Dietics Creche Outing
Mokopane Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
There was high admission rate of malnutrition especially Severe Acute Malnutrition (SAM)in children at Mokopane Regional Hospital and the fact that most children were found to be stunted, wasted and underweight , mainly due to poor household food security, lack of health knowledge, chronic medical conditions such as HIV and TB , and cultural taboos. During normal school outreach for grade 1 learners, most children were found to be malnourished and it was too late to correct this. The team also observed a gap in lack of health assessment in children below six years. There was also low Vitamin A supplementation coverage in Waterberg district for children between 1-5 years. There was also a problem of unbalanced crèche menu which led to poor feeding practices. Another challenge was that therewere different nutrition messages given by health professionals at the clinic level and Dieticians about infant and young child feeding that confused mothers. Another big challenge in Mapela area was traditional practices around infant and young child feeding that led to high rate of children being vulnerable to sickness and poor growth.

B. Strategic Approach

 2. What was the solution?
A dietician proposed the initiative in a sectional meeting ( April 2012) and there was a buy in by all Dieticians. Biweekly crèche outreach (all children under five years of age) visits in Mahwelereng and Mapela area which is the catchment area for our hospital was started following the approval from the hospital management. The project is committed to providing sustainable services that include assessment, education, technical support and integrating nutritional well-being. These are a pre-requisite for the achievement of the full social, mental and physical potential of a population, a population that can lead full productive lives and contribute to the development of the nation with dignity. This project is aiding the government in its most important task of ensuring quality service delivery to its people. Access to decent public service and resources is a rightful expectation of all citizens in Republic of South Africa (RSA). The Constitution of the RSA recognizes nutrition as a basic human right; therefore it is imperative to ensure protection of this right by doing it early in child’s life. Through its efforts of early screening, this project aims to achieve the latter. The project also aim to help meet millennium development goals 1(Eradicate extreme hunger) by feeding correct from birth 2. (Achieve universal primary education) by giving uniform nutrition messages to caregivers and health staff at the clinics and 4. (Reduce child mortality) by early screening, issuing improved menus, giving Vitamin A and worm-go, and giving health education.

 3. How did the initiative solve the problem and improve people’s lives?
The project is a new idea which is unique and one of its kind, and aiming to solve problems at the community by doing regular effective (multidisciplinary) crèche outreach. These activities lead to cost effective measureable outcomes such as improved Vitamin A coverage, reduced incidents of diseases, reduced hospitalisation, improved child growth, better learning outcomes and reduced child mortality. It gave support to primary healthcare by making our services accessible at community level. It helped to improve nutrition knowledge to care givers at crèches and mother lodgers /visitors in the hospital’s Paediatric ward during visiting hours to empower them with knowledge. And to promote healthy eating and gave technical support in menu planning. Partnerships with Allied Health, Social Development were strengthened in the smooth running and planning of the outreach. The idea was sold to other Dieticians in other sub districts in Waterberg district whereby currently creche outreach is being done the whole district.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Dietetics team wrote a motivational letter to the Hospital management requesting to initiate a crèche outreach in the Mapela area; approval was subsequently granted. Lists of all the crèches in the Mahwelereng/ Mapela area were requested from the Limpopo Department of Social Development. Other sections from within the hospital (Environmental Health Practitioners (EHP), Pharmacy (for procuring and issuing Vitamin A capsules and Worm-go tablets), Oral Health, Infection Prevention and Control Team (for administration of Vitamin A capsules and worm-go tablets to kids and total assessment of hygiene and safety) and Speech/hearing therapists) were formally requested to collaborate with our team for complete health assessment of the children. Nutritionists from the district were also involved for continued nutrition advocacy. Vitamin A tally sheets that were completed were taken to local clinics to be captured on DHIS. Parent’s Consent forms were developed by Dietetics team and delivered to identified crèches before the visit and visit dates were given to the crèche principals in time. The Road-To–Health chart and a signed consent form were prerequisite for a child to be assessed. Prior arrangements were made with the hospital pharmacy to make available Vitamin A and de-worming medication during our crèche visits. Following the assessment of each child, those found to be malnourished were referred for further management at their local clinic and hospital’s dietetics department. Follow –up is done on monthly basis until the patient is growing satisfactorily. Menus used at the crèches were reviewed and recommended provincial menus were provided considering the financial status of the crèche. Since the commencement of the project, most of Mapela Community Crèches are now empowered with up to date and correct nutritional information. The crèches have made use of this new found nutrition knowledge and has as a result observed that the children grow much better. Since the commencement of the project, the coverage of administering Vitamin A supplementation has improved. This has been achieved through ensuring that at each visit, Vitamin A supplementation is given. In 2013 alone a 107 children received Vitamin A supplementation in 6 crèches. Mapela area clinic staff and Maternity nurses have received regular in-service training on the correct and up to date infant and young child feeding practices. These health professionals are then encouraged to share this information with care givers to prevent malnutrition especially in children under 5 years. The Dietetics team also gave nutrition education to mother lodgers and visitors in the hospital’s Paediatric ward during visiting hours to empower them with knowledge

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Department of Social Development gave us the lists of all the crèches in the Mahwelereng/ Mapela area were requested from the Limpopo. Other sections from within the hospital (Environmental Health Practitioners (EHP), Pharmacy (for procuring and issuing Vitamin A capsules and Worm-go tablets), Oral Health, Infection Prevention and Control Team (for administration of Vitamin A capsules and worm-go tablets to kids and total assessment of hygiene and safety) and Speech/hearing therapists) were formally requested to collaborate with our team for complete health assessment of the children. The hospital transport was provided for the team going out for outreach when requested. Nutritionists from the district were also involved for continued nutrition advocacy. Completed Vitamin A tally sheets were taken to local clinics to be captured on DHIS.
 6. How was the strategy implemented and what resources were mobilized?
All the resources which were utilised such as transport, stationary, height meters, scales, other medical equipments (ALLIED), Vitamin A capsules, Worm-go tablets, waste control equipments and human resource are all under Mokopane hospital budget. Transport requisitions are done the day before the outreach and supplements are requested by the infection control nurse from Pharmacy a week before; stakeholders are primarily responsible to bring along all medical equipments that will be needed for outreach. Nutritionists and the transportation utilised District Health budget.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Since commencement of the project; early identification of children at risk is done timely hence reduced number of children diagnosed with chronic malnutrition. Mothers are more actively utilising primary health care services for follow ups and to also access other child health services such as immunisations. Caregivers at crèches are now offering healthier meals for the children for better growth and development. There is also an improved trans disciplinary team approach when doing crèche assessments. There is a reduced incidence of gastroenteritis admissions in our hospital since the creche outreach started.

 8. What were the most successful outputs and why was the initiative effective?
Monitoring : All Crèches were visited according to the agreed and approved program, all the kids in the targeted crèches were assessed and those who were eligible to receive Vitamin A supplements were given and whereby supplements were no available were referred to the local clinic for further help,. Up to date crèche visits are still done following the approved program still with other stakeholders involved. Dietetics make follow ups with district Nutritionists on continuing to do parents education and monitoring implementation of menus supplied Evaluation: Process : Raw statistics of all assessed targeted kids was kept and tally sheets were tallied for every administered vitamin A (308 received Vitamin A: 2012 May – 2013 April); monthly statistics were kept of all the referred kids brought to hospital for follow ups and they were given appropriate support (education and supplements) to ensure good growth and development ; Nutritionists give us reports on implementation of recommended menus monthly for better advocacy; the program for nurses in-service training at the clinics is still followed. Outcome: There is 17 % reduction in malnutrition cases admitted in Mokopane hospital between May 2013- May 2014; There was reduction of referred undernourished children between 0-24 months in the year 2012- 2013 (n=06 – n=0); Vitamin A coverage in Waterberg district in 2013-2014 was 27,1 % and currently the coverage is 36 %.

 9. What were the main obstacles encountered and how were they overcome?
Shortage of vitamin A supplementation capsules and de-worming medication at times. To order vitamin A supplementation and de-worming medication from pharmacy in advance.2. Poor logistics in arrangements of transport to crèche outreach. Collaborate with hospital transport services and book in advance 3. Lack of consistent commitment by some local clinics to the project Additional support was requested from hospital nurses in Infection control section to assist. 4. Some crèches are not funded, therefore menu planning problems and poor food security for such crèches. To have different menu’s that are balanced and cheap to afford. 5. Geographic location, some crèche are not accessible. To find directions in advance. 6. Poor capturing of Vitamin A statistics on DHIS – Nutritionists from the Districts to monitor the capturing of the Vitamin A tally sheets from clinic level so as to reflect on District data.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Since commencement of the project; early identification of children at risk is done timely hence reduced number of children diagnosed with chronic malnutrition. Mothers are more actively utilising primary health care services for follow ups and to also access other child health services such as immunisations. Caregivers at crèches are now offering healthier meals for the children for better growth and development. There is also an improved trans disciplinary team approach when doing crèche assessments. There are reduced incidences of gastroenteritis and measles admissions in our hospital since the crèche outreach started.(due to improved Vitamin A intake)

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The project has been already successfully replicated in other hospitals and their demarcated areas within the Waterberg District. Voortrekker and FH Odendaal Hospital, George Masebe hospital, Witpoort hospital, Warmbard hospital, Thabadzimbi hospital have also started with crèche outreach following the success of the Mokopane Hospital project. At provincial level, the Project Leaders announced at the Limpopo Provincial Dietetics Forum the successes of the project. The Forum then adopted the project and encouraged its establishment in other districts. The project will be sustained and expanded through continuing to liaise with the Department of Social Development in identifying crèches that are deep in the Mapela community. The Dietetics Department is committed to continue doing crèche outreach, to provide technical support on menu assessment, planning and changes for the crèches. The hospital management is also supportive of this initiative and thus encourages its continuation. The project will continue to involve other stakeholders, such as the Speech and Hearing Department and Oral Health to make sure the outreach is more comprehensive. It shall also continue to involve the area dietician and nutritionist to continue with regular monitoring of modified menus and continue to empower care givers and crèche staff with nutrition education. The project undertakes to help other dieticians in the area and beyond to start similar projects in their area.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The team have learned to partner with both internal and external stakeholders to continue with the service delivery improvement. The team has collaborated with all stake holders which gave the team good ideas on how to facilitate the project well and how to solve problems that comes. The projects helped the team to learn more about leadership. The team managed to change the way Limpopo health outreach has been done by aiding with this new project and managed to instill new change to improve nutrition knowledge for the community at large. Improved interpersonal and communication skills for the whole team was also learned. Irrespective of challenges met such s lack of transport, lack of supplements and lack of nursing staff , the team persevered and applied assertive skills in some instances.

Contact Information

Institution Name:   Mokopane Hospital
Institution Type:   Government Department  
Contact Person:   Thilivhali Mathivha
Title:   Chief Dietician  
Telephone/ Fax:   +27154832405
Institution's / Project's Website:  
E-mail:   thilivhali.mathivha@dhsd.limpopo.gov.za  
Address:   3030 Stand no 1 Dudu Madisha Drive
Postal Code:   0600
City:   Mokopane
State/Province:   Limpopo
Country:  

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