title: Stigma as a barrier to treatment for child acute malnutrition in Marsabit County, Kenya.
abstract: Acute malnutrition affects millions of children each year, yet global coverage of life-saving treatment through the community-based management of acute malnutrition (CMAM) is estimated to be below 15%. We investigated the potential role of stigma as a barrier to accessing CMAM. We surveyed caregivers bringing children to rural health facilities in Marsabit County, Kenya, divided into three strata based on the mid-upper arm circumference of the child: normal status (n = 327), moderate acute malnutrition (MAM, n = 241) and severe acute malnutrition (SAM, n = 143). We used multilevel mixed effects logistic regression to estimate the odds of reporting shame as a barrier to accessing health care. We found that the most common barriers to accessing child health care were those known to be universally problematic: women's time and labour constraints. These constituted the top five most frequently reported barriers regardless of child acute malnutrition status. In contrast, the odds of reporting shame as a barrier were 3.64 (confidence interval: 1.66-8.03, P < 0.05) times higher in caregivers of MAM and SAM children relative to those of normal children. We conclude that stigma is an under-recognized barrier to accessing CMAM and may constrain programme coverage. In light of the large gap in coverage of CMAM, there is an urgent need to understand the sources of acute malnutrition-associated stigma and adopt effective means of de-stigmatization.
authors.affiliation: Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA.
authors.forename: Jessica Robin
authors.initials: JR
authors.lastname: Bliss
authors.affiliation: Concern Worldwide, Nairobi, Kenya.
authors.forename: Martin
authors.initials: M
authors.lastname: Njenga
authors.affiliation: Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA.
authors.forename: Rebecca Joyce
authors.initials: RJ
authors.lastname: Stoltzfus
authors.affiliation: Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA.
authors.forename: David Louis
authors.initials: DL
authors.lastname: Pelletier
mesh_terms: D017028:Caregivers; D002664:Child Nutritional Physiological Phenomena; D002675:Child, Preschool; D003131:Combined Modality Therapy; D003144:Communication Barriers; D005260:Female; D063105:Food Assistance; D005783:Gender Identity; D006297:Health Services Accessibility; D006801:Humans; D015994:Incidence; D007223:Infant; D007390:International Agencies; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008507:Medically Underserved Area; D010342:Patient Acceptance of Health Care; D012423:Rural Health; D057566:Self Report; D000067011:Severe Acute Malnutrition / Q000178:diet therapy / Q000453:epidemiology / Q000628:therapy*; D012752:Shame; D057545:Social Stigma
keywords: access; acute malnutrition; community-based management of acute malnutrition; stigma