Health-seeking behaviour and community perceptions of childhood undernutrition and a community management of acute malnutrition (CMAM) programme in rural Bihar, India

Location: India

What we know: The caseload of severe acute malnutrition in India is significant. Access to treatment is challenging in rural settings; default rates to inpatient and community based treatment options are often high. Community perceptions of undernutrition and treatment can impact on health seeking behaviour.

What this article adds: In 2010, MSF undertook a qualitative study in rural India to understand the community perceptions of undernutrition and an existing CMAM programme and how these affected health-seeking behaviour. Health-seeking behaviour was influenced by social and cultural, logistical and economic factors.  The findings did not differ between households with or without malnourished children and did not appear to be age specific. Undernutrition was attributed to a number of local disease concepts, such as ‘mamarcha’ (moderate acute malnutrition), ‘jallachatu’ (severe acute malnutrition), and the ‘evil eye’. Families favour boys over girls, especially when resources are limited. Mothers lacked decision-making power. Interventions should raise understanding and awareness of undernutrition and treatment in a way that empowers mothers; respond to and respect traditions, religion and customs; engage with the broader community; and consider language skills and dialect in communication. 

In 2006, the National Family Health Survey-3 estimated that in India, eight million children younger than 5 years suffer from severe acute malnutrition (SAM). As in many resource-poor settings, the provision of health care in rural India is often challenged by a shortage of health centres and health workers.

After a nutritional survey demonstrated a 4.8% prevalence of SAM in Darbhanga district in 2008, under a Memorandum of Understanding with the district authorities, Médecins Sans Frontières (MSF) established a community based management of severe malnutrition programme in Biraul block. Biraul block has a population of 300,000 and is one of eighteen administrative areas within Darbhanga district. Although widely practised outside India, community based management of acute malnutrition (CMAM) is a relatively new concept in India, where management of SAM is mostly in-patient based. In the MSF supported programme, SAM cases (6m -5 years) are identified using mid upper arm circumference (MUAC). Treatment involves maternal counselling on the condition and treatment; initial standardised systemic treatment for infection and vitamin deficiency; and weight-based weekly provision of an Indian-produced, pre-packaged, WHO standard F100-equivalent oil-based paste with health review. The average length of treatment is seven weeks.

The CMAM programme in Biraul block involves five therapeutic feeding centres treating ambulatory ‘uncomplicated’ SAM children and one in-patient stabilisation centre treating the more unwell ‘complicated’ SAM children who require in-patient care. In four years, the programme has admitted over 10,000 children, with just over half the children travelling for treatment from outside the block. However, repeated semi-quantitative evaluation of access and coverage (SQUEAC) surveys suggested that there were many more children with SAM within the block not accessing treatment. Additionally, the programme struggled with default rates as high as 38%, particularly in those caregivers who were commuting from outside the block. Data from other facility-based nutritional programmes across India suggest that defaulting is an issue in other states, reaching 47·2 % in in-patient only nutritional rehabilitation centres in Uttar Pradesh.

In order to help identify the underlying causes of poor coverage and default, in 2010, MSF undertook a qualitative study in Biraul block to understand the community perceptions of undernutrition and the CMAM programme and how these affected health-seeking behaviour. The objective was to develop evidence that would be used to adapt the CMAM programme in order to improve outcomes and develop a more appropriate health promotion strategy for the community.

Method

Over a five week period, qualitative semi-structured interviews using a topic guide  and narrative interviews were conducted with families (mothers, fathers and mothers-in-law) of children treated for severe malnutrition (approximately two-thirds of family interviewees), families containing children without severe malnutrition (one-third of family interviewees) and healthcare workers (traditional healers, Hindu and Muslim priests, traditional health practitioners, midwives, hospital nurses, health educators and doctors). Approximately 150 people participated in the discussions, which comprised: (i) 44 one-to-one in-depth key informant interviews in the participants’ first language (Maithili); (ii) five focus group discussions with five to ten people participating; and (iii) nine natural group interviews, with an average of six people participating.  Most participants were female. In the individual interviews, about two-thirds of participants were female; all focus group discussions were women only; and in the natural group interviews, one was men only, five women only and three were mixed. From the religious affiliation perspective, 80% of interviewees were Hindu and 20% were Muslim, reflecting the background demographic in the district.

Findings

In general, the findings did not differ between households with or without malnourished children, and our results did not suggest that health-seeking behaviour was age specific. It appears common for families to favour boys over girls, especially when resources are limited.

Since undernutrition was attributed to local disease concepts, of which all respondents were aware, community perceptions of childhood undernutrition and health-seeking behaviour did not appear to differ between caregivers who had severely malnourished children and those who did not.

All respondents mentioned ‘mamarcha’, a local term for a sickness that matches moderate malnutrition. It was described as being extremely common in early childhood and mothers reported treating their children for it even if the child had no symptoms. The symptoms of mamarcha were described as having big eyelids, weakness, wanting to lay down in cool places or eating salty food, having no appetite, watery diarrhoea and a swollen belly. Symptoms also included the child not being able to walk properly and preferring to crawl. According to the mothers, mamarcha was the result of a child eating ‘delicious’ salty or adult food too early, or as a result of there not being enough food in the family, or of the child not drinking its mother’s milk. When describing mamarcha, non-allopathic health practitioners spoke of a swollen liver, blisters on the tongue, lack of fluids in the body, shortage of blood, anaemia, thin arms and legs, weakness, severe irritability, lethargy and a swollen belly. Allopathic health workers said that mamarcha was caused by undernutrition, anaemia, a shortage of blood due to insufficient birth spacing, suckling while mothers were pregnant, worms in the digestive system, lack of food, lack of health care or a poor diet. Almost all female respondents said that they primarily treated the child themselves and that mamarcha medicine could be found in any pharmacy in liquid form or at the local market as herbal medicine. Most mothers said that they went to the traditional health practitioner, primary health centre or hospital only if the child did not recover.

The symptoms of what most Maithili people call ‘jallachatu’ match those of severe malnutrition. Female caregivers noted that children with jallachatu were often born looking very thin ‘like a bird’, and continued to get thinner after birth. Jallachatu was believed to occur if a vulture flew over a mother during her pregnancy: “When the vulture crosses over the pregnant woman, then the child will be delivered as very weak and slim, and no matter what you do it will keep on being slim and will not gain weight and it will not

survive.” All but one mother-in-law described jallachatu as being an attack by a witch that could only be treated by a Muslim or Hindu priest. Among other respondents, there were a variety of ideas about how jallachatu should be treated. Some respondents (fewer than half), who understood the Hindi word kuposan (ku means deficiency or lack and posahar means nutrition or nourishment) and were already familiar with the CMAM programme, said that kuposan and jallachatu were the same entity, and that both could be treated within the CMAM programme. Numerous others without exposure to the CMAM programme insisted jallachatu should only be treated by traditional health practitioners: “[...] The only way to treat it is with cow dung. You put it into a bag, and we hang it at the back of the house for one month, and when it is dried we throw it into a river. As the cow dung swells in the water, then the body of the child swells too. It is the same for girls. The cow dung is not mixed with anything.” Traditional midwives reported that they treated the condition by heating mustard seeds in mustard oil in order to evoke an aroma to drive away the vulture or by throwing dried cow dung into the river. The cow dung was seen as a proxy for the child’s body; when it swells in the water, the child puts on weight. The majority of caregivers reported that they first consulted the Muslim or Hindu priest and if the child did not improve, mothers would consult an alternative traditional health practitioner or go to the CMAM feeding centres.

Over half of caregivers reported that they would not take children under 6 months of age to the field where they worked out of fear of exposing them to nazar or the ‘evil eye²; as such, they were left at home meaning that for the duration of the work day, the child was not breastfed, in turn predisposing them to becoming weak. Fewer efforts were made to protect female children against nazar compared with males; indeed, females appeared to be disadvantaged in a number of other ways, with lower level of importance during mealtime food distribution and the threshold for seeking health care and treatment for SAM for female children appeared to be higher than that for male children.

Since undernutrition was generally not considered to be a disease by mothers, they sought to understand it from the perspective of traditional medicine. Thus, most mothers did not consult traditional health practitioners or visit primary health-care centres if their child was ‘only skinny’. If the mothers felt their child required medical treatment, their initial action was to provide medication themselves. If these were not effective, they would then consult a health practitioner. Several allopathic and non-allopathic healthcare options were available to the caregivers, such as registered medical practitioners or traditional health practitioners. The majority of mothers reported that they treated their children themselves on the advice of their in-laws or other elders before consulting a healthcare provider, or through purchasing medicine recommended by local shopkeepers, whose opinion was generally accepted.

Most respondents considered the CMAM programme to be functioning within the government allopathic healthcare system. Allopathic health care included certified doctors and nurses and most respondents held them in high esteem, but reported that they were also expensive and the quality of care not always consistent. Government primary health centres were most often located in bigger communities and often at a distance from villages. Most respondents stressed that even though drugs were supposed to be free of charge at primary health centres, they were generally of poor quality and sometimes unavailable. If drugs were unavailable, respondents said the doctor would then prescribe medication privately, for which they had to pay.

Respondents described a wide spectrum of traditional birth attendants (dais), priests, witch doctors, tent doctors, local drug mixers (vaidhs), healers and Godmen as traditional health practitioners. They lived within the community and were usually the first to be consulted. There appeared to be a strong feeling of trust towards traditional healers and respondents reported taking their advice seriously. A common theme was that these individuals shared the same cultural values and were able to communicate more freely with them than allopathic health-care providers. In particular, respondents from lower castes and with low literacy stated that these practitioners were their first port of call when their children were ill.  According to the majority of the respondents, the advantage of these healers was their low cost compared with ‘private doctors’ or primary health centres.

Several factors significantly affected the health-seeking behaviour of the community in Biraul with regard to their utilisation of the CMAM programme. These factors can be categorised as: (i) social and cultural (perception of the problem by the patient and others around her/him); (ii) logistical (existing transport, availability and proximity of medical care); and (iii) economic (transport costs, wage loss, affordability of health care and acceptance of costs). Other important factors included the previous experiences of the caregivers and their perception and understanding of how prescribed medicines work on the body.

The majority of women interviewed appeared to lack decision-making autonomy and reported that it was necessary for them to ask their mothers-in-law or other senior, female family members for advice on what to do with a sick child. Figures of lay authority, such as village elders, appeared to play a major role in the diagnosis and treatment of illness. An additional factor mentioned by the majority of respondents influencing health-seeking behaviour was temporary migration. They explained that roughly twice per year, women took their children to their home villages to stay for a month at a time. During these periods, they were unable to attend their local health centres, leading to difficulty in completing longer treatments such as CMAM. Finally, the cultural practice of mothers remaining strictly within the house following the birth of a child was widely mentioned as a reason for difficulty in attending the CMAM programme if another child was enrolled.

The availability of medical care played an important role in the caregivers’ decision-making process. Modern healthcare facilities, such as the block-level primary health centres, were considered to be located only in more populous areas and respondents emphasised that no appropriate health facility was available at the village level. Caregivers living further away from CMAM facilities reported that it was difficult for them to reach the therapeutic feeding centres, especially during heavy rains when transport is challenging due to frequent flooding. In contrast, every village was reported to have a traditional health practitioner and/or a Muslim or Hindu priest. Even if most of the respondents did not necessarily consider these health-care providers to be ideal, they felt that they were sometimes their only option.

Mothers stressed the fact that in addition to caring for their sick child, they had to take care of housework, work in the fields (especially around planting or harvest times) and look after their other children. For caregivers commuting from outside the block in particular, visits often took an entire day since travelling could entail a 4 h round trip in addition to the 2–3 h waiting time at the therapeutic feeding centre. Hence other family members had to shoulder an extra burden of work and thus would not always encourage mothers to visit the CMAM programme.

The choice of whether to access care was linked more to the perception of the disease and hence the importance of how much money and time should be spent on the treatment and within which sector. Most of the caregivers complained that they could not afford the transport costs to come each week for treatment in the CMAM programme.

Based on the responses of mothers whose children had been treated within the programme, the overall perception of CMAM was positive. Weight gain was seen as a measure of success and the positive perception of the service was expressed by mothers, family members and community participants who were aware of the programme. The concept of baby ‘strength’ rather than size was important; a healthy child was a ‘strong ‘ one, However, a significant number of caregivers said that they did not consider the peanut oil-based treatment offered to their children as effective enough and consequently would frequently think about stopping the treatment. The caregivers wanted to see immediate results when their child started any treatment, so many were discouraged when the child did not rapidly gain weight.

Recommendations

As a result of this study MSF provide a number of suggestions to target undernutrition and the beliefs surrounding undernutrition that should be incorporated into CMAM programming.

Primary interventions should focus on the dissemination of basic information about undernutrition and on clarification of misconceptions. The aim should be to raise understanding and awareness of severe malnutrition as a disease, while empowering mothers to decide whether they want to seek treatment for their child or not.  Longer term, secondary interventions should address behaviour change, taking into account the socio-economic, religious, cultural and political consequences of changes in the perception of undernutrition and the adaptation of health seeking behaviour of caregivers. Above all, active engagement and collaboration with communities is essential in order to address the barriers to enable change in such societies.

The success or failure of health programmes ultimately rests on how well they adapt to the local population. A fundamental focus of the training of health personnel should be the importance of being responsive and respectful to the traditions, religion and customs in the environment they are or will work in. Language is also important in the delivery of messages to the community. In countries with many dialects, it is important that local language skills are considered in communication strategies. For example, the staff within the CMAM programme routinely used the Hindi word kuposan to explain undernutrition. Yet, many of the respondents did not understand this; it is an elite Hindi word that is rarely used in these communities. Hindi is widely spoken in northern India, however, the standard of Hindi used may sometimes not be appropriate for the local context. In addition to using local language, disease can be understood through the use of local concepts. Expressions such as mamarcha and jallachatu can be used by health workers in the Biraul area to explain undernutrition to communities who would normally not think in terms of allopathic medicine.

Caregivers often do not make decisions alone; frequently, family elders decide whether a mother may seek and receive treatment for her child. Therefore, it seems imperative that information, education and communication programmes target communities broadly, including educators, youth and decision-making groups, and in particular those whose opinions are respected and considered most important in the social structure. Crucially, community engagement programmes must include both priests and healers, who could assist in encouraging appropriate referrals into the CMAM programme.

Footnotes

¹Burtscher.D and Burza. S (2015). Health-seeking behaviour and community perceptions of childhood undernutrition and a community management of acute malnutrition (CMAM) programme in rural Bihar, India: a qualitative study. Public Health and Nutrition. doi:10.1017/S1368980015000440

²Described by respondents as a look believed to bring bad luck, to the person at whom it was aimed for reasons of envy or dislike.