Household and Health-System Factors Contributing to Poor Treatment Outcomes of Malnutrition among Preschool Children: Perceptions of Nurses in General Hospitals of Northwest Nigeria

AbstractBackground: Facility-based treatment of severe malnutrition can achieve low case-fatalitywhen World Health Organization guidelines are followed, yet outcomes in many Africanhospitals remain poor. In Northwest Nigeria, where the burden of child malnutrition is thehighest in the country, little is known about how frontline nurses explain suboptimaltreatment results.Objective: To describe nurses' perceptions of the proximal (facility-level) and upstream(household and system-level) factors that contribute to poor malnutrition treatment outcomesamong preschool children.Methods: A cross-sectional survey was conducted among nurses in nine state-owned generalhospitals selected by multistage sampling across three Northwest states. A 10-item, 4-pointLikert scale adapted from health-worker reports in comparable settings was administered to370 nurses; 352 valid responses (95.1%) were analysed. Item means were compared with acriterion of 2.50, and the composite score was tested against the criterion with a one-sample ttest.Results: The composite score exceeded the criterion (M = 2.62, 95% CI [2.52, 2.71], t(351) =2.47, p = .014). Nurses most strongly endorsed household child neglect (M = 3.29),misdiagnosis at the first point of care (M = 3.21), inadequate bed capacity (M = 3.15), lack ofbasic resources for preparing therapeutic feeds (M = 3.12), turnover of skilled personnel (M =2.97) and limited capacity to manage complex cases (M = 2.95). They did not endorseintermittent shortages of therapeutic supplies (M = 1.91), organisation-wide systemchallenges (M = 1.79), inadequate after-hours staffing (M = 1.58) or traditional medicine (M= 2.21) as contributors.Conclusion: Nurses located the main threats to treatment success at the household interfaceand at the facility's front door, in diagnosis, beds, feed preparation and skills. A nurse-ledmanagement approach that strengthens triage, ward capacity, feed preparation, staff retentionand caregiver engagement is likely to improve outcomes.