Scheduled Follow-Up Referrals and Simple Prevention Kits Including Counseling to Improve Post-Discharge Outcomes Among Children in Uganda: A Proof-of-Concept Study

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FIGURE
Study Flow of Subjects Enrolled and Excluded

TABLE 1 Baseline Characteristics of Study Subjects (N = 216)

Variable	Value
Male sex, No. (%)	107 (49.5)
Age, months, median (IQR)	16.1 (10.2, 29.1)
Prior care sought for illness, No. (%)	160 (74.1)
Referred for the initial hospital admission	42 (19.4)
Referral source: hospital	3 (7.0)
Referral source: health center	33 (78.6)
Referral source: untrained health worker	6 (14.3)
MUAC <115 mm, No. (%)	14 (6.5)
MUAC 115–125 mm, No. (%)	21 (9.7)
Underweight (WAZ <-2), No. (%)	53 (24.7)
Severely underweight (WAZ <-3), No. (%)	24 (11.2)
Wasted (WHZ <-2), No. (%)	56 (26.2)
Severely wasted (WHZ <-3), No. (%)	28 (13.1)
Stunted (HAZ <-2), No. (%)	59 (27.4)
Severely stunted (HAZ <-3), No. (%)	31 (14.4)
HIV positive, No. (%)	15 (7.0)
Maternal education, No. (%)
No school	18 (8.3)
Less than primary 3	17 (7.9)
Primary 4 to primary 7	91 (42.1)
Secondary 1 to secondary 6	60 (27.8)
Post-secondary	30 (13.9)
Discharge diagnosis, No. (%)
Malaria	43 (19.9)
Pneumonia	104 (48.2)
Diarrhea	17 (7.9)
Discharged against medical advice, No. (%)	17 (8.0)
In-hospital mortality, No. (%)	14 (6.5)
Referred to higher level of care, No. (%)	4 (1.9)

Abbreviations: HAZ, height-for-age z score; IQR, interquartile range; MUAC, mid-upper arm circumference; WAZ, weight-for-age z score; WHZ, weight-for-height z score.

TABLE 2 Post-Discharge Referral Completions and Outcomes Among Discharged Children

	No. (%)
Referral program completions (N = 202)
At least 1 visit	170 (84)
At least 2 visits	143 (71)
All 3 visits	96 (48)
Outcome for visit 1 (n = 171)
No intervention	111 (65)
Outpatient-based intervention	54 (32)
Admission	2 (1)
Referral to higher level of care	4 (2)
Outcome for visit 2 (n = 141)
No intervention	88 (62)
Outpatient-based treatment	42 (30)
Admission	8 (6)
Referral to higher level of care	3 (2)
Outcome for visit 3 (n = 95)
No intervention	60 (63)
Outpatient-based treatment	31 (33)
Admission	2 (2)
Referral to higher level of care	2 (2)
Reasons for missed referral visits (n = 104)
Child not sick/visit not considered important	22 (22)
Child away	12 (12)
Child admitted	7 (7)
Child died	3 (3)
Forgot to go	15 (15)
Visit not possible (health system factors^a)	16 (16)
Visit not possible (family factors^b)	23 (23)

↵a Examples of health system factors include closed health center and unavailable community health worker.
↵b Examples of family factors include cost barriers, no transportation available, and husband denied permission.

TABLE 3 Analysis of Factors Associated With Post-Discharge Referral Completion (N = 202)

Variable	OR (95% CI)	P Value
Sex (female)	1.03 (0.48, 2.21)	.93
Age (for each month increase)	1.00 (0.97, 1.02)	.77
Referral at initial admission	0.85 (0.32, 2.60)	.74
MUAC (for each 1 mm increase)	1.01 (1.00, 1.04)	.10
WAZ (for each 1 SD increase)	1.20 (0.96, 1.50)	.11
HIV positive	2.52 (0.32, 19.96)	.38
Crowding (for each additional household member)	1.09 (0.90, 1.31)	.38
Sibling death	1.03 (0.39, 2.72)	.95
Maternal age (for each 1-year increase)	1.01 (0.94, 1.08)	.81
Mosquito net use (always vs. no/sometimes)	2.00 (0.90, 4.47)	.09
Length of stay > 5 days	0.53 (0.24, 1.19)	.12

Abbreviations: CI, confidence interval; MUAC, mid-upper arm circumference; OR, odds ratio; SD, standard deviation; WAZ, weight-for-age z score.

TABLE 4 Post-Discharge Mortality and Readmission Details (N = 202)

	No. (%)
Mortality within 60 days post-discharge	5 (2.5)
Location of death
Home	3 (60.0)
Home of a relative or friend	1 (20.0)
Hospital	1 (20.0)
60-day post-discharge readmission	22 (10.9)
Once	16 (72.7)
Twice	4 (18.2)
Three times	2 (9.1)
Source of readmission (n = 28)
Self-referral	16 (57.1)
Scheduled post-discharge referral	12 (42.8)

TABLE 5 Caregiver Satisfaction With Interventions^a

	No. (%)
Did the education provided at discharge improve your ability to take care of your child? (n = 191)
Yes, strongly	147 (76.9)
Yes, somewhat	44 (23.0)
No	2 (1.0)
Were the soap, oral rehydration salts, and mosquito net helpful in better caring for your child after discharge? (n = 189)
Yes, strongly	123 (65.1)
Yes, somewhat	66 (34.9)
No	1 (0.5)
Did you feel that the referrals were helpful in caring for your child after discharge? (n = 170)
Yes, very helpful	105 (61.7)
Yes, somewhat helpful	54 (31.8)
Not sure	5 (2.9)
No	6 (3.5)
Did you find the referrals difficult/inconvenient? (n = 170)
Yes, very difficult/inconvenient	3 (1.8)
Yes, somewhat difficult/inconvenient	32 (18.8)
Not sure	7 (4.1)
No, not difficult/inconvenient	128 (75.2)
Overall satisfaction with discharge kit and post-discharge referral (n = 195)
Very satisfied	72 (36.9)
Somewhat satisfied	117 (60.0)
Not satisfied	4 (2.1)

↵a Sample size for the satisfaction indicators are slightly different, reflecting that not all children discharged (such as most who were discharged against medical advice) received the counseling and incentives, and not all caregivers participated in the satisfaction survey.

TABLE 6 Comparison of Outcomes Between Earlier Observational Cohort (N = 1,242) and Current Intervention Cohort (N = 202)

Outcome	Earlier Observational Cohort, No. (%)	Current Intervention Cohort, No. (%)	OR (95% CI)
Readmission	72 (5.8)	22 (10.9)	1.97^b (1.14, 3.23)
Any visit	383 (30.8)	177^a (87.6)	14.61^b (9.41, 22.67)
Death	41 (3.3)	5 (2.5)	0.75 (0.29, 1.92)

Abbreviation: CI, confidence interval; OR, odds ratio.
↵a Also includes non-referral visit; therefore, the number in this table is higher than the 170 indicated in Table 2.
↵b Adjusted for site of enrollment and post-discharge mortality risk score.

TABLE 7 Characteristics of Discharged Subjects, Comparison Between Earlier Observational Cohort (N = 1,242) and Current Intervention Cohort (N = 202)

	Earlier Observational Cohort	Current Intervention Cohort
Male sex, No. (%)	682 (54.9)	103 (51.0)
Age, months, median (IQR)	18.1 (10.8, 34.6)	16.2 (10.0, 29.0)
MUAC <115 mm, No. (%)	96 (7.7)	12 (5.9)
MUAC 115–125 mm, No. (%)	87 (7.0)	19 (9.4)
Severely underweight (WAZ <-3), No. (%)	188 (15.1)	20 (10.0)
Severely wasted (WHZ <-3), No. (%)	232 (18.7)	24 (11.9)
Severely stunted (HAZ <-3), No. (%)	187 (15.0)	28 (13.9)
Mean SpO2 at admission	94.0 (90.0, 96.0)	91.0 (85.5, 97.0)
Percent with abnormal BCS score (<5)	133 (10.7)	31 (15.4)
HIV positive, No. (%)	58 (4.7)	14 (7.0)
Maternal education, No. (%)
Less than primary 3	250 (20.1)	29 (14.4)
Primary 4 to primary 7	630 (50.7)	85 (42.1)
Secondary 1 to secondary 6	269 (21.6)	58 (28.7)
Post-secondary	93 (7.5)	30 (14.9)
Discharge diagnosis, No. (%)
Malaria	418 (33.6)	39 (19.3)
Pneumonia	390 (31.4)	98 (48.5)
Diarrhea	96 (7.7)	17 (7.4)
Discharged against medical advice, No. (%)	120 (9.6)	17 (8.4)

Abbreviations: BCS, Blantyre Coma Scale; HAZ, height-for-age z score; IQR, interquartile range; MUAC, mid-upper arm circumference; WAZ, weight-for-age z score; WHZ, weight-for-height z score.