J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 Research Article Community-Based Management of Acute Malnutrition Programme: Rural and Urban Maternal Socio-Demographic and Implementation Differentials in Ghana Joana Apenkwa1, Samuel Kofi Amponsah2,3*, Anthony Edusei1, Emmanuel Nakua1, Sam Newton1, Easmon Otupiri1, Chukwuma Chinaza Adaobi2 1 Kwame Nkrumah University of Science and Technology (School of Public Health, KNUST), Kumasi, Ghana 2 Catholic University College of Ghana, Fiapre (Health and Allied Sciences), CUCG, Sunyani-Fiapre, Ghana 3 Christian Health Association of Ghana (Health Information Department), Accra-Labone, Ghana * Corresponding Author: Samuel Kofi Amponsah, Christian Health Association of Ghana, Health Information Department, Accra-Labone, Ghana Received: 20 April 2022; Accepted: 27 April 2022; Published: 19 May 2022 Citation: Joana Apenkwa, Samuel Kofi Amponsah, Anthony Edusei, Emmanuel Nakua, Sam Newton, Easmon Otupiri, Chukwuma Chinaza Adaobi. Community-Based Management of Acute Malnutrition Programme: Rural and Urban Maternal Socio-Demographic and Implementation Differentials in Ghana. Journal of Food Science and Nutrition Research 5 (2022): 498-519. Abstract Malnutrition is a public health problem in Ghana, and quantitatively, is estimated to contribute indirectly to more than half qualitatively, and 25 mothers/caregivers qualitatively. of under-five deaths. This study was designed to Quantitative data were analysed descriptively with describe how implementation of the Community- Stata 14.0 (Stata Corp, Texas, USA) while the based qualitative data were analysed thematically with Management of Malnutrition (CMAM) 25 health service providers programme in Ghana differs in the rural and urban Atlas.ti, parts of the country. A mixed methods approach was Development used in a community-based survey that studied 497 implementation was assessed using the following mothers/caregivers variables: availability of CMAM tools, availability of and under-five pairs Journal of Food Science and Nutrition Research version 7.5 GmbH, (Scientific Berlin). Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] Software Programme 498 J Food Sci Nutr Res 2022; 5 (2): 498-519 CMAM supplies, out-patient among children globally and there is insufficient therapeutic and supplementary feeding programmes, progress to achieve the Sustainable Development personnel availability, availability of community- Goals [2]. Globally, Severe Acute Malnutrition based maternal (SAM) is one of the commonest causes of morbidity experience with CMAM services. While the number and mortality among children-under five as it affects of children alive, provision of nutrition education and at least 19 million children worldwide [3], and counselling, and demonstration of food preparation accounts for 8.0% of annual child deaths [4]. A significantly effectiveness severely wasted child is nine times more likely to die (p<0.05) in the urban site, no variables were found to than a child who is not wasted [5]. The Community- do similar in the rural district. The rural facilities based Management of Acute Malnutrition (CMAM) were more likely than the urban ones to be without programme was therefore introduced to achieve early tools. Less than 10% of mothers/caregivers in both detection of SAM (without complications), and to study sites acknowledged the availability of the appropriately manage cases with the help of ready-to- community-based CMAM. use therapeutic foods (RUTFs) or other nutrient- Programme implementation in the two study districts dense foods at the community level [1]. In Ghana, is poor; in order to ensure that the CMAM according to the 2014 Demographic and Health intervention translates into a reduced malnutrition Survey, among children under-five years, 19.0% are burden among children under-five in Ghana, the stunted, 5.0% are wasted, 11.0% are underweight and programme implementation should be revised to 4.0% are overweight [6]. CMAM was introduced in address the identified shortcomings. Ghana in June 2007 to manage cases of SAM components organization of influenced CMAM of DOI: 10.26502/jfsnr.2642-11000094 and program components of recorded at the community level [7,8]. Four learning Keywords: Community-based Management of sites were established in the Greater Accra and Acute Malnutrition; Implementation; Maternal socio- Central regions to train workers for the programme. demographics and experience; Effectiveness; Ghana Ashanti Region of Ghana piloted this project in 2010 at the Maternal and Child Health Hospital (MCHH), 1. Introduction Kumasi, and trained a number of health workers in In spite of remarkable global reductions in under-five the Kumasi metropolis and the Ahafo Ano South mortality over the last two decades, the United district for scale up to other areas in the region [9]. Nations Inter-Agency Group for Child Mortality Data at the MCHH, the main referral centre for the Estimation (UN IGME) estimates that 5.3million Ashanti region, only show the cases that arrived at children under-five died in 2018, with the highest the hospital; it is plausible that the community and burden in sub-Sahara Africa (SSA), where the household levels could have a much greater burden average under-five mortality rate is 78 per 1, 00 live of malnutrition among children under-five. This births; one in 13 children dies in SSA before her/his study therefore sought to assess the effects of fifth birthday. Nearly half of these deaths have maternal socio-demographics and experience with malnutrition as an underlying factor [1]. Malnutrition CMAM services on the effectiveness of the CMAM in children under-five years is an important public intervention in two districts in the Ashanti region, health issue that contributes greatly to morbidity Ghana- Kumasi Subin sub-metropolis and the Ahafo Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 499 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 Ano South district - to ascertain whether there are as cleft palate, or who were seriously ill at the time of differences within these areas. the study were excluded. Additionally, mothers/caregivers who had malnourished children 2. Materials and Methods under-five but the mothers/caregivers were not 2.1 Study area emotionally stable or had depression or were unwell The survey was carried out from July 2017 to January during the time of the survey were also excluded. 2018 in communities and public health facilities Health workers who were CMAM frontline health within the Kumasi Subin sub-metropolis (KSSM- workers but were not on duty at the time of the urban setting) and the Ahafo Ano South district survey were excluded. (AAS-rural setting). Prior to 2019 KSSM was one of the ten sub-metropolitan areas within the Kumasi 2.3 Sample size and sampling technique metropolis. It has 66 communities with an estimated The study adopted the Simplified Lot Quality projected population of 238,005. Eighteen percent Assurance Sampling Evaluation of Access and (18%) of the population is aged 6-59 months with an Coverage estimated SAM prevalence of 8%. The lowest level communities for the study. The SLEAC sampling of health care is provided through 10 functional method is a quick non-expensive method, which Community-based Planning and Health Services classifies coverage at the community level. The (CHPS) zones. The doctor to patient ratio is 1:57,183 community could be a health center, a community- while the nurse-to-patient ratio is 1:2,383. ASS is one based of the 43 administrative districts of the Ashanti compound or zone, a sub-district, a district, a region region with Mankranso as its capital. The district has or a country; any clearly defined cluster. This method 6 sub-districts with a total of 32 CHPS zones in 141 was adopted because it reaches a wider study area communities. therefore making the sample a true representation of (SLEAC) Health [10], Planning method and to Services sample (CHPS) the population under study. With the SLEAC method, 2.2 Study design and population the health districts (Ahafo Ano South - AAS and The study had a community-based analytical cross- Kumasi sectional design with a mixed-methods approach. The considered as sampling zones with a sample size of study participants were mothers/caregivers and their 40 communities each. The minimum numbers of malnourished children under-five, and frontline communities to be sampled were calculated using the health care providers who were directly involved in Spatially Stratified Sampling Method provided by the the CMAM intervention. To be included in the study, Coverage Monitoring Network [11]. In AAS, because the mother/caregiver with a malnourished child there were no available maps for the area to show all under-five must have been resident in the study are the communities, the Spatially Stratified Sampling for at least three years. The health worker had to be a Method was used to select the study communities. CMAM frontline health worker. Mothers/caregivers All the names of the sub-districts together with their with malnourished children under-five who had CHPS zones were listed, then all the communities underlying conditions or severe co-morbidities such under the zones were also listed. The grouping of the Subin sub-metropolis - KSSM) were communities under the various zones ensured a Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 500 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 spatially representative sample [12]. The sampling through the register or through snow balling, were interval was then calculated by dividing the total identified, and the children under-five in these number of households communities by the sample size were assessed so that the (141÷40=3.525 which was rounded up to 4). A mothers/caregivers with malnourished children were random number was generated with Excel (3) which surveyed. served as the starting point for the counting and identification of sampled communities. The third 2.4 Variables community on the list was chosen as the starting We point and the sampling interval was applied till the effectiveness, from the responses mothers/caregivers sample size was achieved. These calculations were provided to a specific question: CMAM has been not done for KSSM because the communities were operational in your community at least for the past not many so all the 66 communities were included in three years. Would you say it has been very effective, the study sample. KSSM has 10 CHPS zones with 66 effective, not so effective or not at all effective? We communities and AAS has 32 CHPS zones with 141 coded the responses from the 4-point Likert scale into communities. Three approaches were used to ensure a binary outcome; very effective and effective as that all the households (census) in the study „effective‟ and not so effective and not all effective as communities were visited, and all children aged 6 – „not effective.‟ For the independent variables we 59 months were screened for their nutritional status examined factors identified as associated with with the aid of the United Nations Children‟s Fund CMAM program effectiveness: maternal socio- (UNICEF) mid-Upper Arm Circumference (MUAC) demographics (age, education level, occupation, tape; the children were classified under either severe religion, ethnicity, relationship with child, child‟s acute malnutrition (SAM) cases or moderate acute age, number of children under 18), and program malnutrition (MAM) cases or not malnourished. implementation (availability of supplies and tools, First, the names of mothers/caregivers captured in the organization community-based CMAM attendance register were supplementary followed up to their homes where they were invited availability, to participate in the study if they consented to be components and maternal experiences with CMAM studied, and if any of the children under-five was services). derived our dependent of out-patient feeding availability variable, therapeutic programs, of program and personnel community-based assessed to be SAM or MAM. Second, a snow balling sampling approach was also used to reach 2.5 Data collection mothers/caregivers were Eight enumerators were trained to use a structured malnourished. The snow balling was facilitated by questionnaire to survey mothers/caregivers of the 497 the mothers/caregivers who had been identified in the malnourished children identified in both districts register, these (240 in KSSM and 257 in AAS). The respondents mothers/caregivers directed the research team to decided on a suitable time and place for the another mother until the last person was interviewed. interviews. The interviews were conducted in English Third, the rest of the households within the study or Twi as preferred by the respondent; the interviews communities, which had not been reached either lasted up to 30 minutes. A data capture form was followed whose up and children interviewed; Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 501 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 used to obtain additional data on coverage through a Microsoft Excel, for generating tables and figures. At review of consulting room registers, child welfare the univariate stage, the characteristics of the clinic (CWC) registers, monthly CWC reports, and sampled (study) population were summarized using CMAM registers at the CMAM centres. Qualitative descriptive analyses to determine the frequencies of interviews, in the form of knowledgeable informant study variables of interest. At the bivariate level, interviews (KIIs) and focus group discussions cross tabulations with chi-square tests were employed (FGDs), were carried out among service providers to show associations between the dependent and and The independent variables. In addition, the chi-square purposefully independence test was used to test for independence selected due to their in-depth knowledge about the between the dependent variable and the independent topic as service providers; one paediatrician and one variables. Finally, binary logistic regression models physician assistant, five nutritionists, 12 community were employed at the multivariate level of the health officers/nurses and six nurses all drawn from analysis to determine the statistically significant the two study sites. The KIIs assessed programme predictors of the dependent variable (thus, either implementation and the perceived challenges. These there has been improvement in the management of interviews, as well as the FGDs, investigated the malnutrition availability The children in the study communities or not). It is mothers/caregivers who participated in the focus important to state that since this study is using two groups were not studied in the quantitative survey; different datasets, the univariate, bivariate and they were invited to participate in the FGDs as they multivariate analyses were employed in two stages, accessed services at the CMAM centers. thus the KSSM and the AAS datasets were run mothers/caregivers knowledgeable respectively. informants of were CMAM services. (programme effectiveness) among separately. The regression models were assessed using Hosmer and Lemeshow‟s goodness-of-fit test 2.6 Quality control the (p0.001). Statistical significance was set at 0.05 mothers/caregivers of the quantitative component of with 95% confidence interval. At the end of the the study were re-surveyed; they were asked qualitative survey, the data were analysed using questions related to variables that would not have Attride-Stirling‟s changed within two weeks of being interviewed, such framework. The Attride-Stirling thematic network as, an framework allows for an open and methodical enumerator, whether they had a malnourished realization of emergent themes and concepts through child/children under-five, and examples of questions the application of inductive reasoning and deductive they had been asked. coding to shape the analysis and interpretation of As a data quality check, whether they had been 10% surveyed of by thematic network analysis qualitative data [13]. The qualitative analysis went 2.7 Data analysis through several steps: all audio-recorded interviews The analysis of the quantitative datasets was carried were transcribed. The transcriptions were read and out at three stages, the univariate, bivariate and reviewed alongside the field notes to ensure a clear multivariate understanding of the data. Then codes were generated stages, using STATA version 14 (StataCorp, Tx, USA), for the statistical analysis, and Journal of Food Science and Nutrition Research by assigning symbolic meaning to descriptive or Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 502 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 inferential information compiled during the study. Certificate (JHS/MSLC) when compared with their The aspect of the data to be coded during first cycle urban counterparts (15.4%), in terms of education coding processes, the portions coded can be exact lower than JHS/MSLC, the rural residents were same units, longer passages or text, analytic memos worse off when compared with their urban colleagues about the data, and even a reconfiguration of the (37% versus 25.4%). In KSSM, virtually all the codes of women were mothers to the index child (93.3%) transcripts was guided by list of organising themes compared with 60.3% in AAS. The modal age group (deductive) which were modified and expanded in both study districts was the 21-35 group. The based on information derived from reading the modal age group for children under-five in both study transcripts (inductive). Coding was done by two data districts was 12 – 23 months. The number of children entry clerks with each coding all transcripts. After under-18 who were alive ranged from one to more coding all transcripts, a review of generated codes than five. A much higher proportion of respondents was done to ensure consistency in coding (constant had five or more living children under-18 in AAS comparison approach). The process continued with a when compared with KSSM; 27.6% and 12.9% more nuanced linkage of codes, this was done by the respectively. This pattern was maintained when the relationship between codes and the underlying number of children under-five was considered (Table meaning across codes. Representative quotes that 1). In both districts, the demographic characteristics best captured the idea were presented for illustration. of the FGD participants were not far different from The data were analysed with the qualitative software that of the mothers/caregivers who participated in the package, Atlas.ti, version 7.5 (Scientific Software quantitative survey. The ages of the discussants in Development GmbH, Berlin). both districts of this study ranged between 19 and 64 themselves developed. The coding years. With regards to the level of education, about a 3. Results half of them had completed primary/junior high 3.1 Descriptive analysis schools. In terms of occupation, majority (two thirds) In the Kumasi Subin sub-metropolis (KSSM) which were traders or farmers. The discussants were mostly is urban and a business hub, about 48% of mothers of the malnourished children, with Asantes respondents were into petty trading whereas in the as the most common tribe in the group. Ahafo Ano South (AAS) district, which is rural, only 16% were traders. The unemployment figure was 3.2 Availability of CMAM tools marginally higher in AAS (14.4%) when compared We used a checklist to verify the availability of tools with KSSM (11.7%). Asantes are the major ethnic such as: SAM protocols, Out-patient Therapeutic group in the Ashanti region, and as expected, the Program (OTP) quick reference, mid-Upper Arm majority of the respondents in KSSM and AAS were Circumference (MUAC) classification table, MUAC Asantes; 60% and 55% respectively. The education tape, functioning weighing scale with basin or pants status of caregivers/mothers varied between the rural and weight for height reference card; none of the and urban areas; even though a higher proportion of facilities, neither urban nor rural, had these tools. In rural residents (39.3%) had an education level higher addition to the tools listed as not available at both than Junior High School/Middle School Leaving Journal of Food Science and Nutrition Research rural and urban facilities, the rural facilities did not Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 503 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 have the following: OTP card, SAM classification severe shortage of beds/cots for SAM children on algorithm, F-75 reference card, F-100 reference card, admission in both study sites. During the focus group Ready-to-use Food (RUTF) ration reference card, discussions, mothers/caregivers in both districts Therapeutic Feeding Program (TFP) multi-chart, and mentioned inadequate supplies as a major challenge. the TFP monthly form (Table 2) “We really get frustrated when we travel with our little money to come here only to be told there are no 3.3 CMAM supplies supplies, our families don‟t even trust us when we RUFTs and supplementary foods were supplied in tell them we came to the facility “FGD in rural adequate quantities by donor agencies to the AAS district 2 R1 (a thirty-two-year-old mother). “We health facilities but in short supply in KSSM. In come here because of supplies so if there are no KSSM, mothers/caregivers had to buy the supplies supplies, then we will spend out transportation fare to themselves. The combined vitamin/mineral mix buy food for the kids rather than making useless supplies were commonly found in the rural setting; trips” FGD in urban district 3 R3 (a twenty-six-year- however, mothers/caregivers were made to buy old mother). vitamin/mineral mix in the urban setting. There was a KSSM Characteristics AAS Frequency Percentage Frequency Percentage 240 100 257 100 Respondent's occupation Artisan 65 27.1 13 5.1 Farmer 32 13.3 166 64.6 Trader 115 47.9 41 16 Unemployed 28 11.7 37 14.4 Ethnicity Asante 144 60 142 55.3 Others 96 40 115 44.7 Education level Below JHS/MSLC 61 25.4 95 37 JHS/MSLC 142 59.2 61 23.7 Above JHS/MSLC 37 15.4 101 39.3 Relationship with child Caregiver 16 6.7 102 39.7 Parent (Mother/Father) 224 93.3 155 60.3 77.9 206 80.2 22.1 51 19.8 Respondent's religion Christian 187 Islam 53 Respondent's age  17 7.1 15 5.8 21-35 168 70 179 69.7 Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 504 J Food Sci Nutr Res 2022; 5 (2): 498-519  DOI: 10.26502/jfsnr.2642-11000094 55 22.9 63 24.5 Child's age (months) 0-11 62 25.8 26 10.1 Dec-23 94 39.2 124 48.3 84 35 107 41.6 24-59 Number of children alive (under-18) 1 79 32.9 31 12.1 2 63 26.3 49 19.1 3 40 16.7 55 21.4 4 27 11.3 51 19.8 5 or more 31 12.9 71 27.6 Number of children under-five One 167 69.6 128 49.8 Two or more 73 30.4 129 50.2 Table 1: Socio-demographic characteristics of the mothers/caregivers Urban area Rural area (KSSM) (AAS) SAM protocol Yes Yes OTP quick reference (in the appropriate local language) Yes No SAM classification algorithm Yes No MUAC classification table Yes Yes Item ICCM protocol No Yes IMNCI protocol No Yes MUAC tape Yes Yes Functioning Salter weighing scale with basin or pants Yes Yes Functioning electronic weighing scale No Yes Length board No No Stadiometer No No Weight-for-height reference card Yes Yes F-75 reference card Yes No F-100 reference card Yes No RUTF ration reference card Yes No OTP card No No TFP multi-chart (for in-patient or SC) Yes No TFP registration book No No TFP monthly statistics report form Yes No Referral form Yes Yes Table 2: Availability of tools for the CMAM programme by district Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 505 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 3.4 Out-patient therapeutic and supplementary 3.5 Trained frontline workers feeding programmes AAS knowledgeable informants mentioned that due serves to limited resources (both human and material), they mothers/caregivers only at the referral centre on were compelled to operate only the out-patient and specific days. A knowledgeable informant in the community urban setting noted that Wednesdays were for out- programme. The Nutrition Officers in the rural patient clients but throughout the week, they received district who were interviewed explained that the referrals from around the region. “We organize Out - community used to have volunteers who were patient Therapeutic Programme. The cases are demanding wages for every activity so the district referred to the nutrition rehabilitation centre of our only engages them when provision is made for facility and they have clinic days on which the volunteers to be paid. A knowledgeable informant in mothers are served”. [Nutritionist 2, urban area]. Two KSSM mentioned that though they have frontline knowledgeable informants in the rural study site workers for community mobilization, the numbers highlighted The out-patient therapeutic component mobilization components of the of the are not encouraging for work within the urban (SFP) was setting. When it comes to the treating of children dependent on the availability of RUTFs. When the under-five years old, it must be noted that it goes RUTFs are available, they are given to the beyond treating children and their families but the Community Health Officers (CHOs) to give out as whole community. A Nutrition Officer from the supplementary feeds but one of them explained that urban district noted that doctors and nurses are this is not often. “Sometimes when we have enough trained to take care of in-patient cases whereas the Plumpy Nuts and the CHOs come with a client who nutritionist manages the out-patient section. She is poor and cannot afford balanced diet for the child, explained that resource persons are usually invited to then we will give the client some of the Plumpy Nuts the facility for training and she had attended one of and educate her on how to prepare balanced diet for such trainings. In the urban district, with the the child”. [Nutrition Officer 2, rural area]. With exception of the paediatrician who was on study reference to treating SAM with complications, these leave, they had all the categories of nurses needed as children were stabilized at the children‟s ward in the well as doctors at the stabilisation centre. In AAS rural district hospital and then transferred to the there were suggestions that the district should be Regional for served with at least a paediatrician to take care of the management, in that the rural hospital does not have children whereas the adults could be managed by the paediatricians to take care of such severe childhood physician assistant; a specialist should visit the illnesses. Knowledgeable informants raised concerns district hospital once or twice a month to take care of that although CMAM programmes are supposed to be special cases to prevent the patients from travelling to available at the CHPS level, it is only screening and Komfo Anokye Teaching Hospital all the time for referrals that is done in such facilities by Community special services. “The district should have specialist Health Nurses and CHOs. for special services, paediatrician for the kids, and that supplementary their feeding Referral implementation programme Centre (MCHH-Kumasi) another specialist for the grownups while we manage the OPD cases. The community-based volunteers Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 506 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 should be considered as part of the CHPS workers to based components of the CMAM programme; out- assist the CHOs /CHNs carryout their work at the patient treatment of severe acute malnutrition without community levels.” complications, [Physician Assistant, rural management of moderate acute district]. Though CHOs in AAS maintained that they malnutrition and outreach. Both study districts all have general training on malnutrition as well as recorded very low levels of availability regarding the informal tutorials from the nutritionist they have three community-based components; in both places, never had CMAM-specific training. One of them had for each of the components, not more than 10% of this to say: “The district has not come here or invited mothers/caregivers acknowledged the availability of anyone of us for any CMAM programme or activity the components (Table 3). Here is a comment from a before. It is our female Nutritionist who updates us discussant from the urban district on community on issues from time to time. Sometimes too at our outreach services by health workers: “I don‟t even usual workshops we learn about malnutrition in know health workers go out to visit sick children in infants and breastfeeding, complementary feeding but their homes; never in my life have I seen one before not CMAM” [Community Health Officer 1, rural unless it is national immunization day (NID)” FGD 1 district]. in rural district R5. (A 36-year-old mother). “Once a month a health worker does visit to give education, 3.6 Community-based components encouragement and invites my auntie to hospital if In the quantitative survey, mothers/caregivers were there is the need”. FGD 2 in urban district R5. (A 30- asked about the availability of the three community- year-old trader). KSSM Characteristics AAS Frequency Percentage Frequency Percentage 240 100 257 100 Availability of out-patient treatment of SAM without complications Yes 7 No 233 2.9 5 2 97.1 252 98 Availability of MAM management Yes 8 3.3 16 6.2 No 232 96.7 241 93.8 Community outreach availability Yes 10 4.2 2 0.8 No 230 95.8 255 99.2 Table 3: Availability of community-based components of CMAM 3.7 Maternal experience with services the As part of the coverage assessment of the CMAM mothers/caregivers were likely to remember easily. project implementation, mothers/caregivers were Across both study sites, the service component which asked about their experiences with CMAM services; most mothers/caregivers acknowledged as present Journal of Food Science and Nutrition Research questions bordered on Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] services that 507 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 (having experienced it), was the nutrition education 91.2% of mothers/caregivers in KSSM and 94.5% in and counselling component; even then, in both sites, AAS had reportedly not experienced this service. less than 50% of mothers/caregivers acknowledged Overall, mothers/caregivers reported the following having experienced this service (42.5% in KSSM services as the least likely to have been offered: versus 47.9% in AAS). The service, least likely to supervised feeding, home visits and screening for have been experienced by mothers/caregivers and malnutrition (Table 4). their under-five children was supervised feeding; KSSM CMAM services AAS Frequency Percentage Frequency Percentage 240 100 257 100 Provision of nutrition education and counselling Yes 102 42.5 123 47.9 No 138 57.5 134 52.1 Provision of food supplies for malnourished children Yes 62 25.8 128 49.8 No 178 74.2 129 50.2 Demonstration of food preparation Yes 64 26.7 94 36.6 No 176 73.3 163 63.4 Yes 69 28.8 84 32.7 No 171 71.2 173 67.3 Monitoring of children’s weight Visiting of malnourished children in their homes Yes 13 5.4 42 16.3 No 227 94.6 215 83.7 Supervised feeding of children enrolled in the programme Yes 21 8.8 14 5.5 No 219 91.2 243 94.5 Screening children for malnutrition Yes 39 16.3 20 7.8 No 201 83.7 237 92.2 Referring sick children to a health facility/clinic Yes 72 30 53 20.6 No 168 70 204 79.4 Table 4: Maternal experiences CMAM services Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 508 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 3.8 Maternal socio-demographics and experiences centres in urban and rural respectively with a associated with program effectiveness Nagelkerke‟s R2 value 77.70%. This means that the A bivariate logistic regression model was run to model explains 77.70% of the variation of the determine the predictive effect of maternal socio- effectiveness of CMAM in KSSM. In KSSM, number demographics and maternal experience of CMAM of children alive (with increasing number of children services The alive, mothers/caregivers were significantly less relationship between the availability of CMAM likely to find the programme effective), provision of community-based components (proxy for coverage), nutrition education and counselling (when compared and programme effectiveness was not assessed as the with mothers who had experienced provision of cell values were too small and hence the model nutrition education and counselling, those who had output was impossible to interpret. All socio- not, had significantly lower odds of reporting demographic variables and maternal experience of programme effectiveness), and demonstration of food CMAM services were considered in the model as preparation (mothers who had not experienced predictors of the effectiveness of the CMAM demonstration programme. The Hosmer and Lemeshow (H-L) malnourished child were significantly less likely to goodness of-fit test of 0.001 for both districts was report statistically significant and that implies the model influenced programme effectiveness. Yet these same estimates fit the data at acceptable level and thus the socio-demographic and other co-variates that affect model is a good fit. The inclusion of all the the effectiveness of CMAM in KSSM, did not explanatory variables yields a better fit and the model significantly predict CMAM effectiveness in AAS predicts (Table 5). on programme 66.7% and effectiveness. 85.6% of the correct of programme food preparation effectiveness), for the significantly categorization of children enrolled in the CMAM KSSM Indicator variables OR [ 95% CI] AAS P-Value OR [95% CI] P-Value Occupation Earning income (ref) 1 1 Not earning income 1.023 [0.190, 5.506] 0.979 0.671 [0.120, 3.734] 0.648 Ethnicity Asante (ref) 1 1 Others 0.704 [0.170, 2.916] 0.629 0.898 [0.304, 2.651] 0.846 Education level Below JHS/MSLC (ref) 1 JHS/MSLC 0.497 [0.076, 3.263] 0.466 1.435 [0.428, 4.810] 1 0.559 Above JHS/MSLC 0.398 [0.087, 1.827] 0.236 0.770 [0.244, 2.427] 0.655 Relationship with child Caregiver (ref) 1 1 Mother 0.889 [0.134, 5.899] 0.903 1.330 [0.425, 4.160] 0.624 Religion Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 509 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 Christian (ref) 1 1 Islam 5.298 [0.954, 29.426] 0.057 1.556 [0.409, 5.922] 0.517 Respondent's age (years) <20 (ref) 1 1 20-35 3.195 [0.128, 79.690] 0.479 0.139 [0.010, 2.004] 0.147 36+ 2.484 [0.511, 12.078] 0.259 0.584 [0.150, 2.280] 0.439 Child's age (months) 0-11 (ref) 1 1 Dec-23 0.594 [0.133, 2.662] 0.496 1.808 [0.425, 7.696] 0.423 24-59 2.328 [0.575, 9.429] 0.237 1.069 [0.367, 3.112] 0.902 Number of children alive 1 (ref) 1 1 2 0.022 [0.002, 0.282] 0.003 5.899 [0.662, 52.583] 0.112 3 0.033 [0.003, 0.370] 0.006 1.837 [0.343, 9.857] 0.478 4 0.087 [0.009, 0.796] 0.031 0.786 [0.141, 4387] 0.784 5 or more 0.149 [0.015, 1.465] 0.103 0.895 [0.207, 3.878] 0.882 Number of children under-five Below 2 (ref) 1 1 Two or above 2.414 [0.609, 9.574] 0.21 0.819 [0.279, 2.403] 0.716 Provision of nutrition education and counselling Yes (ref) 1 No 0.009 [0.001, 0.065] 1 0.001 0.137 [0.004, 5.207] 0.284 Provision of food supplies for malnourished children Yes (ref) 1 No 0.566 [0.144, 2.229] 1 0.416 0.129 [0.003, 4.773] 0.226 Demonstration of food preparation Yes (ref) 1 1 No 0.227 [0.065, 0.793] 0.02 0.634 [0.196, 2.053] 0.447 Monitoring of children’s weight Yes (ref) 1 1 No 0.497 [0.143, 1.603] 0.232 0.604 [0.201, 1.818] 0.37 Visiting of malnourished children in their homes Yes (ref) 1 1 No 0.255 [0.016, 4.125] 0.336 1.083 [0.382, 3.066] 0.881 Supervised feeding of children enrolled in their programme Yes (ref) 1 1 No 0.740 [0.091, 6.048] 0.779 1287844952.936 [0] 0.998 Screening children for malnutrition Yes (ref) 1 No 1.940 [0.437, 8.599] Journal of Food Science and Nutrition Research 1 0.383 1.801 [0.453, 7.157] Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 0.403 510 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 Referring sick children to a health facility/clinic Yes (ref) 1 1 No 1.552 [0.468, 5.148] 0.473 0.778 [0.286, 2.119] 0.624 0 0.998 Model summary Constant (β) 70.067 Correct % prediction 66.7 85.6 Nagelkerke R2 77.70% 0.435 model Chi square (df) 196.911 (23) 0.001 72.035 (23) 0.001 H Lemeshow Chi square (df) 5.212 (8) 0.735 3.511 (8) 0.898 0.029 Table 5: Socio-demographics and maternal experience associated with CMAM programme effectiveness 4. Discussion health care provision in any health care system is A community-based strategy is predicted to thrive in based on the availability of the required human the Acute resource, infrastructure and equipment. Therefore, Malnutrition (CMAM). Three of the four CMAM the quality of CMAM service delivery is linked to the components are community-based, according to the available tools at the CMAM centre and within the UNICEF (2013a) framework, and the promotion of CMAM coverage area [14,15]. The current study in the community-based idea was to encourage early the Kumasi Subin sub-metropolis (KSSM) and the detection and management of malnutrition cases at Ahafo Ano South district shows that rural (AAS) the community level, in order to avoid progression to facilities were more likely than the urban (KSSM) Severe Acute Malnutrition (SAM); community ones to be without the CMAM tools; in addition to engagement is one of the key tenets of Primary the tools listed as not available at both rural and Health Care.Improper organisation/implementation urban facilities, the rural facilities did not have the of the intervention simply means that cases which following: OTP quick reference, SAM classification always start as Moderate Acute Malnutrition (MAM) algorithm, F-75 reference card, F-100 reference card, and or uncomplicated SAM, will be missed, and RUTF ration reference card, TFP multi-chart, and the progression to SAM with complications means that TFP monthly statistics form. Less than half of the 20 community participation will be a challenge. As an items assessed were available in the rural setting, and assessment programme only in three instances did the rural area have a tool implementation, this study focused on how the that the urban facilities did not have – Integrated community-based CMAM Community Case Management protocol, Integrated intervention were implemented in the study districts; Management of Newborn and Childhood Illness availability out-patient protocol and a functioning electronic weighing scale treatment organisation, trained staff availability and were the only three items. The qualitative results availability of the community-based CMAM services corroborated these quantitative findings; a good were used as proxy indicators for implementation number of the knowledgeable informants in both assessment. It is important to note that, effective districts reported the non-availability of essential Community-based of of Management the CMAM components tools and of of the supplies, Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 511 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 tools for CMAM implementation. It is pleasing to CMAM, supplies such as RUTF and other food note that one of the most basic but very important supplements are essential for the process to reverse tools required for successful implementation of the mortality in Severe Acute Malnutrition (SAM) cases. community-based CMAM component, the mid- Out-patient care (OPC) is an integral part of the Upper Arm Circumference tape, was available in CMAM project as most cases of SAM are usually both study sites; the comforting fact here is that if the screened at the OPC facility [18,19]. To provide a programme was being implemented successfully, the better understanding of the Out-Patient Therapeutic lowest cadre of CMAM-specific health workers, the Programme of the CMAM intervention in KSSM and Community Health Workers (CHWs), would have a AAS, this study assessed the out-patient treatment tool with which they could screen children at the component of the programme by looking at the household refer availability of supplies such as: RUFT, F-75, F-100, appropriately; CHWs have been at the centre of the routine medication and measuring tools for height CMAM the and weight. In the current survey, RUTFs and malnourished children at the household level [16]. supplementary foods and vitamin/mineral mix were However, it is difficult to imagine how the children found to be in adequate quantities in the rural district, on the programme were documented since the Out- and this was because donors/development partners patient Therapeutic Programme card was missing in supported the provision of such supplies but the both places. Additionally, it is mind bugling to donor support was not enough to meet the F-75 and reconcile the absence of tools such as SAM F-100 needs of the rural setting. Meanwhile, RUTFs classification and and supplementary foods were not in adequate Stadiometer with the tracking of improvements made quantities in the urban district due to high patronage by children on the programme; how do the facilities and track weight and height gain, and determine the mothers/caregivers were buying supplies from shops RUTF ration based on weight and specific for each at prices that were beyond the reach of poor child? Inconsistencies in record keeping, outright households [20]. The urban health facilities asked zero record keeping, and non-use of monitoring parents information will collectively contribute to poor vitamin/mineral mix to support the programme programme implementation in the study areas. Even however, the National Health Insurance Scheme if programmes have well-trained and qualified staff, (NHIS) covered the cost of medications. It is worthy and in the numbers required, this human resource will to note that, the presence or absence of a donor for be limited in its output by lack of tools (materials) each with which to work hence we cannot expect implementation in the study districts. Park et al. and successful CMAM programme implementation. Low UNICEF are strong advocates of the notion that, tool stocks can be expected to negatively impact the children with Severe Acute Malnutrition without effectiveness of the CMAM intervention in both medical complications, should be referred to a urban Supplies Supplementary Feeding Programme (SFP), where (materials) constitute a required input for processes they can receive RUTFs, take-home dry rations and within systems to yield the desired output. In immunisation; especially in the urban study area level for programme malnutrition since algorithm, and rural settings they Length in and identify Board, Ghana. Journal of Food Science and Nutrition Research over to input reliance buy has on RUTFs, donor F-100, implications for Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] support; F-75 and programme 512 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 (KSSM), these supplies were not available at the in health institutions had a great impact on the quality centres, and one wonders how mothers/caregivers of care provided to malnourished children [24,25]. were expected to follow referral instructions [21]. In Stock outs of essential supplies may lead to Ethiopia, the Out-patient Therapeutic Programme is programme considered CMAM therapeutic component serves mothers/caregivers intervention, and the country ensures that RUTFs and only at the referral centre on specific days, and other supplies are always available to children who mothers are to feed their children in their homes with are referred. Unfortunately, the CMAM programme visits and counselling by the CHWs. This has been in KSSM and AAS do not have this focus, and documented by Frankel, Roland and Makinen as a mothers/caregivers are likely to be frustrated at solution to prolonged hospital stay and its related having to travel long distances and to pay for the challenges [26]. According to Tadesse, Ekstrom and transportation costs only to arrive at the centres to be Berhane, these children come once a week or twice a told that supplies are stocked out. In the qualitative month to the OTP site to receive RUTF, a course of survey in both study sites, mothers/caregivers poured oral out their anger at this gap; they would rather spend treatment, folic acid and vitamin A supplementation, the little money they had to buy food for the children measles vaccination and antimalarial drugs where than to waste money on transport to pick up zero appropriate. According to UNICEF (2013a), the OTP supplies. is also intended for children presenting with SAM as the Frustrated heartbeat of the mothers/caregivers can be ineffectiveness. broad-spectrum The antibiotics, out-patient anti-helminthic expected to be very harsh with health workers at the with centres, and this will lead to mistrust between the two complications, and for children who are transferred key parties in the quest to address malnutrition at the from in-patient care after they recover. On their part, household/community levels; mothers/caregivers are Park stated that, OTP involves admissions of children unlikely to return to these centres to seek treatment with SAM but with no complications, who are for their malnourished children. Shortages of Plumpy referred from the targeted communities by CHWs, Nuts for malnourished children impeded progress and being made by CMAM since mothers/caregivers did complications who are provided appropriate medical not go back after long breaks of shortages of the nuts care to prevent further complications [27]. Ethiopia [22]. gain has embedded the OTP services into their Primary maltreatment and strong vituperations from their Health Care facilities, therefore bringing OTP closer male partners when the women, after being trusted to to target communities [19]. The qualitative findings fetch such supplies with meagre household earnings, from the current study support the findings in return only to report stock out of supplies. Shanka, literature with reference to the OTP component Lemma and Ayu [23] found that in some CMAM serving programmes, RUTFs were being distributed to non- knowledgeable informants in the urban setting noted SAM children and in the current study, such that Wednesdays were for out-patient clients but misapplication of supplies and false enrolment may throughout the week, they received referrals from be contributing to shortages in supplies. English et al. around the region. However, since the OTP services and Nolan et al. report that availability of resources are rendered at the district health directorate and Some mothers/caregivers will also Journal of Food Science and Nutrition Research good appetite severely mothers and malnourished only on without children specific Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] medical with days; 513 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 regional referral centres instead of CMAM centres in including traditional birth attendants were trained to the communities, both KSSM and AAS were not aid early detection, referral, and treatment of acutely implementing the concept in the communities; the malnourished children in their communities. The CMAM programme in the study sites is heavily results of this survey paint a different picture about weighted towards the facility-based component the current situation in KSSM and AAS. The two because districts appear not to have enough trained workers there are not enough health staff (Community Health Nurses and Officers) and neither for the are there functional Community Health Workers to programme inception in 2012, only eight health effect the community-based component of CMAM. workers have been trained in the urban district. It This may not allow many MAM cases to be appears the regional scale up in the Ashanti region identified early enough for treatment before they that must have resulted in the Food and Nutrition progress into SAM with complications, and this will Technical Assistance (FANTA) III trainings in the contribute outcomes/programme Asante Akim North district, did not ensure that the effectiveness. Human resources make up the most training covered all the districts within the region. important input for any system. The CMAM services Frequent staff transfers, staff rotations and staff go beyond treating children under-five years and their desire for further training/schooling would deplete families to the inclusion of the whole community. some districts off CMAM trained staff. The training According to the World Vision International [28], status in the rural district was despicable; there has community leaders, volunteers, health staff and never been any formal CMAM training for health families participate in the screening, care and follow staff. It is plausible that poorly trained and untrained up of children with acute malnutrition. In Ethiopia, staff would misapply anthropometric tools in case Health Extension Workers and Community Health detection which would affect admission into, and exit Workers are the drivers of CMAM services in the from the CMAM programme in the study districts local health facilities [29]. On a weekly basis, these [30]. Community Health Workers/Volunteers were CHWs update their supervisors at the health posts, not functional in any of the districts because the meet fortnightly with their HEWs in their localities, districts cannot afford to pay for their “voluntary and have monthly meetings at the corresponding services.” This raises serious concerns because the health posts. An evaluation report by UNICEF (2012) front-line workers such as CHWs are key in the shows that as at August 2011, over 7,000 Community screening and early case detection for referral of Health Volunteers had been trained to provide OTP uncomplicated cases; CHWs and volunteers have services in Ethiopia. In support of getting the critical been at the centre of the CMAM programme since in mass needed to achieve programme effectiveness, the the FANTA III project trained a total of 3,063 health care malnourished children at the household level. The providers and 6,753 community volunteers, opinion success (programme effectiveness) of a CMAM leaders and traditional and spiritual healers six intervention is accurately predicted by active case months after the implementation of CMAM in finding, referral to the community-based component Ghana. In the Asante Akim North district of Ghana, of the programme, and effective follow up measures five scores of volunteers and traditional healers at the community and household levels, and the to poor Journal of Food Science and Nutrition Research community-based target communities, activities; they Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] since identify the the 514 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 CHWs provide the well-oiled nexus between these levels of availability regarding the three community- predictors. With this link missing in the study areas, based components; in both places, for each of the SAM cases may not be picked up early enough to components, quantitative data suggest that not more meet the aim of the CMAM programme and this may than 1-in-10 mothers/caregivers acknowledged the lead to low programme effectiveness. Since the Alma availability of the components. The component with Ata Conference in 1978, community participation has the highest availability rating was management of been identified as a pillar for primary health care MAM in the Ahafo Ano South (AAS) district; a especially in developing countries where populations disappointing 6% of mothers/caregivers reported that are the poorest and the most powerless to have the this component was available to them. Community right and the duty to participate in the planning and outreach in AAS was the least likely available implementation of their health care Community component to women and their malnourished participation helps the community recognize the children under-five; virtually no woman reported this problem at hand and possible ways to solve it on their component as available (0.8%). Surprisingly, the own, with or without help from professionals [31]. least available component to women in the rural Myatt and Guerrero [32], in their model that looked setting (Ahafo Ano South), community outreach, at the relationship between factors affecting coverage received the highest availability rating in the urban and effectiveness, conceptualised that all the four setting (Kumasi Subin sub-metropolis). It is possible components of the CMAM programme need to that in the face of zero CHWs and few CHNs, KSSM function optimally for the attainment of positive with the smaller number of communities was easier results, as in programme effectiveness. They opined to cover with outreach. Another issue that could be that health services programmes do better when there responsible for the low outreach availability was is community sensitisation and mobilisation by tendency of some mothers/caregivers, for reasons trained professionals. This will translate to early case unknown, detection with fewer complications and therefore Choudhury et al. report from their study in managed at the OTP units with all the accruing Bangladesh; benefits. The implementation of the community- uncomfortable with home visits to dwelling places based components of CMAM has been uninspiring in that house many households that are a bit unfriendly the two study districts (KSSM and AAS). As a proxy, towards each other. With very low community the outreach levels, it follows that out-patient treatment availability of three community-based to give wrong home women/caregivers addresses may as feel components were assessed in the current survey; out- of patient treatment of Severe Acute Malnutrition management of MAM will both have very low (SAM) without cases without complications and management of availability levels; without the SAM and MAM cases (MAM) and being picked up through community outreach, there community outreach. Women/caregivers from both would be no cases to offer them these treatment study districts were asked whether services within the services. Qualitative data from the FGDs with the three components were available to them – were mothers/caregivers backed this finding of very low these services there any time the women went to availability; when a mother, who is a resident of the access the services? The survey found very low rural study area, reports that she has never in her Moderate Acute complications, SAM Malnutrition Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 515 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 lifetime as a mother, observed any health worker visit approach and the fact that this is the very first attempt a sick child (malnourished) in the home then the at assessing CMAM at sub-national levels within quantitative finding is difficult to dispute. The urban and rural settings is a great plus for the study. effectiveness of the CMAM programme in the two study districts is likely to be affected by non- 5. Conclusions availability of supplies and service components as The community-based component of the Community- affirmed by qualitative data; mothers bemoaned based Management of Acute Malnutrition (CMAM) issues such as: inadequate staff, recurrent shortages programme in the Kumasi Subin sub-metropolis of Plumpy Nuts, F-75, and F-100, and the obligation (KSSM) and the Ahafo Ano South (AAS) district of to buy ingredients for health staff to prepare milk (F- Ashanti region, Ghana, has serious implementation 75 and F-100) for their children. In our study, we challenges. The health administrations in both asked to rate the effectiveness on an ordinal scale, settings should use effective community entry and the relationships between socio-demographics, approaches to engage the community gate keepers maternal experiences with CMAM services and and effectiveness were determined. The results were very contextualised different in the two study districts; while socio- improve programme impact while ensuring that demographics such as number of children alive, and adequate numbers of CMAM-trained health staff are maternal experience variables such as provision of operational in the study districts. nutrition education and counselling, other relevant stakeholders to community-directed determine pathways to and demonstration of food preparation, significantly Acknowledgements affected programme effectiveness in the urban The current study did not benefit from any external setting, no variables was found to do similar in the funding. We acknowledge the study participants and rural district. This finding may suggest that different the enumerators for working together to undertake variables, other than those studied, may be the this study. determinants of programme effectiveness in the rural district [33]. Conflict of interest None to declare. Strengths and weaknesses This study has limitations. First, we had no way of verifying the answers given by the mothers/caregivers since their contacts with health workers may have resulted in the mothers/caregivers providing socially desirable answers. Second, the period of recall for some of the issues studied was over a decade and respondents may have been unable to vividly recollect the related events. Third, it is difficult to determine cause and effect with cross- Ethical Statements This study does not involve any human or animal testing. The Kwame Nkrumah University of Science and Technology/Komfo Anokye Teaching Hospital Committee Publications on Human Research, approved the Ethics and study (CHRPE/AP/314/15). Administrative clearance was sought from the Regional Health Directorate and the Metropolitan/District Health Directorates as well as sectional surveys. However, the mixed methods Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. 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Communitybased Management Malnutrition. of Geneva: Severe World Acute Health Organization (2007). Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 518 J Food Sci Nutr Res 2022; 5 (2): 498-519 DOI: 10.26502/jfsnr.2642-11000094 This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license 4.0 Journal of Food Science and Nutrition Research Vol. 5 No. 2 - June 2022. [ISSN 2642-1100] 519