition#tab=tab_1 USAID. Global Malnutrition Prevention and Treatment Act of 2021 Implementation Plan. Available from: https://www.usaid.gov Alflah YM. Severe acute malnutrition and its consequences among malnourished children. J Clin Pediatr Res . 2023 Mar 1. World Health Organization. Guideline: Vitamin A supplementation in infants and children 6–59 months of age. Geneva: World Health Organization; 2011. Available from: https://iris.who.int/bitstream/handle/10665/44664/9789241501767_eng.pdf?sequence=1 Additional Declarations No competing interests reported. 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Berhanu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDAD9gbmA0BKQoZI9QkMDDwH2BJAWnhI0cJjAGIS1sI/u/nYg48/bOx52M98fnWjxoKHgf3w0Q34tEjcOZZuOCMhLbGHJ3ebdc4xoMN40tJu4LXmRo6ZNE/C4QR7htxtxjlsQC0SPGZ4tcjfyP8m/Sfhvz0P/5tnxjn/iNBicCOHTZoh4QBjj0QO8+PcNiK0GN5IM5PsSUtO7JF4Zsac2yfBw0bIL3I3kp9J/LCxAzos+fHnnG91cvzsh4/h9z4SYJMAk8QqBwHmD6SoHgWjYBSMgpEDAHaVRNuu7F97AAAAAElFTkSuQmCC","orcid":"","institution":"Ethiopian Public Health Institute","correspondingAuthor":true,"prefix":"","firstName":"Anene","middleName":"Tesfa","lastName":"Berhanu","suffix":""},{"id":452190812,"identity":"ddc0957f-6044-41d5-b4fa-93c2407cc2e7","order_by":1,"name":"Kedir Teji Roba","email":"","orcid":"","institution":"Haramaya 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University","correspondingAuthor":false,"prefix":"","firstName":"Aboma","middleName":"","lastName":"Motuma","suffix":""},{"id":452190816,"identity":"9f210e2d-dd08-46e6-8bd5-3aa1729ccc12","order_by":5,"name":"Suleiman Yakubu","email":"","orcid":"","institution":"Power of nutrition","correspondingAuthor":false,"prefix":"","firstName":"Suleiman","middleName":"","lastName":"Yakubu","suffix":""},{"id":452190817,"identity":"7f0896a7-c893-4991-9e7a-aaa3610d9951","order_by":6,"name":"Bedasa Tessema","email":"","orcid":"","institution":"Ethiopian Public Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Bedasa","middleName":"","lastName":"Tessema","suffix":""},{"id":452190818,"identity":"2a84ae84-2149-4b4a-b456-8b8edb819b85","order_by":7,"name":"Jeffrey Misomali","email":"","orcid":"","institution":"Power of nutrition","correspondingAuthor":false,"prefix":"","firstName":"Jeffrey","middleName":"","lastName":"Misomali","suffix":""},{"id":452190820,"identity":"8059a76d-42e9-479c-8167-beaada905ca5","order_by":8,"name":"Anne Walsh","email":"","orcid":"","institution":"Power of nutrition","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Walsh","suffix":""},{"id":452190821,"identity":"95246a45-7338-4ed9-9f06-c8a9fe6dcaee","order_by":9,"name":"Masresha Tessema","email":"","orcid":"","institution":"Ethiopian Public Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Masresha","middleName":"","lastName":"Tessema","suffix":""}],"badges":[],"createdAt":"2025-03-04 07:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6151650/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6151650/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82349618,"identity":"6feaa9f1-70f8-45f3-8c1e-55c18caf922a","added_by":"auto","created_at":"2025-05-09 10:47:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":259766,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMap of the Babile district\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6151650/v1/6cd69c791adca2f4bf9c9fea.png"},{"id":82349615,"identity":"ad1866e4-99a8-46f6-9c54-aab94a53c260","added_by":"auto","created_at":"2025-05-09 10:47:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":31037,"visible":true,"origin":"","legend":"\u003cp\u003eReasons for not attending SAM treatment\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6151650/v1/6672ad7f5b3fd7c609bb90d9.png"},{"id":82349614,"identity":"f35992ff-69d1-45df-8be2-f4c9911a8851","added_by":"auto","created_at":"2025-05-09 10:47:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":27088,"visible":true,"origin":"","legend":"\u003cp\u003eReasons for not attending MAM treatment\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6151650/v1/ed7f3d241e98933e7cb328e0.png"},{"id":82351409,"identity":"7787986e-8c08-4a13-ba47-088cc2317a32","added_by":"auto","created_at":"2025-05-09 10:55:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21903,"visible":true,"origin":"","legend":"\u003cp\u003eRanked list of reasons for not having received vitamin A in the past 6 months.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6151650/v1/62fae79745a190ff98f8aba8.png"},{"id":82354823,"identity":"ef24afae-6ccd-44cb-b548-bc643fda182b","added_by":"auto","created_at":"2025-05-09 11:11:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":987614,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6151650/v1/e562ad1a-5673-4568-9bc0-ab0a0f84feb3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ethiopian Children Missing Out on Nutrition Treatment Program: A Simple Spatial Survey Method (S3M II)","fulltext":[{"header":"Background","content":"\u003cp\u003eSAM is a significant public health challenge worldwide, particularly in developing countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. SAM is a severe condition characterized by extreme wasting or weight loss due to prolonged inadequate nutrition [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 2022, an estimated 45\u0026nbsp;million children under five suffered from wasting, a severe form of malnutrition, with the number of children experiencing severe wasting rising alarmingly in the 15 most affected countries due to global food and nutrition crises. The majority of these cases were reported in South Asia and sub-Saharan Africa. SAM significantly increases the risk of death, accounting for about one in five deaths in this age group [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, in 2022, Stunting affected an estimated 22.3% or 148.1\u0026nbsp;million children under 5 globally in 2022. Children with SAM are 11.6 times more likely to die than those not affected [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eThe main causes of SAM include poverty, inadequate access to safe drinking water, poor sanitation, inadequate breastfeeding practices, and insufficient food intake. Factors such as climate change, conflict, and displacement also significantly contribute to the prevalence of SAM [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. SAM treatment is typically administered either in inpatient units or through outpatient therapeutic feeding programs (OTP), which are part of community-based management of acute malnutrition (CMAM) for children with uncomplicated SAM [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. OTP services include the diagnosis and provision of ready-to-use therapeutic foods (RUTF) for two months, along with supplementation of medications like amoxicillin, folic acid, vitamin A, measles vaccination, and deworming. The Sustainable Development Goals (SDGs) and the World Health Assembly have set targets to reduce the proportion of children suffering from wasting to less than 5% by 2025 and less than 3% by 2030. However, the situation remains dire, as children with severe wasting are 11 times more likely to die from common childhood illnesses compared to well-nourished children [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The number of children suffering from wasting has risen significantly due to factors such as conflict, COVID-19, and climate change, all contributing to global food insecurity.\u003c/p\u003e \u003cp\u003eUndernutrition is a major public health problem in Ethiopia, particularly among children. According to the UNICEF report released in February 2022, there has been a concerning surge in Severe Acute Malnutrition cases in regions affected by both drought and conflict. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The recent national food and nutrition survey also revealed that in Ethiopia, 39% of children are stunted and 11% are wasted. The Oromia region has one of the highest stunting rates at 41% and wasting rates at 9% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Babile woreda, situated within one of these impacted areas, is grappling with alarmingly high levels of Severe Acute Malnutrition and Moderate Acute Malnutrition among its children, a substantial proportion of whom are not receiving the necessary treatment. These rates are among the highest in the world, leading to severe long-term health and developmental consequences [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Several factors contribute to malnutrition in Ethiopia, including poverty, food insecurity, poor hygiene and sanitation, and limited access to healthcare and education. Natural disasters such as droughts and flooding further exacerbate food insecurity and malnutrition [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address this issue, the Ethiopian government and its partners have implemented a variety of nutrition programs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Selective-entry programs such as Community-based Management of Acute Malnutrition (CMAM) and Targeted Supplementary Feeding Programs (TSFP) target children who are already malnourished or at risk of malnutrition. CMAM focuses on identifying and treating SAM in children under five years old through community-based management, while TSFP provides supplementary feeding to moderately malnourished children. In addition, universal programs like the Expanded Program on Immunization (EPI), Growth Monitoring and Promotion (GMP), General Food Distribution (GFD), and blanket Supplementary Feeding Programs (SFP) aim to address malnutrition on a wider scale across Ethiopia. EPI provides vaccines to prevent childhood illnesses, GMP monitors the growth of children under five and promotes healthy nutrition practices, GFD provides food assistance to vulnerable households and blanket SFP targets entire populations in regions with high malnutrition rates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aims to assess the coverage of SAM treatment and other direct nutrition interventions, identifying barriers and facilitators to coverage in the East Hararghe Zone, specifically in Babile Woreda.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003e\u003cstrong\u003eStudy Area\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Babile Woreda in the East Hararghe zone.\u0026nbsp;The Ethiopia Statistical Service Services provided PDF maps of the Babile district shown below.\u003c/p\u003e\n\u003cp\u003eWe followed two-step sampling procedures.\u003c/p\u003e\n\u003cp\u003eStep 1:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDoor-to-door assessment of children 6-59 months old from 30 evenly spatially distributed primary sampling units (PSUs)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnumeration areas from Babile Woreda, East Hararghe were selected.\u003c/li\u003e\n \u003cli\u003eOnly households with children were included.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eStep 2:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMUAC and bipedal edema to identify SAM children.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCaregivers asked about their knowledge of the CMAM program.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCaregivers asked about Vitamin-A supplementation, GMP, Iron-Folic Acid supplementation during their last or current pregnancy, and Infant and Young Child Feeding counseling.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA community-based survey was conducted in October 2023 as a baseline study. The study design involved a two-stage evaluation approach. The first utilized a wide-area coverage assessment called the Simple Spatial Survey Method (S3M). This was conducted at baseline to identify geographic program units with high coverage of IMAM and related nutrition interventions and those with low coverage. S3M II is a valuable tool for assessing malnutrition in Ethiopia, a country that faces significant challenges in terms of nutrition. The S3M II method, developed by the World Health Organization (WHO) and UNICEF, offers a simple, cost-effective, and reliable way to collect data on malnutrition rates in different areas of the country[13]. The S3M II method involves taking anthropometric measurements of children under 5 years old in households of a given area. The data is then analyzed to determine the prevalence of malnutrition in that area. This information is crucial for planning and implementing effective nutrition programs, as it allows policymakers and health workers to identify areas with high levels of malnutrition and target interventions accordingly [13]. Several studies have shown that the S3M II method is effective in identifying areas with high rates of malnutrition. Recent studies conducted in South Sudan and Liberia are two specific instances that serve as examples of the S3M II method applied in least-developed countries. The study conducted in South Sudan found that the S3M II method was able to accurately identify areas with high rates of acute malnutrition and that these areas were associated with poor food security, poor access to health services, and a high burden of infectious diseases [14]. The study conducted in Liberia with a similar study method indicated that Program coverage such as IFA supplementation, IYCF counseling, and vitamin A supplementation have performed fairly well. Further, the majority of women and children targeted by these programs are knowledgeable about the program and are beneficiaries of the program. In Ethiopia, where resources for nutrition programs are limited, the S3M II method may be proven to be a valuable tool for prioritizing interventions and ensuring that resources are used effectively. Overall, the S3M II method is a simple yet powerful tool for addressing malnutrition in Ethiopia. By providing accurate data on malnutrition rates in different areas of the country, the method helps ensure that limited resources are used effectively and that nutrition programs are targeted where they are most needed. The second adopted the more targeted Semi-Quantitative Evaluation of Access \u0026amp; Coverage (SQUEAC) investigations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection team members participated in a five-day training program, which included field-based piloting of the data collection process. Although the data collectors were professionals, refresher training sessions on MUAC measurement were conducted. Under-five children not included in the study were used for MUAC training and standardization. Feedback was provided to teams on their MUAC measurements, and corrective actions, including additional training, were implemented to ensure accurate and precise measurements.\u003c/p\u003e\n\u003cp\u003eSeven teams, each consisting of two members, visited allocated households in the 30 PSUs of the study area. If a household had at least one child aged 6\u0026ndash;59 months, the primary caregiver was asked to provide verbal assent for the child\u0026rsquo;s participation. The team explained the MUAC measurements, the purpose of the survey, and the approximate time required (10 minutes) to complete the survey. Upon receiving consent, MUAC measurements were taken for each child. Two supervisors oversaw the data collection teams to ensure adherence to protocols.\u003c/p\u003e\n\u003cp\u003eDuring the survey, a systematically selected subset of every 10th household with children aged 6\u0026ndash;23 months was invited to answer additional questions about specific interventions. These surveys took approximately 20\u0026ndash;25 minutes, following the assent or consent process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and \u0026nbsp; exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible population groups of the survey were: 1) mothers having under-five children; and 2) children 6-59 months. The survey included population groups with children under the age of 5 residing in the study area who gave consent and participated in interviews. We excluded households without children under the age of five or with children older than 59 months or less than six months. Additionally, households that did not provide consent were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData management\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using an electronic data entry system via the ODK application, running on the Android\u0026reg; operating system for mobile devices. The study instrument was pre-encoded into the electronic system and hosted on EPHI\u0026rsquo;s remote cloud server. Each data collection team was equipped with Android\u0026reg; devices configured to receive the electronic data form. Measurements and responses were recorded on mobile devices and transmitted to the server whenever a mobile or Wi-Fi signal was available.\u003c/p\u003e\n\u003cp\u003eAppropriate data validation mechanisms were implemented in the field. Study supervisors conducted spot checks to ensure enumerators performed measurements correctly, administered the survey instrument appropriately, and entered data accurately. Updates and feedback were communicated to the study team to address and rectify any data collection issues promptly.\u003c/p\u003e\n\u003cp\u003eThe digital data form was designed to replicate the paper-based forms and sampling design described in the survey. Once data were cleaned and processed, analysis was conducted using Stata 16. Descriptive analyses were performed on the collected observations. An automatic reporting format, including figures and tables, was generated to summarize the findings.\u003c/p\u003e"},{"header":"Result","content":"\u003ch2\u003e\u003cstrong\u003eSocio-demographic characteristics\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe total number of households reached was 5023, with nine mothers refusing. The majority of mothers were in the age group of 20\u0026ndash;29 (55%), with a significant percentage having only one child (61%). Antenatal care utilization for the first child was reported by 74% of the mothers. Only 3% reported that they have a health card for their children on hand. The number of children we approached for the study was 7203, with 54.1% of them falling within the age range of 6 months to 24 months, and an almost equal distribution between males (49.7%) and females (50.4%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Sociodemographic characteristics of study participants\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"659\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s Age N (5014)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e15-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e20-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (7203)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e6mo-24mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3307\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e25mo-59mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3895\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e54.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex of children\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3627\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e50.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3576\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA significant portion (55.0%) indicate having had a health card for their babies but it is not currently available or has been lost. Additionally, a small number of participants (191) report having their MUAC measured within the last month.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: Health-seeking behavior and awareness of study participants\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave a health card (N=7203)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eYes (and available)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eYes (but not available/lost)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e3958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eNo (never had one) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eDon\u0026apos;t know/Not sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAware of treatments \u0026nbsp;(N=342)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e76.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e23.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMUAC measured last month \u0026nbsp;(N=7203)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know/not sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e6998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e97.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn this study, the prevalence of SAM among children aged 6-59 months was found to be 1.6%, with a total of 113 children identified. Of these children, 67.3% (n=76) were not enrolled in any nutritional program. For MAM, the prevalence was 4.6%, with 328 children affected. Among these children, 78.0% (n=256) were not receiving any program interventions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3: Nutritional status of study participants\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003eChildren with SAM (N=7203)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003eNot enrolled in any nutritional program (N=113)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e67.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003eChildren with MAM N=7203)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e328\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003eNot receiving any program interventions (N=328)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e78.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSeveral barriers to program participation were identified for both SAM and MAM cases. For SAM, out of 76 children not enrolled in any nutritional program, the most common barriers included a lack of awareness about treatments in place (25%) and facilities being out of stock (22.4%). \u0026nbsp;Similarly, for MAM, for the 256 children not receiving program interventions, the primary barriers were facilities being out of stock (25%), \u0026nbsp;and lack of awareness (23%).\u003c/p\u003e\n\u003cp\u003eOne of the additional assessments conducted in every 10th household focused on Vitamin A supplementation coverage. Among the 463 participants identified, 256 reported that their children had received Vitamin A supplementation, resulting in a coverage rate of 57.2%.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the ongoing challenges in addressing Severe Acute Malnutrition in Ethiopia, particularly in a selected rural woreda. Despite efforts by the Ethiopian government and international organizations to combat malnutrition, the findings indicate significant gaps in treatment coverage and participation in nutrition programs. Before the implementation of OTP in Ethiopia, children with SAM were treated in inpatient units, which presented several limitations, including limited coverage, high costs, cross-infections, and high mortality rates [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Due to these challenges, OTP was endorsed as part of the healthcare system in 2005 after pilot testing in 2000. The timely identification and effective management of SAM are critical elements in contemporary medical practice, helping reduce the number of children requiring hospital admission for treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, community-based management facilitates the early detection and prompt recovery of children with SAM. Providing treatment through OTP centers also reduces costs compared to inpatient programs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite notable progress in reducing SAM rates in Ethiopia through community-based management programs, the overall coverage of treatment and access to services remains low. Interventions aimed at mitigating SAM include improving maternal nutrition, promoting exclusive breastfeeding, and strengthening healthcare systems.\u003c/p\u003e \u003cp\u003eIn this study, the prevalence of SAM among children aged 6\u0026ndash;59 months was 1.6%, while the prevalence of Moderate Acute Malnutrition was 4.6%, with the majority of affected children (67.3% for SAM and 78% for MAM) not enrolled in nutritional programs. These findings align with previous research showing low coverage and participation in SAM treatment programs in Ethiopia and other low-income countries. For example, a study reported that SAM children's access to treatment remains limited due to barriers such as stock shortages and inadequate healthcare infrastructure.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne key barrier identified is the lack of awareness about available treatments for malnutrition. Communities often fail to recognize the symptoms or are unaware of accessible treatment options, such as ready-to-use therapeutic foods or community-based management programs, delaying intervention and exacerbating the risk of complications. Efforts to enhance targeted communication and awareness campaigns are crucial to educate caregivers about the importance of early identification and care-seeking behaviors. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eAnother significant barrier is the unavailability of treatment stock, which caregivers frequently cited as a reason for not enrolling their children in programs. This issue is common in other low-resource settings, where supply chain disruptions often hinder the consistent availability of therapeutic foods. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, caregivers often fail to seek treatment because they do not perceive their child as being sick, underscoring the need for robust community engagement and health education initiatives. Community-based approaches, such as the Community-based Management of Acute Malnutrition, have proven effective in improving awareness and early detection of malnutrition, leading to better health outcomes. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eThis study also found that routine nutritional monitoring, such as MUAC assessments, is inadequate. Regular monitoring is critical for the early detection and management of malnutrition, but implementation remains inconsistent. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Furthermore, 78% of children with MAM did not receive any program interventions. If left untreated, moderate malnutrition can progress to severe forms, increasing the risk of morbidity and mortality.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eEthiopia's unique challenges, such as a large rural population, limited healthcare infrastructure, and frequent natural disasters, exacerbate food insecurity and malnutrition. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, the successful implementation of community-based programs, like the Integrated Management of Acute Malnutrition in Malawi, demonstrates that significant progress is possible with appropriate strategies and resources. These strategies include community engagement, decentralization of services, capacity building, simplified treatment protocols, integration with health initiatives, robust monitoring, adequate funding, policy support, and awareness campaigns. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eThe coverage of Vitamin A supplementation in this study was found to be 57.2%. This result is comparable to findings in other low- and middle-income countries, where Vitamin A supplementation coverage often remains inadequate despite its critical role in preventing childhood morbidity and mortality. According to the World Health Organization, Vitamin A supplementation is essential for reducing child mortality and promoting immunity. Barriers to full coverage include logistical challenges, lack of awareness, and inadequate distribution systems [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These factors highlight the need for strengthened distribution systems and increased community education to ensure that all children receive this essential micronutrient. In addition, programmers could consider aligning the provision of Vitamin A supplementation with vaccination programs, as both national and our data indicate good coverage of vaccination in Ethiopia.\u003c/p\u003e \u003cp\u003eIn conclusion, while progress has been made in addressing SAM in Ethiopia, this study highlights the need for expanded program coverage and improved effectiveness. Addressing barriers such as treatment awareness, supply chain management, and community education is essential. Future research should evaluate the impact of targeted interventions and explore innovative solutions to overcome these challenges.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003eThis study's strengths include its use of the S3M II, which provides a cost-effective and reliable means of assessing malnutrition rates across different regions, thereby enabling targeted interventions. The focus on Babile Woreda, a high-risk area for SAM, offers valuable insights into local challenges and gaps in nutrition programs, making the findings highly relevant for addressing specific regional needs. The practical recommendations provided are grounded in the study\u0026rsquo;s results, aiming to improve the coverage and effectiveness of nutrition programs.\u003c/p\u003e \u003cp\u003eHowever, there are limitations to consider. The focus on Babile Woreda means that the findings may not be fully generalizable to other areas with different socio-economic and environmental conditions. Furthermore, the study primarily examines existing nutrition programs and does not extensively address other potential factors influencing malnutrition, such as socioeconomic conditions or climate change impacts. Acknowledging these strengths and limitations provides a nuanced understanding of the study\u0026rsquo;s context and implications.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the urgent public health challenge of SAM in Ethiopia, particularly in Babile Woreda, where high rates of SAM and MAM conditions persist. Contributing factors such as drought, conflict, and inadequate healthcare infrastructure exacerbate the problem, despite the presence of nutrition programs like CMAM and OTP. The S3M II has been instrumental in identifying high-risk areas, yet there are significant gaps in treatment coverage and program effectiveness.\u003c/p\u003e \u003cp\u003eTo address these issues, it is crucial to enhance the accessibility and coverage of nutrition programs, particularly in drought and conflict-affected regions. Strengthening healthcare infrastructure, addressing the underlying causes of malnutrition such as poverty and food insecurity, and improving monitoring and evaluation processes are essential. Additionally, promoting community engagement and education on nutrition can support effective interventions and foster better health outcomes. By implementing these recommendations, stakeholders can make meaningful progress in reducing SAM rates and improving child health in Ethiopia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the EPHI ethical review board (EPHI-IRB-524-2023). All methods were performed according to the relevant guidelines and regulations. Written informed consent was obtained from the mothers of under-five children involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project /research was funded by the generous support of Irish Aid. The funders had no direct input in the design, analysis, or interpretation of the study, and the opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the funding organizations. The Power of Nutrition team provided technical support in designing the program, played a program management role, and participated in key activities such as data collectors training, field visits for supportive supervision during the survey and participation in Dissemination activities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eATB, MT: contributed significantly to the conception, design and data acquisition of the paper.\u003c/p\u003e\n\u003cp\u003eATB, KTR, IM, AM, SY, BT, JM, AW, MT: contributed significantly to design, data collection, analysis, interpretation, and drafting of the article.\u003c/p\u003e\n\u003cp\u003eATB, KTR, IM, AM, SY, BT, JM, AW, GT and MT: critically revised the paper for important intellectual content, gave final approval to the version to be published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors have agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to extend our gratitude to the Babile Woreda Health Office and its staff, the non-governmental organizations operating in Babile Woreda, the quality control team, data collectors, and all the study participants in Babile Woreda.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMoyer JD, Bohl DK, Petry C, Scott A, Sol\u0026oacute;rzano JR, Kuhn R. The persistent global burden of severe acute malnutrition: Cross-country estimates, models and forecasts. \u003cem\u003eGlob Transitions\u003c/em\u003e. 2020 Jan 1;2:167-79.\u003c/li\u003e\n\u003cli\u003eAhmed AT, Abas AH, Elmi A, Omer A. Determinants of severe acute malnutrition among children aged 6-36 months in Kalafo district (riverine context) of Ethiopia. \u003cem\u003eSci Rep\u003c/em\u003e . 2022 Dec 1;12(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35338207/\u003c/li\u003e\n\u003cli\u003eZhang X, Tang M, Zhang Q, Zhang KP, Guo ZQ, Xu HX, et al. The GLIM criteria as an effective tool for nutrition assessment and survival prediction in older adult cancer patients. \u003cem\u003eClin Nutr\u003c/em\u003e. 2021 Mar 1;40(3):1224-32. Available from: https://pubmed.ncbi.nlm.nih.gov/32826109/\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eUNICEF. Nutrition, for every child. 2024. Available from: [https://www.unicef.org/reports/nutrition-strategy-2020-2030]\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eJoint child malnutrition estimates (JME) (UNICEF-WHO-WB). Available from: https://www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb\u003c/li\u003e\n\u003cli\u003eAlflah YM, Alrashidi MA. Management and preventive strategies of uncomplicated severe acute malnutrition among children. 2023.\u003c/li\u003e\n\u003cli\u003eNational Food and Nutrition Strategy Baseline Survey - Key Findings Preliminary Report - Ethiopia | ReliefWeb . Available from: https://reliefweb.int/report/ethiopia/national-food-and-nutrition-strategy-baseline-survey-key-findings-preliminary-report.\u003c/li\u003e\n\u003cli\u003eCSA/Ethiopia CSA-, ICF. Ethiopia Demographic and Health Survey 2016. 2017 Available from: https://www.dhsprogram.com/publications/publication-fr328-dhs-final-reports.cfm\u003c/li\u003e\n\u003cli\u003eThe State of the World\u0026rsquo;s Children 2023 | UNICEF. Available from: https://www.unicef.org/reports/state-worlds-children-2023\u003c/li\u003e\n\u003cli\u003eBelay DG, Chilot D, Alem AZ, Aragaw FM, Asratie MH. Spatial distribution and associated factors of severe malnutrition among under-five children in Ethiopia: further analysis of 2019 mini EDHS. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2023 Dec 1;23(1):1-13. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15639-2\u003c/li\u003e\n\u003cli\u003eGlobal Nutrition Report: Shining a light to spur action on nutrition - World | ReliefWeb. Available from: https://reliefweb.int/report/world/2018-global-nutrition-report-shining-light-spur-action-nutrition\u003c/li\u003e\n\u003cli\u003eMinistry of Health F, Health Department F. National Strategy for Infant and Young Child Feeding - Ethiopia - Federal Ministry of Health, Family Health Department. 2004.\u003c/li\u003e\n\u003cli\u003eThe Global Hunger Index. Global Hunger Index 2022: Nigeria. \u003cem\u003eGlob Hunger Index Annu Rep\u003c/em\u003e . 2021 Oct. Available from: www.globalhungerindex.org\u003c/li\u003e\n\u003cli\u003eAbu-Manga M, Al-Jawaldeh A, Baseer Qureshi A, Elmunier Ali AM, Pizzol D, Dureab F. Nutrition assessment of under-five children in Sudan: Tracking the achievement of the global nutrition targets. 2021; Available from: https://doi.org/10.3390/children8050363\u003c/li\u003e\n\u003cli\u003eOlofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, Fawzi WW, et al. Associations of suboptimal growth with all-cause and cause-specific mortality in children under five years: A pooled analysis of ten prospective studies. \u003cem\u003ePLoS One\u003c/em\u003e. 2013 May 29 ;8(5):e64636. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064636\u003c/li\u003e\n\u003cli\u003eGolden MH, Grellety Y. Integrated Management of Acute Malnutrition (IMAM) Generic Protocol ENGLISH version 6.6.2. Available from: https://www.researchgate.net/publication/292131715_Golden_MH_Grellety_Y_Integrated_Management_of_Acute_Malnutrition_IMAM_Generic_Protocol_ENGLISH_version_662#fullTextFileContent\u003c/li\u003e\n\u003cli\u003eBhutta ZA, Berkley JA, Bandsma RHJ, Kerac M, Trehan I, Briend A. Severe childhood malnutrition. \u003cem\u003eNat Rev Dis Prim\u003c/em\u003e. 2017 Sep 6;3(1). Available from: https://pubmed.ncbi.nlm.nih.gov/28933421/\u003c/li\u003e\n\u003cli\u003eBachmann MO. Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model. \u003cem\u003eCost Eff Resour Alloc\u003c/em\u003e. 2009 Jan 15;7:2. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2630929/\u003c/li\u003e\n\u003cli\u003eTekeste A, Wondafrash M, Azene G, Deribe K. Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia. \u003cem\u003eCost Eff Resour Alloc\u003c/em\u003e. 2012 Mar 19 ;10(1):1-10. Available from: https://resource-allocation.biomedcentral.com/articles/10.1186/1478-7547-10-4\u003c/li\u003e\n\u003cli\u003eMalnutrition. Available from: https://www.who.int/health-topics/malnutrition#tab=tab_1\u003c/li\u003e\n\u003cli\u003eUSAID. Global Malnutrition Prevention and Treatment Act of 2021 Implementation Plan. Available from: https://www.usaid.gov\u003c/li\u003e\n\u003cli\u003eAlflah YM. Severe acute malnutrition and its consequences among malnourished children. \u003cem\u003eJ Clin Pediatr Res\u003c/em\u003e. 2023 Mar 1.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Guideline: Vitamin A supplementation in infants and children 6\u0026ndash;59 months of age. Geneva: World Health Organization; 2011. Available from: \u003cu\u003ehttps://iris.who.int/bitstream/handle/10665/44664/9789241501767_eng.pdf?sequence=1\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Severe Acute Malnutrition (SAM), Nutritional status, Ethiopia, Treatment coverage, Nutrition interventions, Simple Spatial Survey Method (S3M II)","lastPublishedDoi":"10.21203/rs.3.rs-6151650/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6151650/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSevere Acute Malnutrition (SAM) is a critical public health issue, particularly in developing regions like sub-Saharan Africa and South Asia, where it significantly contributes to child mortality. In Ethiopia, SAM continues to affect a substantial proportion of children under five, with persistent challenges in treatment coverage, especially in rural areas. We aimed to evaluate the coverage of SAM treatment and the availability of nutrition interventions using the Simple Spatial Survey Method (S3M II) while identifying the challenges encountered in accessing treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was conducted in rural Ethiopia, specifically in Babile Woreda, East Hararghe Zone, using a community-based S3M II design. Data collection took place in October 2023 A total of 5,023 households were surveyed, reaching 7,203 children aged 6\u0026ndash;59 months from Vv enumeration area. The survey assessed socio-demographic characteristics, nutritional status, challenges in treatment, and participation in nutrition programs. The data was analyzed using STATA Software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe prevalence of SAM among the surveyed children was about 1.6%, with 67% not enrolled in any nutritional program. Additionally, about 4.6% of children were identified with Moderate Acute Malnutrition (MAM), with 78% not receiving any program interventions. Key barriers to program participation included lack of awareness about available treatments (25%) and stock unavailability (22.4%)at health facilities. During the assessment, we found few number of households (3.2%) having a health card provided by health facilities, and also a small percentage of children(2.7%) had their Mid-Upper Arm Circumference (MUAC) measured within the previous month from the month of assessment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study highlights significant gaps in the coverage of SAM treatment and the critical need for improved implementation of programs in Ethiopia. The findings also underscore the importance of monitoring the effectiveness of existing program interventions.\u003c/p\u003e","manuscriptTitle":"Ethiopian Children Missing Out on Nutrition Treatment Program: A Simple Spatial Survey Method (S3M II)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 10:47:40","doi":"10.21203/rs.3.rs-6151650/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-20T17:30:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118245156257730434802588734160652132607","date":"2026-04-17T19:52:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-20T14:41:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75564557526311125265626464848030706257","date":"2025-05-18T10:29:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239641962352066568254253601728346376893","date":"2025-05-02T11:25:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-02T07:55:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T07:33:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-07T05:49:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-06T07:01:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-04-06T07:00:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"815641d1-d53e-4fe6-91b1-d3e098d1d9a4","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T10:47:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 10:47:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6151650","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6151650","identity":"rs-6151650","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}