Socio-Anthropological Aspects of Home Recovery from Severe Manutrition

By Adrienne Daudet and Carlos Navarro-Colorado

Morlaï, cured at home, at last weekly visit.

Adrienne Daudet is an agronomist and has an MA in anthropology. She has four years field experience working with ACF.

Carlos Navarro-Colorado is a medical doctor and is a research officer at Action Contre la Faim.

We would like to thank the families in Makeni that warmly received and hosted Adrienne during her field work, the ACF field workers and headquarters staff that supported this research, Jane Cobbi, CNRS (Centre National de la Recherche Scientifique) who has directed the anthropological research, and Charlotte Dufour for comments on the draft.

This article shares the experiences of a programme- based field study1 in Makeni, Sierra Leone, which looked at how home based rehabilitation of severe malnutrition was perceived, and whether it was more acceptable and beneficial than centre-based management in this context.

The recent development of strategies that allow rehabilitation of severely malnourished individuals at home, are largely thanks to the development of RUTF (Ready to Use Therapeutic Foods), and the experience accumulated on TFCs (Therapeutic Feeding Centres) and NRUs (Nutrition Rehabilitation Units). It is widely assumed that this type of treatment is more socially advantageous to families and the community. However, the assumption has never really been tested at field level. The social implications of treating severely malnourished children at household level need to be understood in order to improve home-based strategies, enabling us to adapt home-based strategies to each intervention in the field and informing choices between centre-based and home-based strategies (with its different options and own adaptations). We therefore decided to complement an ongoing clinical trial of home-based rehabilitation of severely malnourished children in Makeni (see box 1) with an anthropological evaluation.

Morlaï at Makeni TFC, starting phase II and ready to continue at home.

The objectives of the study were to evaluate both the day-to-day perception and acceptance by families of the treatment protocol, and the wider impact on the child's social group. Together with experiences from other settings, we also attempted to define socio-anthropological indicators to guide choice between existing treatment strategies for rehabilitation of severely malnourished children.

The study took place over three months, based in the Makeni area of the Northern Province in Sierra Leone. The area is largely Temne (one of the major ethnic groups of the country), and livelihoods are essentially based on subsistence agriculture. Limitations of the study included a small sample size (only 50 children were being treated at home in the clinical trial), as well as the period of the year for the fieldwork (which did not coincide with either agricultural labour peaks or hunger gaps).

Fieldwork took place in the TFC and in the weekly food distribution structures, using participant observation, open and semi-open interviews and focus groups. An important part of data collection was done in nine villages with children on treatment. More extensive anthropographical work was done in two of the villages, including overnight stays with the families. In these two villages, the food system (from production to final consumption), how the family implemented the nutrition protocol, and the effects that this had on the wider social group was studied through observation, focus groups and open interviews. Home based treatment of severe malnutrition: a randomised clinical trial in Makeni, Sierra Leone
Action Contre la Faim completed a Randomised Clinical Trial in Makeni (Sierra Leone) in the first half of 2003. The study compared TFC treatment with an alternative treatment based on an inpatient Phase I and recovery phase (Phase II) at home.

Caretaker feeding her infant Plumpy'nut in Makeni TFC.

Patients that presented with no severe complications, severe oedema (+++) or chronic associated disease, were randomised to one of the two treatments (50 patients in each group). The mothers of the patients placed in the home treatment group received health education and were trained to undertake the treatment at home. On arrival to Phase II, and once the appetite of the child was well established, the children were sent home. There, they received three meals a day of RUTF (Plumpy'nut, produced by Nutriset) and were followed up weekly in the closest SFC.

Recovery rates were 90 % in the TFC group and 95 % in the group that completed treatment at home (p = ns). Patients in the TFC had an average weight gain of 13.4g/kg/day and those recovering at home, 11.9 g/kg/day (p = ns). The study concluded that, under appropriate circumstances and with good management, treatment at home can obtain the same recovery rates as classical TFC treatment.

Perception of RUTF

Most of the children liked the Plumpy'nut product, ate it without difficulty and even played with it during the meal. Only the seriously sick children refused to eat it (confirming previous field observations). All the caretakers tested the product when giving it to the child and liked the taste of it. The caretakers in both the TFC and home treatment (HT) groups had the impression that Plumpy'nut makes the children grow more quickly than therapeutic milk (F100). This has not been confirmed by the clinical trial results.

The name that the field team gave to the product, "makantl" - which means [groundnut] in Temne language - was used by families, and only if needed, qualified as "makantl uma opoto" [groundnut of the white people], to avoid confusion with the local groundnut paste. The fact that the families have kept the name "makantl" indicates that they have appropriated the product. In response to whether they considered Plumpy'nut to be a food or a drug, all responded that it was BOTH - this suggests the messages of the nutrition team were understood and accepted, and may have played a large role in preventing sharing of the product with other family members.

Use of RUTF

Caretakers were advised to give the Plumpy'- nut three times a day (at 8 a.m., 12 and 6 p.m.), and to use a spoon, which was provided, to feed the child. We found that they adapted the meal hours to fit in with the family activities, and the manner of feeding according to individual preference. While some children held the spoon themselves, others let the caretaker hold the spoon, and some others preferred to eat in other ways. A preliminary phase of this study (not reported here) has identified the quality of the mother to child relationship, caring practices and the psychological health of the mother as some of the main causes of malnutrition in this area of Sierre Leone. Cases we encountered in this study (see case study) demonstrate how improvement in maternal selfesteem through this type of programme may help prevent further episodes of malnutrition, as well as strengthening the image of woman in the social group. The flexibility of use allowed by the product has been key in promoting the appropriation of the treatment by the families.

Impact on the social group

According to the caretakers interviewed, the treatment had little negative impact on the housework, including care for the other children and elderly relatives. The strong social networks in the villages allowed others to take on some of the caretakers' domestic and work responsibilities, allowing her to concentrate on the treatment of the child. About half of the interviewed caretakers chose to go to the field with the malnourished child, taking the Plumpy'nut and water with them. The other half of the interviewed families had chosen that the caretaker should not to go to work on the farm, but stay at home until the child had recovered. Therefore, home treatment can affect agricultural production, though in different ways than TFCs. The social group also benefited from the presence of the woman in the household. In one case, the caretaker was the only Traditional Birth Attendant of her village. Had she needed to stay in the TFC for 3 or more weeks, her services would have been greatly missed.

Treatment strategy and care practices after treatment

Follow-up after end of treatment found that families that participated in home treatment continued applying some of the practices that they had adopted during the programme. These included feeding and washing the child in the mornings (this was not always done during the peaks of agricultural work) and spending more time with the child (i.e. the child was taken with the caretaker to the field). Our hypothesis is that adoption of new practices was facilitated as the family had been directly involved in the programme. This contrasts with a situation where health education messages given in a TFC are less integrated in the family context.

We also found that treatment preference depended on individual experience. Women who had treated their children at home would again choose home treatment, as they could continue to fulfil their social obligations and felt that Plumpy'nut is better for the malnourished child than the F100. However, women that had TFC treatment would not choose treatment at home. Despite having contact with caretakers from home treatment, they feared being alone in charge of the treatment at home (without the help of nurses, etc.). They also appreciated that they could rest in the TFC.

These findings indicate that when the treatment is completed at home, the mother becomes the main healer of the child, reinforcing self-confidence. In contrast, the TFC can undermine selfconfidence and self-esteem, by placing the women in a passive role. Our observations also suggest that the mother-to-mother education component of the programme does not automatically lead to acceptance of the new strategy by the wider community. Indeed, if the experience of some patients in home treatment was negative, mother-to-mother feedback could jeopardise the programme.

Discussion

At the individual level, results from the clinical trial for the home-based treatment group are as good as those obtained in TFCs (in terms of recovery rates and weight gains) (see box 1). In addition, the new strategy is well accepted by the social group. Moreover, it seems that home treatment can have a more positive impact on mothers' psychological health than the TFC, a fact that may have important consequences beyond the treatment of the malnourished child.

Figure 1 summarises the key variables which contributed to the success of home based rehabilitation of the severely malnourished in this study. These variables could be taken into account when deciding on the best strategy to implement in a particular context (TFC, outpatient department, treatment at home, etc.). A good knowledge of these factors may be critical to help develop a home treatment strategy that is best adapted to a specific population. Each context is likely to pose different challenges so it is vital to remain flexible in applying any model. Such flexibility is key to the success of home-based strategies.

Can these positive results be extrapolated to other situations, and, is treatment at home the best option in all contexts? In order to consider this, we need to think especially about a number of factors which applied in this study, using a framework recently proposed by URD2 - namely the context, the population benefiting from the programme, and the agency implementing the programme.

Child eating Plumpy'nut under mother's watchful eye during weekly visit to SFC

In terms of context, the area was secure, most people were resettled, and there were no significant food shortages in the area (at least in quantity, if not always in quality). This partly explains why there was no sharing of Plumpy'nut. In situations of insecurity, there might be dangers of looting the Plumpy'nut, or sharing with other family members if the area was more food insecure. Furthermore, if the population had been displaced, it may not have been possible to establish the social support mechanisms which contributed to the success of the programme.

This study has shown how treatment at home has a positive impact on both the psychological health of the mother and the quality of the mother-child relationship. This, in turn, positively impacts on recovery. Treatment at home, and its impact on the whole social group, may have a different outcome when the main cause of malnutrition is related to food shortage, epidemic disease or displacement. The results of this study may not apply to these contexts.

ACF has been present in Sierra Leone and in the area for several years. The agency is well known and trusted by the population (most admissions to TFC are spontaneous). ACF has good knowledge of the area, and has been working in nutrition, water and sanitation, and food security with efficient logistics and skilled and experienced personnel. ACF had chosen this area for the trial precisely for these reasons.

Choices about the protocol were key to the success of the strategy in Makeni. The fact that all patients went through a stabilisation phase (Phase I), where life threatening conditions and complications were treated before being sent home, contributed to high recovery rates and good weight gains. The health education and information about specific treatments given to the caretakers during the initial phases of treatment on the TFC, as well as identification of an appropriate name for the product, helped the appropriation of the product and compliance with the protocols. Also, the food system in the area includes groundnut paste, which is very close in taste and appearance to the Plumpy'nut. This undoubtedly increased product acceptability.

Most significantly, the society in Makeni area has strong social networks including mutual support, landlord systems, traditional chiefdoms, secret societies, etc. During the rehabilitation phase, all the family and close community members mobilised to provide care to the child, or allow the mother to do so. However, it cannot be assumed that such social support capacity would always exist in an emergency affected area. Indeed, social and community disruption is a major characteristic in many disaster situations.

There is a need for similar studies in different contexts, specifically in situations where there is insecurity, displacement, lack of social cohesion, lack of access to water or food, etc. Other factors not studied here will also need to be considered, including coverage of the programmes, cost effectiveness of the intervention, and long-term impact on nutrition and health.

Home-based strategies are new tools to be added to the toolbox of potential interventions that can be applied in a particular context to address severe malnutrition. By shifting the treatment location from a centre (known and under control of the medico nutritional team) to the society itself (mostly unknown and definitely out of their control), the nutritionist needs to adapt him/herself to the local culture. Only a good understanding of the beneficiary population and context will allow us to choose the most appropriate strategy and tailor it to their particular needs and characteristics. No strategy works perfectly on its own in every context. The challenge ahead consists of learning from TFC and home based strategy experiences, in order to deliver the best quality of treatment in an appropriate, socially sensitive and respectful way, to as many malnourished children as possible, in a variety of contexts.

For further information, contact Adrienne Daudet, email: adrienne.daudet@voila.fr and Carlos Navarro-Colorado, email: navarro_colorado@hotmail.com

¹This research was presented at the CTC workshop held in Dublin in October 2003, see summary this issue of Field Exchange.

²Groupe URD, "Practioners' Handbook - draft" for ALNAP's Global Study on Participation by crisis-affected populations in humanitarian action. London, Overseas Development Institiute, 2003.