“When they stop coming, we lose them”: a qualitative study assessing health workers’ experiences on treatment default during outpatient therapeutic care for severe acute malnutrition at Gulu regional referral hospital, Uganda

Abstract

Background
Outpatient therapeutic care (OTC) programs are essential for managing severe acute malnutrition (SAM) among children under 5 years. However, default rates in northern Uganda remain high- reaching up to 21.9%. This study explored the experiences of health workers delivering OTC services on outpatient therapeutic care treatment default at Gulu regional referral hospital (GRRH).
Methods
This was a qualitative descriptive study that employed phenomenology. Semi structured interviews were conducted with nine purposively selected health workers. All interviews were transcribed verbatim and analyzed thematically.
Results
Six core themes emerged from the data analysis: organization of the OTC program, causes of treatment default, consequences of default, management and prevention strategies, programmatic challenges, and recommendations for program improvement. Many health workers described multiple drivers of default, including structural and systemic barriers (e.g., long distances, transport costs, RUTF stockouts, staff absenteeism, and seasonal farming), caregiver-level challenges (e.g., Domestic violence, long distances, transport costs, family separation, poverty, seasonal farming, inadequate social support, and cultural beliefs), health literacy gaps (e.g., misinformation, misconceptions and negligence), and child-level clinical complications (comorbidities e.g., HIV, TB, cerebral palsy).
Conclusions
Outpatient therapeutic care treatment default is driven by a complex intersection of health system and structural limitations, caregiver socio-economic challenges, and child-related factors. Addressing these requires strengthening defaulter tracing via systematic tracking and community follow up, decentralizing OTC services to lower level facilities with dedicated staff, and ensuring consistent RUTF supply, staffing, and clinic schedules.