# PS‐SAM: A Mixed Methods Study to Understand Current Practice and the Facilitators and Barriers to the Utilisation of Psycho‐Social Stimulation Interventions in Severe Acute Malnutrition

## TL;DR

This study explores how psycho-social stimulation interventions for severe acute malnutrition are being used globally and identifies the challenges and enablers of their implementation.

## Contribution

The study provides new insights into the heterogeneous implementation of psycho-social stimulation interventions and factors influencing their use in real-world settings.

## Key findings

- Implementation of psycho-social stimulation interventions for severe acute malnutrition is highly variable across different sites and contexts.
- Barriers include financial, human, and physical resource limitations, as well as prioritization of life-saving care over stimulation.
- Facilitators include inclusion in national guidelines and the enjoyment experienced by staff and parents.

## Abstract

Psycho‐social stimulation interventions, recommended in the WHO guidelines for severe acute malnutrition (SAM), have been demonstrated to improve neurodevelopment and growth. However, interventions which have proven effective in clinical trials are resource‐intensive and may be challenging in many contexts. This study aimed to explore facilitators, barriers and the existing provision of psycho‐social stimulation interventions. We undertook a survey targeting practitioners across the globe who are involved in SAM care and/or programme management. We then undertook 12 semi‐structured key informant interviews with practitioners from diverse professional contexts. We transcribed and coded interviews using a deductive approach based on the Consolidated Framework for Implementation Science Research (CFIR). We gained 42 responses from 18 countries for our survey with 29 respondents including psycho‐social stimulation interventions in their SAM programmes. Our 12 key informant interviews described several barriers (financial, physical, and human resource limitations, prioritisation of life‐saving care, and staff beliefs) as well as some potential facilitators (inclusion in guidelines, enjoyment for staff and parents, and emerging evidence of benefits in terms of short and long‐term outcomes). This multi‐country mixed methods study revealed that there are very heterogeneous patterns around the implementation of psycho‐social interventions in children with SAM. Our study has demonstrated the perceived challenges by professionals involved in SAM care of the feasibility of implementing interventions from research trials. Pragmatic studies are needed which also include an assessment of implementation to enhance an understanding of what might drive uptake. Limitations of our study include a potential respondent bias and small sample size.

Implementation of psychosocial stimulation interventions for children with severe acute malnutrition is heterogenous with different levels of intervention by site and context delivered by different staff groups with no universal understanding on what it entails.Gold standard psycho‐social stimulation interventions for children with SAM are not feasible in all settings due to a range of factors particularly human and financial resource limitations and relative prioritisation of immediately lifesaving care.Facilitators of psycho‐social stimulation interventions include it being prioritised by policy makers through inclusion in national guidelines and that staff and parents can derive enjoyment from it.There are still significant gaps in terms of understanding feasibility and how to implement these interventions in a range of settings.

Implementation of psychosocial stimulation interventions for children with severe acute malnutrition is heterogenous with different levels of intervention by site and context delivered by different staff groups with no universal understanding on what it entails.

Gold standard psycho‐social stimulation interventions for children with SAM are not feasible in all settings due to a range of factors particularly human and financial resource limitations and relative prioritisation of immediately lifesaving care.

Facilitators of psycho‐social stimulation interventions include it being prioritised by policy makers through inclusion in national guidelines and that staff and parents can derive enjoyment from it.

There are still significant gaps in terms of understanding feasibility and how to implement these interventions in a range of settings.