Home Based Treatment of Severe Malnutrition in Kabul

By Muriele Therry

Muriele Therry studied ethnology at Masters level. After two missions with ACF, one year in Sakhalin as food security officer and 6 months in Afghanistan as Home Treatment officer, she is waiting for a new post with ACF.

Action Contre la Faim (ACF) has been working in Afghanistan since 1995. The nutrition programme in Kabul includes three therapeutic feeding centres (TFC) within paediatric hospitals in the city, and a network of smaller TFCs providing care close to the population. ACF works mainly with a population of young children and infants and their caregivers. Owing to the high rate of defaulting from this centre-based TFC programme, the option of Home Treatment (HT)¹ was introduced in February 2004 to provide a more flexible alternative. Understanding the cultural context has been central to how the programme has developed, and its success.

Cultural context

Arzo is taking the plumpy nut for her last day of treatment. She recovered completely.

HT is suitable in the Afghan cultural context, where women have difficulty accessing services outside of the home, as it allows a reduction of the length of stay outside the house. It may even be the only acceptable option for some mothers. This can be largely explained by the societal perception of women and their role.

The familial sphere:

Within the household, there is a strict division of roles. A woman must carry out her assigned household duties or she comes under pressure from the family to do so. As the only person responsible for her children, social rules dictate that a mother shouldn't leave them with other members of the family. Many different families may live in close confinement, and leaving the children alone can create a lot of problems within the compound, and provokes harsh criticism from the other women of the family and the neighbours. Maintaining good relationships within the compounds is a social preoccupation, which may in some cases lead to extreme choices whereby the health of the child is compromised.

The perception of the child as part of a larger unit and not an individual person, also explains the behaviour preventing a mother from going to the TFC. Children assure the future of the parents and a sick child, even if he is near death, is not considered a priority compared to other roles such as caring for healthy children and the remainder of the family.

The spatial sphere:

Women occupy the inside or private sphere, while men have the outside and public space. In some neighbourhoods, a woman going to the TFC everyday may encounter security problems from 'soldiers' who order her to return home. She may therefore, depend on a mother-in-law to be chaperoned outside. Due to a lack of understanding regarding the treatment for severe malnutrition and its duration, neighbours may criticise a woman for "wasting her time" and the husband may order his wife to stay at home. The shorter length of stay with HT may alleviate (although not completely solve) some of these difficulties.

The social sphere:

The socio-familial links go beyond the interest of the individual. In Afghan culture, continuity of the relationship with relatives must be maintained through physical presence and help given during key family events (births, weddings, funerals, religious ceremonies or sickness). Women cannot escape these responsibilities. In the TFC, these commitments have led to absences. However with HT, mothers have expressed their satisfaction that these responsibilities can still be executed without interrupting the treatment of their child.

Economic considerations are another important factor for HT. Often the mother works from home to generate income (teaching, making handicrafts, sewing, preparing food for sale by the husband). This source of income disappears when the mother is in the TFC. Furthermore, treatment at home saves daily transport costs to and from the TFC.

These same reasons (the pressure on the woman) can also lead to a refusal to take part in HT by some caregivers who prefer the TFC option. However, the rate of refusal remains low (6% (8 women)) of the mothers who were offered the HT option. Furthermore, the approach established by the psychosocial team (see later) allows the personal constraints of caregivers to be taken into account. This highlights the importance of giving treatment choice to caregivers.

Programme experience in HT

Twelve per cent of the children to whom RUTF was offered failed to gain weight or refused to eat RUTF during the initial three day trial and were not included in HT. For the remainder, after seven months of implementation (February - August 2004), the HT indicators (see tables 1 and 2) show a positive effect of the programme on defaulting and overall acceptance within the Kabul socio-cultural context.

Management of defaulters

While most of the caregivers in this situation returned to the TFC after discussion with the mother and/or the family, five caregivers (25% of the total having to return to the TFC) defaulted and refused to come back. Since the defaulting took place after the request to return, modifications were made to the initial protocol. The first change was to lower the criteria of weight gain. If the child had gained weight, even less than 5g/kg/day, or has a stable weight, then treatment could continue at home. The decision was subject to medical criteria and to a satisfactory appetite for the RUTF (based on observation in the TFC and discussions). If the child had lost weight, then he must stay in the TFC.

The second modification was to give another weekly ration of RUTF, even when the child should really be readmitted to the TFC. However this was only considered when the mother (family) absolutely refused to return to the TFC, and was the exception rather than the rule.

An additional reason for the introduction of more flexibility was that weight loss seems more often due to some 'common' condition, such as a cold, slight fever or diarrhoea, rather than a child refusing to eat RUTF, or sharing of RUTF amongst the family.

Utility of home visits

The home visits were perceived positively by both the caregiver and the family, while improving the effectiveness of the HT. First, the visits encouraged the mother to give the RUTF properly. The main problems observed at home were that the mother didn't give enough water with RUTF, the child didn't get enough RUTF because the mother didn't take enough time to feed the child, and poor hygiene, possibly leading to diarrhoea (un-boiled water or not washing the hands). The mothers themselves appreciated the home visits for "helping to refresh the education".

Secondly, HT allowed for involvement of all the family members in decision-making regarding the treatment. This is an important matter in a socio-cultural context where the mother lives with her in-laws and is not the one taking the decisions. The ACF presence encouraged attention to the treatment, e.g. the other family members were able to encourage and guide the mother (to give enough water, to improve hygiene, to complete the treatment, to help her during the feeding). The home visit also supported the mother's views when the family didn't want her to pursue the treatment correctly (in one case a grandmother did not want the mother to give three sachets of Plumpy'nut a day, because it was 'hot food' (see section on perceptions), but finally accepted after explanation by the team).

It appears that one home visit during the first week is enough to ensure adequate practices at home. However, the home visits also represent a heavy workload for staff so that the necessity of a home visit remains subject to the decision of the team. This is based on behaviour of the mother, the family situation, and knowledge they have gleaned from the close contact established during the psychosocial activities.

Ahome visit is also useful for discussions with the family when the child has lost weight and should return to the TFC. It allows discussion with the whole family. In these cases, repeated home visits may be necessary. The home visit also increases awareness of the HT option within the community.

Perception of Plumpy'nut® in Afghanistan

Peanut based foods are not common in Afghanistan and children are not used to them. This may explain why the majority don't eat Plumpy'nut (PN) well or with enthusiasm on the first day of introduction. After a day or so, they get used to it and if there is no medical problem or poor appetite, they really appreciate it.

Plumpy'nut is considered more as a medicine than food and the education reinforces this point. The mothers mentioned that it was similar to medicine in that the child does not eat it easily on the first day. Mothers argue that if the child gains weight with the Plumpy'nut this "proves" it is medicine. Due to this medicinal perception, the sharing of the product among other children was not common, although it did occur in some families. The sharing tends to occur due to other family members who don't value or consider the opinion of the mother (at least two cases of sharing were confirmed).

According to the popular classification of food in Afghan culture, Plumpy'nut, due to the nut content, is defined as a 'hot' or 'strong' food. 'Hot foods', warm the body and may provoke disease (in particular during the hot season), such as sore throat or fever, jaundice, and skin rashes. 'Strong foods' include 'expensive' protein or vitamin rich foods such as meat or eggs. These foods are considered to cause stomach ache in children. However, it seems these perceptions have not interfered with the use of Plumpy'nut because it is considered to be a medicine and in the TFC, the mothers observed that it doesn't cause any damage and can help the recovery of children. These perceptions are to be kept in mind however, during the education sessions as some mothers/ families may refuse or incorrectly use the Plumpy'nut.

Flexibility and facilities with RUTF

Treatment with RUTF is appreciated since the mother doesn't have to prepare the meal specifically for the malnourished child. Furthermore, the packaging allows it to be carried with the child so that the feeding can continue even if the child is not at home. However there are limitations of Plumpy'nut. Children don't eat it all at once and one sachet can last all morning. When the mother is in a rush, this can be an inconvenience and the mothers will not always take all the time needed to feed the child.

* Comprises 98 marasmus and 4 kwashiorkor
**Others: 2 children were discharged before reaching 85% after a length of stay of more than 2 months; they were included in dry ration.

*Figures reflect period Feb-August, 2004, for marasmus and kwashiorkor

Effect of HT on defaulting

A key reason for implementing HT in Afghanistan was the high rate of defaulting in the TFC. These first months in Kabul showed that HT doesn't completely eradicate defaulting (10% of children admitted to HT defaulted). This can be partially explained by the limits of HT itself, namely the medical and age criteria restricting inclusion, coupled with the mandatory stay in the TFC in phase I and transition. Among all the children older than 12 months, there was a degree of defaulting during these phases, highlighting that even this shorter stay is unachievable for some families.

When the default rate for children aged more than one year is compared, the advantage of HT is more clearly seen. Over a period of three months (March to May 2004)³, 60% of the children not included in HT became defaulters, compared to 20 % of the children included in HT. Other noted advantages were that some children would probably have defaulted in Phase II - on the day of admission to the TFC, some mothers accepted enrolment simply because HT was proposed⁴. Also some children would not have come to the TFC at all, but presented after hearing about HT from relatives or the ACF team.

HT: an answer to malnutrition in Afghanistan?

The main effects of home treatment have been to reduce defaulting in Kabul and to allow more children to receive treatment for malnutrition, compared to when full centre based TFC treatment was the only option.

If we compare the indicators between the two programme types (see table 3), the results are more than acceptable. It should be noted that the length of stay in the HT is longer, as the child stays an additional week after reaching the discharge criteria of 85% weight for height.

There are instances, however, where HT is clearly not the answer. It is not appropriate for all children, i.e. those with certain medical complications, and in Kabul, there are many malnourished children less than one year of age for whom HT has not been tested. Additionally, since the HT begins in Phase II, it doesn't necessarily reduce defaulting in Phase I and the Transition Phase - five children more than one year of age defaulted from the initial phase, before being included in HT. HT remains an appropriate alternative option for some children, yet it must be offered in addition to the TFC structures, which are still necessary.

HT has partly addressed the situation where a problem during the week at home has led to defaulting at a TFC. However, there will probably still be absences and default if the stay is too long. Involvement of the family is a way to ensure better compliance and this can be strengthened through the home visits and the psychosocial support.

This experience in Kabul shows the importance of taking the social contexts into account in designing sound nutrition programming. Setting up a HT programme provides added flexibility and improves programme effectiveness. However, the advantages do not automatically apply to all caregivers so that individual follow-up and the alternative treatment options allow the choice to be taken by women according to their familial/ psychological context. A child will probably have more chance of recovery if the mother is in an environment that suits her best.

¹The Ready-to-Use Therapeutic Food (RUTF) used in the HT protocol in Kabul is Plumpy'nut (PN), produced by Nutriset, France.

²In Afghanistan, women cannot easily move around alone and conducting home visits to promote greater effectiveness means having a team of two women. Initially it was considered necessary to attach additional personnel (HTW) to the PSW to have a good follow-up of the patients.

³At the time of writing, disaggregated data for children >=12 months were not available for the months of June to August. There were no defaulters or children cured in February. This explains the comparison of the periods March - May and not until August.

⁴From February to May, amongst 25 children included in HT, 15 would have reportedly become defaulters or would not have accepted the admission in the TFC.