Quality Improvement of a Community-Based Childhood Nutrition Program in Rural Guatemala

Abstract

Purpose: Various organizations have made efforts to reduce chronic malnutrition in children under 5 years old in Guatemala but have had limited success. Quality improvement endeavors have the potential to maximize a program’s impact in resource-limited settings. We describe our experience implementing quality improvement (QI) of our childhood nutrition program in rural Guatemala. Our principal aim was to reduce the prevalence of chronic malnutrition in children under 5 years old by 15% each year in the communities served. Methods: Direct observation of nutrition programming and meetings with key staff were used to inform our QI efforts. We established, tracked, and presented to staff monthly quality metrics, including the percent of children receiving growth monitoring, micronutrient supplementation, and deworming medication. We measured average height-for-age Z (HAZ) score, a proxy of chronic malnutrition, as well as the percentage of children with stunting in each community. We used run chart analysis to assess for improvement. Results: Our QI efforts addressed four key drivers for mitigating stunting in Guatemalan children under 5 years old: (1) food security, (2) environmental health, (3) provision of health services, and (4) empowerment and education of caregivers. Incorporating elements of standards-based management and recognition as well as implementation science, our QI interventions included re-training staff, continued nutrition education, hiring a full-time licensed nutritionist, revision of educational instruments, checklists and algorithms to guide data interpretation and reinforce nutrition protocols, and constructive individualized feedback. The percentage of children who had growth monitoring per the protocol markedly improved. Administration of micronutrient supplementation and deworming medication was poorly documented. There was minimal improvement in average HAZ score and the stunting prevalence in children under 5 years old from February 2016 to February 2017. Conclusions: The process outcome of growth monitoring coverage improved, but we still need to streamline our documentation system. Minimal improvement in average HAZ scores and stunting prevalence could be secondary to confounding factors, such as the overrepresentation of children enrolled in the recuperative program in our calculations, expansion of our program to include more severely stunted children, climate change, and crop failure. More sophisticated control chart analysis is warranted to further explore if our quality improvement interventions impacted the severity and prevalence of stunting.