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Med. J. Cairo Univ., Vol. 86, No. 3, June: 1635-1648, 2018
www.medicaljournalofcairouniversity.net
Assessment of Nutritional Services Provided for Hepatitis C Patients
Attending the National Nutrition Institute in Cairo
YOSRA A. EL-SHAIKH, M.Sc.*; HANAN A. EL-RAGHY, M.D.**; HANAA A. ABOU-ZEINA, M.D. **;
DINA I. SHEHAB, M.D.*** and HANADY G. SHEHA, M.D.***
The Department of Preventive Medicine, Faculty of Medicine, Helwan University*,
The Department of Public Health & Community, Medicine, Faculty of Medicine, Cairo University** and
The Department of Clinical Nutrition, National Nutrition Institute***, Cairo
Abstract Introduction
Malnutrition is common among chronic
Background: EGYPT
liver diseases patients. Thorough nutritional counseling should has the highest prevalence of the Hepatitis
insure adequate dietary intake of different nutrients to prevent C Virus (HCV) in the world, with approximately
malnutrition and improves the prognosis. Maintenance of 22 percent of Egyptian blood donors testing positive
weight loss and exercise in overweight patients with liver for the deadly disease. Lacking in infrastructure
disease results in a sustained improvement in liver enzymes, to deal with the virus, Egypt suffers from a partic-
serum insulin levels, and quality of life. Adequate nutritional
service is mandatory to overcome the challenge for obese ularly high morbidity and mortality rate, with
Hepatitis C patients on a dietary regimen to supply adequate 40,000 dying from the disease each year [1].
nutrients. Different studies on chronic Hepatitis C patients
Aim of the Study: To assess the effect of nutritional concluded that even in the absence of cirrhosis
counseling provided for obese Hepatitis C on their dietary patients with chronic viral hepatitis are prone to
pattern. experiencing a decline in nutritional status [2,3].
Subjects and Methods: This is an operational study that Even in patients with well-compensated cirrhosis,
was conducted on NNI outpatient hepatic clinic. Two groups
of those receiving and providing the nutritional services were malnutrition affected prognosis. Among those that
interviewed; a sample of 120 obese Hepatitis C patients were malnourished, 20% had a 1-year mortality
attending the NNI for at least the second time to follow-up rate, whereas none of the patients who received
their nutritional status (only 100 of patients agreed to complete proper nutrition died within a 1-year period [4].
the questionnaire and the 24 hour food intake recall with a
response rate of 83.3%), all the health care providers in the
outpatient hepatic clinic were interviewed. Multiple data Intervention in the early stages of malnutrition
collecting tools were used; direct informal observation of in Hepatitis C patients can improve outcome [5].
activities for hepatic patients attending the NIOHC. Review Lifestyle interventions including healthy eating,
of existing documents: Policies, protocols, standard operating
exercise and controlled weight loss have been
procedures. Review of the health record system. shown to improve liver damage related to hepatic
Results: The results of the analysis of the exit questionnaire steatosis. Lifestyle changes should be an important
showed insufficient provided services and insufficient satis-
faction of studied patients. adjuvant to medical therapies for patients with
HCV infection, and NAFLD as well as other chron-
Conclusion: This study concluded that there was lack of ic hepatic conditions [6].
standard nutritional services provided for HCPs. Many factors
have contributed to the ineffectiveness of this service. There
are opportunities for improvement of the nutritional services Maintenance of weight loss and exercise in
provided to HCPs. overweight patients with liver disease results in a
Key Words: Services assessment – Nutritional guidelines – sustained improvement in liver enzymes, serum
Nutritional services. insulin levels, and quality of life [8]. The benefits
of low-calorie diet and low-fat diet in management
Correspondence to: Dr. Yosra A. El-Shaikh, of patients with Hepatitis C regarding improvement
The Department of Preventive Medicine, Faculty of Medicine, of insulin resistance, steatosis and also fibrosis
Helwan University were shown in many studies [7].
1635
1636 Assessment of Nutritional Services Provided for Hepatitis C Patients
It is important that gastroenterologists be proac- out of a total of 120 patients; 100 agreed to com-
tive regarding nutritional counseling and both plete the questionnaire, with a response rate 83.3%.
patients and their primary care physicians under- Patients who approved to participate were inter-
stand the importance of not imposing unnecessary viewed at the end station for their round in the
restrictions on dietary intake [8]. NIOHC.
Early and evidence-based nutritional interven- All health care providers actively working in
tions are eagerly needed to minimize the nutritional the NIOHC at the time of the study were inter-
decline associated with chronic liver disorders and
viewed by the researcher. (The clinical nutrition
ultimately improve the prognosis of such patients physician, the dietitians and the nurse).
[9] . Future research should focus on identifying
Study phases: This study was conducted on
modifiable factors that affect quality of life of three phases:
hepatic patients and can be targeted for improve-
ment [10]. I- Preparatory phase: Getting the formal agree-
In Egypt the National Nutrition Institute estab- ment to conduct the study in the NNI (Annex 1).
lished since 1955 to provide the nutrition services •
for patients attending the outpatient clinics of the Reviewing literature and available standards for
nutritional services for compensated hepatitis c
institute. It also provides nutrition education for patients in order to identify criteria and standards.
Egyptian citizens through different media tools Basically, it was needed to define the standards
and educating booklets and handouts or through of nutritional services for them against which the
direct nutrition education sessions for patients services will be compared. So it was difficult to
attending the out clinics of the institute. The insti- reach national standards of nutrition in compen-
tute provides its services through general and
specialized out clinics and other related units that sated hepatitis c patients, except that found in
works under the supervision of nutrition consultants the NIOHC. Unfortunately no available written
standards were found there. So the Canadian
and specialists. The institute provides nutritional Guidelines for Nutrition care of Hepatitis C (2003)
[11] .
services for patients with chronic diseases & Guidelines on nutritional management in Jap-
Due to an increasing number of hepatic patients anese patients with liver cirrhosis, (2012) and
in need of nutritional guidance and counseling, the ESPEN nutrition in liver disease, (2006) were
revised for standards of nutritional care in com-
outpatient clinics affiliated to the NNI, are probably pensated Hepatitis C patients.
facing difficulties with work pressure. Nonetheless,
multiple evidences are needed to explore the un- • Preparing the study tools by reviewing different
met expectations of the attendant patients [12].
study methods and tools used for assessment of
Subjects and Methods service delivery.
• Pilot study for the prepared exit interview ques-
Study site: National Nutrition Institute's Outpa- tionnaire.
tient Hepatic Clinic in Cairo (NIOHC). • Preparing administrative issues and ethical per-
Study design: An interventional operational mission needed for conduction of work.
study. Situation analysis was done to identify the II- Data collection phase: For the assessment
actual activities of nutritional services and its of the actual nutritional services provided in the
different components. Challenges and opportunities NIIOHC and its effect on HCPs attending the
for improvement of the services were pointed, in
NIOHC. five methods were used including:
order to identify areas to be addressed and plan A-
for appropriate solutions. A policy brief was formed Direct informal observation: To what is going
to be introduced to the NIOHC manager for oppor- on for hepatic patient attending the NIOHC. A
flow chart for patients coming for the first time
tunities of improvement.
was done and another flow chart for those fol-
Study subjects: The study included two groups lowing-up in the NIOHC, to describe the fol-
lowing.
of those receiving and providing the nutritional
services in the NIOHC: i- Work load: The available documents were
A purposive sample was taken from hepatitis revised for the number and clinical categories of
C patients attending the NIOHC for following-up the attendant Hepatitis C patients in the latest four
their nutritional status during the period of data year quarters. This is to calculate the average work
collection (January 2015-December 2015). Where, load in the concerned clinics.
1637
Yosra A. El-Shaikh, et al.
ii-
Service delivery: Service delivery assessment were reviewed for the following: Sources of data,
was organized into the following areas: coding, completeness, utilization to obtain infor-
a- Adequate physical health systems facilities and mation to be used for decision making and planning.
equipment. C- Semi structured exit interview questionnaire
b- Executed activities and service delivery: with the attendant follow-up patients: The ques-
• Organization of Health Service: Existence and tionnaire was prepared in Arabic, with most of
description of referral system and patients' the questions closed ended. Themes of this
flow charts and total turnaround time and questionnaire included:
waiting times. • Their personal and socio-demographic data
• (name, sex, age, residency, education, marital status
Access to health service: Physical and financial
accessibility. and work).
• Their medical history (their current height
• Nutrition education: Nutrition education ses-
sions pamphlets. and weight measurement, duration of Hepatitis C
• infection, concomitant diseases, receiving antiviral
Assessing whether service providers perform treatment for HCV).
according to standard policies and procedures. • The services they received in the NIOHC,
Assessing whether these standards are adapted their attitude towards and adherence to these serv-
into a practical form that providers can use,
such as clinical guidelines or manuals, job ices, their acquired knowledge about nutrition in
HCV infection.
aids, charts, forms, checklists, or poster.
iii- • Their satisfaction; the questionnaire included
Human Resources Management: Assessment direct and indirect questions about patients' satis-
profile included the following components: faction, the degree of benefit from their visit,
• Current situation of health care providers: The recommending the institution for other patients,
physician, the nurse and the dietitian in terms of difficulties faced them, whether their expectations
qualifications and duty rotation. are fulfilled, and any raised suggestions to improve
• Education and training activities: This process the delivered nutritional services.
was investigated for pre-service education, in- D- A full 24 hour food
service and specialty training including profes- 24 hour food recall intake:
recall intake was done for the study patients.
sional development. Frequency and quality of on
job training. III- Data processing and analysis:
Data obtained from direct observations were
iv- Record keeping system: Assessment of described in flowcharts.
record keeping system was done by assessing the
following areas: Quantitative data from the questionnaire was
a- Existence of policies or procedures for data coded and analyzed using (SPSS) program. De-
entry, data access, data management, medical scriptive statistics were done.
records storage, retrieval, maintenance and keep-
ing. Also, policies or procedures for data security, Data obtained from 24 hour food recall analysis
review property or for quality control. was analyzed according to food composition tables
of the NNI [33], using SPSS 21 program. Descrip-
b- Infrastructure and physical resources for paper tive statistics were done and analytical statistics
based medical records.
were done to compare between subgroups using
c- Data storage: Organization of records in such a manwhitney test.
way that they can be accessed easily while
maintaining patient confidentiality. Records Ethical considerations:
management system: Storage, retrieval and • Verbal consent was obtained from all study par-
maintenance. ticipants.
B- Review of existing documents: Policies, proto- • Privacy of participants as well as confidentiality
cols, standard operating procedures and the of data collected were ensured by giving each
participant a serial number.
record keeping system:
• Collected data was used only for the stated re-
Medical record keeping and filing system
whether computerized or paper based (Annex 4) search purpose.
1638 Assessment of Nutritional Services Provided for Hepatitis C Patients
Results Studied patients were of low educational level
This study assessed the nutritional services as about half of them (45%) were illiterate while
provided to Hepatitis C patients attending the the highest educational level was the secondary
education and was achieved only by (1%). About
NIOHC. The aim was to improve the nutritional
services provided to these patients. Results are of the (77%) of them were either with no formal
divided into two sections. work or farmers, about (61 %) of them had one or
more other chronic concomitant diseases.
I-
Results of the exit interview questionnaire of Table (2) shows that, 61% of the studied pa-
the studied patients. tients had one or more other chronic concomitant
II- Description and analysis of the activities deliv- diseases.
ered to hepatitis c patients attending the NIOHC. Table (2): Medical history of the studied patients.
I-
Results of the studied patients' exit interview Other concomitant chronic diseases*
questionnaire: No diseases 39 39.00
In this study 100 Hepatitis C patients attending Diabetes 35 35.00
24 24.00
the NIOHC for following-up were interviewed to Gastrointestinal
Cardiovascular 17 17.00
assess the nutritional services they received, their
knowledge about nutrition in Hepatitis C, practice Table (3) shows that almost all of the studied
of recommended therapeutic life style changes and patients (98%) were obese.
attitude towards the nutritional services provided
to them in the NIOHC.
Table (3): The studied patients according to BMI.
Table (1) shows that the majority of the studied N.=100 %
patients (58%) were females. About two thirds of 2
them (66%) were aging 40-<60 years. Residents Obese (BMI >_30kg/m ) 98 98.00
Overweight (BMI=25-29.9kg/m2) 0 0.00
of rural areas were nearly equal to those of urban Normal weight (BMI >_18.4-24.9kg/m2) 1 1.00
areas; 51% and 49% respectively. Most of the Underweight 1 1.00
studied patients were married (77%).
Table (1): Personal characteristics of the studied patients. Table (4), shows that (72%) of them were at-
tending the NIOHC to lose weight for different
(N.=100) % reasons. The majority of the studied patients (62%)
Sex: used to follow-up every month. Studied patients
Female 58 58.00 adherent to the follow-up schedule were 53% while
42 42.00 47% were non-adherent.
Male
Age (years): Table (4): The studied patients' utilization pattern of the
18<40 NIOHC.
9 9.00
40<60 66 66.00 N.=100 %
>_60 25 25.00
Residence: Number of follow-up visits*:
2nd or 3rd 48 48.00
Rural
51 51.00 4th
to 5th 33 33.00
Urban 49 49.00 6th
or more
19 19.00
Marital state: Reasons patients attend the NIOHC:
41 41.00
Married To lose weight to get better
77 77.00
Others (divorced/widows/never married) 23 23.00 To lose weight to receive antivirals 31 31.00
Seek nutritional guidance
20 20.00
Education: Others ** 8 8.00
Illiterate 45 45.0 Patien ts' adherence to the follow-up visits:
Read and write 20 20.0 Yes 53 53.00
Basic education 34 34.00 No 47 47.00
1
Secondary 1.00
Occupation: * : Patients with first visit were excluded.
**: Others (Ex. abnormal bowl habits and to gain weight).
No formal job 55 55.00
Farmer 22 22.00
Fig. (1) shows that the majority of the studied
Technician 21 21.00
patients (59%), were advised by the physician of
Employee 2 2.00
the NIOHC to follow-up every month.
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