1. Improving defaulter rates in Ambulatory Feeding Programs Ellen van der Velden (Investigator) Saskia van der Kam June 2008

2. Background High defaulter rates in ATFP

3. Objectives Identify key factors modifiable by MSF that would decrease defaulting in ambulatory feeding programs (ATFP)

4. Methods Analysis of available quantitative program data Analysis of qualitative information from interviews and observation (all under program field conditions)

5. Methods CountryRegular program report Patient data analysis Beneficiary interviews Observation & staff interviews QuantitativeQualitative South Sudan ++ 9 + Darfur ++ 6 + Burma +++ Ivory Coast +-+ Ethiopia +-- Some defaulter interviews in South SudanPlus

6. Results Quantitative methods Defaulters do not differ from non- defaulters in terms of Age Gender Weight on admission Height on admission Irregular attendance not associated with defaulting Defaulting occurred regardless of last recorded W/H status

7. Timing of defaulting %

8. Defaulting after 1 st and 2 nd visit % of all defaulters Darfur45 % South Sudan55 % Burma62 %

9. Outreach CountryOutreachDefault rates Darfur (Feina)1 person who could contact everybody < 10% Myanmar11 local ORWs, 3 per site < 10% Ivory coastStandard visit 1 st week < 10% South SudanAbsent30-50 % Ethiopia (Abdurraffi) Volunteers for health education; 1 day/week, > 20 %

10. Behaviour analysed from three perspectives 1. Personal perception of likely consequences (Behaviour belief) 2. Social norms (Normative belief) 3. Personal perception of ability to act (Control belief) Qualitative methods

11. Result Personal and Social Beliefs Caretakers perceived their child was sick, not malnourished Caretakers lacked an understanding of the purpose of the nutritional program Social beliefs/norms have a limited impact on defaulting rates

12. Results Control Beliefs Security Insecurity related to traveling was identified as a barrier Influence of insecurity not measurable Costs Direct costs (money) seen as low Indirect costs are considerable (e.g. long waiting time, travel time, opportunity costs)

13. Distance as barrier to completion of treatment % Cured/ defaulter

14. Limitations of study Conducted under field conditions while providing technical support to programs Limited access to beneficiary perspectives

15. Conclusion Many obstacles identified are modifiable Mother’s understanding of program aims Geographical access Patient waiting times and clinic opening Food stock ruptures

16. Recommendations Improve MSF- caretaker communication (personal and community level) Outreach indispensable for retention and tracing Decentralization to increase access Efficient patient flow

17. Acknowledgements Field teams and beneficiary participants in the 5 programs Royal Tropical Institute (KIT), Amsterdam