Severe Acute Malnutrition (SAM) is widespread in South Asia, and affects 2.6% of under-fives (about 76,000 children) in Nepal. It is treatable through the administration of ready-to-use therapeutic foods (RUTFs) and medico-nutritional treatment (vitamins, antibiotics). However, what is often missed in malnutrition treatment programmes is the opportunity to combine with early child development interventions to improve both nutrition and development outcomes.+M. T. Ruel and H. Alderman, ‘Nutrition-sensitive Interventions and Programmes: How Can They Help to Accelerate Progress in Improving Maternal and Child Nutrition?’, The Lancet 382(9891), 2013. Very few nutrition treatment programmes include a psychosocial intervention, and systematic evaluations of community programmes are few and far between.+P. L. Engle et al., ‘Strategies for Reducing Inequalities and Improving Developmental Outcomes for Young Children in Low-income and Middle-income Countries’, The Lancet 378(9799), 2011. Action contre la Faim’s Follow-up of Severely Malnourished Children (FUSAM) project, which ran from 2014 to 2017 in Nepal, aimed to address this.
We wanted to assess the effectiveness of a brief psychosocial intervention on child nutrition, health and development by comparing the effects of a combined psychosocial and nutrition intervention to a stand-alone nutritional treatment of children with uncomplicated SAM aged six to 24 months admitted to a Community Management of Acute Malnutrition (CMAM) programme in Saptari district in the Eastern Terai sub-region of Nepal, implemented in collaboration with the District Public Health Office (DPHO).+Funding for the study was provided by Elrha’s Research for Health in Humanitarian Crises (R2HC) programme, supported by the UK Department for International Development and the Wellcome Trust. This article describes how we designed a psychosocial component for mothers and caregivers whose children were being treated for SAM. Our research highlights the value of including a psychosocial intervention to improve parenting skills, leading to enhanced child development. However, the direct impact on SAM treatment was found to be more limited than anticipated.
Designing the intervention: improving childcare practices to reduce under-nutrition
Saptari district is home to a variety of tribes and castes. Agriculture is the main occupation, though it is also common for husbands to work abroad or elsewhere in Nepal, coming home once a year or less. Women face strong social pressures, have few resources and a high workload and can lack the support of their in-laws. Mothers are often busy with other duties, such as household chores and agricultural work, leaving limited time for childcare, and young and single mothers in particular may not have the resources to provide proper care. Hygiene practices are very poor, and although food is available and dietary diversity does not seem to be a problem, children’s diets are insufficient for optimal development and growth. Children may also be weaned too early (around three months) or too late (at one year). There is gender discrimination against girl babies because the family is expected to pay a dowry for marriage.
With the involvement of the local community, we designed psychosocial interventions to support behaviour change in both the mother and the child by:
- supporting mothers and children with stimulation activities;
- increasing mothers’ knowledge of appropriate child-rearing practices;
- enhancing mothers’ wellbeing and self-esteem; and
- promoting children’s growth through better nutrition.
The psychosocial intervention portion of the FUSAM comprised fortnightly follow-up sessions on the same day as the nutrition follow-up. Five sessions were scheduled, of around 30 to 45 minutes each. Each session had a specific objective:
- Session 1: ‘Family Welcome’ aimed to welcome the mother and the child (or other family members), exploring their thoughts and feelings around nutrition and the future of the child.
- Session 2: ‘Communication, play and have fun’ aimed to sensitise mothers on the importance of communication and play in enhancing children’s stimulation and development.
- Session 3: ‘Breastfeeding and feeding practices’ aimed to explore new strategies and skills for transforming these moments into positive experiences both for the child and for the mother.
- Session 4: ‘Massage, bathing, sleep and relaxation’ aimed to explore strategies of reassurance and relaxation for the baby that are feasible and enjoyable for both the child and the mother.
- Session 5: ‘Family sharing’ aimed to reflect with the mother on lessons learned and to share this information with other family members.
Implementing a psychosocial intervention as part of a CMAM programme
CMAM programmes rely on a range of community and health services, including Female Community Health Volunteers (one for around every 20 families), who provide services such as family planning and child immunisation, and refer children presenting signs of undernutrition to Outpatient Therapeutic Programme (OTP) centres. The psychosocial component was set up with a team of psychosocial workers recruited by the DPHO and trained by ACF. In OTPs, the nutrition focal point or general practitioners referred SAM children and their mothers to psychosocial workers, and their performance was regularly monitored by a supervisor, either on site or via video when insecurity did not allow field visits.
Integrating psychosocial interventions in CMAM programmes is challenging: it requires collaboration with various health professionals to set up a reliable referral system; it requires appropriate training for health practitioners and psychosocial workers; and it requires a safe and confidential space in the health premises. Even so, the intervention was practically feasible in this remote area of Nepal, and could be delivered more generally even in challenging contexts. Between August 2015 and February 2016, communal tensions stoked by changes to the Nepali constitution triggered regular strikes and violent demonstrations, forcing people to curtail their movements and reducing the number of mothers visiting OTPs. In order to allow the FUSAM team to continue its work despite restrictions on movement and curfews, changes were made in planning and remote supervision was organised in order to maintain minimum services. While initially only mothers were targeted for psychosocial sessions, this was extended to other family members and caretakers who accompany children to the OTP.
Challenges and successes
The intervention seems to have had a significant impact on child development (gross and fine motor skills, cognitive skills, language, problem-solving and personal/social development), and this improvement has been sustained. Levels of child stimulation at home have also increased. Most of the mothers (50% came to four or five sessions) appreciated the intervention. According to one psychosocial worker: ‘at the beginning [of the project], some people were reluctant to bring their child to the OTP for nutritional treatment but they accepted and continued the treatment after individual or family counselling. Nowadays they thank us for opening their eyes to their child care’. Generally, counselling has made mothers more aware of malnutrition problems, prevention and treatment, parents’ roles and responsibilities, hygiene and proper sanitation, proper feeding and access to health services. They also learned about child development, and felt better equipped to make decisions affecting their children.
We could not demonstrate that the intervention had any significant impact on recovery from SAM. Anthropometric measures were not reliable enough, and the intervention was too short to close the gap between SAM and non-SAM children in terms of development. In the opinion of psychosocial workers, facilitating behaviour changes would take more time than was included in the programme: ‘there are several factors in the community that we can’t change in a short period of time, like girls’ education, family support mechanisms, prevention of early marriage, barriers due to cultural factors, lack of economic activities, and the burden of household activities on women’.
Psychosocial workers have a vital role in sensitising health workers to the link between malnutrition and child development. In order to retain experience and knowledge among health staff, we trained all 62 auxiliary nurse-midwives working in OTPs and remote birthing centres and five health workers at the Nutrition Rehabilitation Home on the FUSAM psychosocial protocol and basic psychosocial support. Other DPHO representatives and staff as well as those responsible for OTPs received a one-day orientation on the psychosocial intervention programme. We have also provided low-intensity training for health workers at OTP centres in Rasuwa district in northern Nepal in an adapted version of the FUSAM protocol (with very similar content and without additional PSWs). A round of supervision provided additional information on adapting the protocol content and implementation modalities to reflect geographical and sociocultural differences in the country. This is the first step in scaling up the intervention. There is also a new opportunity for a collaboration with the National Health Research Council (NHRC), which has invited us to join the technical team developing Nepal’s first national mental health survey.
The psychosocial component of FUSAM was developed taking into consideration the psychosocial impact of SAM on children, their mothers and their relationships. Interventions were delivered despite numerous challenges and under adverse conditions. It had positive impacts, some expected and others not, and will require further study. In the meantime, the programme is being taken forward and adapted with the support of the Ministry of Health and Population.
The FUSAM project was innovative given the lack of clear national policies or guidelines on psychosocial interventions in nutrition programmes. There are multiple benefits in including a psychosocial component alongside SAM treatment, but the results show that it is unrealistic at this stage to expect psychosocial interventions to address the impacts of SAM.
Karine Le Roch is Research Project Coordinator in Mental Health and Care Practices for Action contre la Faim – France. Cécile Bizouerne is Senior Technical advisor in Mental Health and Care Practices for Action contre la Faim – France.