Conflict, mental health, care and malnutrition

The visible causes of malnutrition in humanitarian crises include a lack of food and potable water, and disease. The psychological and social consequences of crisis also have a direct, though less visible, impact on nutritional status and on the treatment of severe malnutrition. UNICEF’s conceptual framework for nutrition identifies three essential elements for the development, growth and survival of children: access to healthcare, access to food and access to nurturing or care. While the consequences of inadequate care on children’s nutritional status have been analysed in development contexts, very little research has been done into typical care practices during crises. Yet the psychological and social effects of war and conflict – personal trauma, depression, chronic stress, the collapse of family structures – strongly influence families’ capacity to care for and protect their dependent members. This suggests the need for a new approach to nutritional programming in conflict, one which includes a mental health component focusing on psychosocial care and the family–child relationship. This article describes two pilot projects set up by Action Contre La Faim (ACF) which sought to address the mental health and care practices of severely malnourished children and their families as part of therapeutic feeding programmes in Afghanistan and Southern Sudan.

The pilot projects

ACF’s pilot projects ran in Kabul in Afghanistan and Juba in North Sudan during 2002–2004. The aim was to improve the mother–child relationship and increase children’s stimulation in order to strengthen the prevention and treatment of malnutrition; enhance the well-being of the people bringing children to the feeding centre, as well as of the children themselves; and limit the negative impact of malnutrition on children’s development. The idea was to see how new activities could be accommodated within existing nutritional protocols, such as three-hourly therapeutic milk schedules, and what activities were most appropriate within the very structured environment of therapeutic feeding centres.

Each pilot project involved a complete nutrition and medical team, including one or two psychosocial workers. The basic package consisted of:

• New welcome and stay modalities, including better information about malnutrition and treatment, greater involvement of families in the treatment of children, improved decoration in the nutrition centres, more flexibility in patient stays and regular meetings and enhanced communication between staff and patients.
• Active support during milk feeding, sensitisation around children’s needs and child development, explanations regarding the impact of malnutrition on child behaviour (such as apathy and irritability), all designed to reinforce the relationship between caregivers and children.
• Social activities for adults.
• Play sessions for mothers and children, to reinforce the caregiver–child relationship and improve care practices, to stimulate children and to teach mothers how to continue stimulation at home. This component also aimed to give enjoyment in a very medical environment, to provide a framework where caregivers could appreciate their children’s skills and to bolster parents’ confidence in their capacity to take care of their children.
• Individual follow-up through interviews, and the creation of psychosocial files for each admission. In this way, psychosocial workers tried to understand the history of a child’s malnutrition, and develop better prevention strategies. The stress caused by the child’s malnutrition and by long stays in the nutrition centre, compelling parents to leave other children alone at home, was also discussed.
• Parents were also encouraged to participate in informal discussion groups: patients in nutrition centres supported each other by talking about their children’s recovery, and staff tried to encourage discussion about specific family concerns, allowing people to talk about their problems and tell others about the solutions they had found.

This basic package of care practices and mental health activities was then adapted to the cultural context, the causes of malnutrition and the profile of the patients in the two pilot sites, as described below.

Kabul: milk insufficiency and severe malnutrition among children under six months

After more than 20 years of war, Afghan women have found themselves in a very precarious situation, both socially and economically. Socially, many married women are isolated in the homes of their in-laws, where they often have little support, and can become victims of violence. Separation from their husbands may only make them more vulnerable. Economically, their living conditions are also often fragile: living costs may be high, and their job opportunities (mainly daily work) are precarious.

In 2003, almost 40% of the severely malnourished children who came to ACF’s nutrition centres in Kabul were under six months of age. Mothers of these infants complained of lack of breast milk. Typically, it is rare to see large numbers of severely malnourished children under six months of age because breastfeeding protects them. In Afghanistan, this protection seems not to be effective. A study is on-going to better understand the causes of mothers’ milk insufficiency. Initial evidence indicates that there are many reasons for milk insufficiency: complementary feeding may be introduced at the wrong time, there may be a lack of support in cases of lactation difficulties, breastfeeds may be too short or too few, the position during breastfeeding may be incorrect, or low-birth-weight children may have difficulty suckling. Psychologists have shown that depression and anxiety among breastfeeding women can lead to difficulties in taking proper care and establishing good relationships with their babies.

Better knowledge of care practices and breastfeeding will help us to define and develop better interventions to prevent lactation difficulties, and to treat severe malnutrition among children under six months of age. Measures include using suckling techniques that permit the child to be fed with therapeutic milk, while stimulating the production of breast milk through continued suckling. The aim is to treat the child’s severe malnutrition without impairing the production of the mother’s milk, and damaging the mother–child relationship. Building mothers’ confidence is key to the success of lactation or re-lactation when breastfeeding has stopped. Psychosocial workers encourage and guide mothers and babies during breastfeeding, adjusting the baby’s position and giving counselling.

Psychological support seems to be well suited to the Kabul context. Most women express their feelings and describe their difficulties very easily. To reach in-depth changes and improvements, we tackle the child-caretaker couple but also the family as a whole, especially within a society where responsibility and power are in the hands of the husbands and/or of the mothers-in-law.

Preventative activities were instituted in the Kabul pilot for pregnant and lactating mothers from January 2005. Women are invited to join group discussions and play sessions, where they receive personal advice and support for breastfeeding; referrals to other institutions and organisations are arranged according to need. Babies’ growth is monitored to confirm that the lactation is adequate and sufficient for development. It is too early to assess the results. In addition, a community approach, including home visiting, is under discussion, to improve access to women in a country where most are still confined to their homes.

Juba: foraging leads to neglect of maternal care

After 40 years of war, people in Southern Sudan regularly face forced displacement, and families are often split up. Frequently, displaced people make for Juba, the main city of Southern Sudan. Once there, they find that their usual mechanism of survival (subsistence agriculture) is virtually impossible due to limited access to land and impoverished soils. Displaced people therefore have to find new ways to survive; women start leaving camps or protected areas to forage for wood or grass to sell in the market in order to buy food for their families. As they are away from home for most of the day, mothers have to leave their youngest children in the care of older children, who themselves are sometimes under seven years of age. In addition, the displaced situation, hunger and serious problems of alcoholism among both men and women lead to family conflict and violence. Children in these situations often suffer from some form of malnutrition due to basic neglect and a lack of resources.

The psychological strains produced by such difficult conditions have both immediate and less direct impacts on malnutrition and its treatment. In Juba, face-to-face interviews are unusual and seem less appropriate to tackling individual suffering. People are not often willing to speak about their past because it ‘makes them sad’ and leads to difficulties in sleeping. The approach ACF has developed is based principally on informal group discussions in nutrition centres, and joint activities, such as dancing and storytelling, where topics of concern to caregivers are more easily discussed. Mutual support among caregivers is much appreciated, and has a greater effect than advice from ACF staff.

Alcoholism and associated violence is a complicated issue to address. ACF’s input is mainly in lobbying with institutions and the ministry of health for the recognition of this major public health problem. The ACF programme includes foetal alcoholic syndrome in health education sessions, to increase awareness and sensitise communities to this risk. Some of the severely malnourished children admitted to nutrition centres are probably victims of alcohol, and we know that one of the consequences of FAS is difficulty in suckling. ACF’s food security programme in Juba also includes psychosocial support for families with alcoholism problems.

The impact of integrating a mental health component into therapeutic feeding

Assessing the impact of a psychosocial component within therapeutic feeding is not easy. Nonetheless, evidence from the Kabul and Juba pilots suggests that adopting a more holistic approach to therapeutic feeding leads to better services for patients.

• Feeding centre staff have a better knowledge and understanding of each family situation and the causes of malnutrition for each case. It is easier for them to give specific and adequate advice to families, and they feel more motivated.
• The children are much more active.
• Support is provided to each family according to its specific situation, weaknesses and strengths.
• The self-esteem of caregivers is reinforced; fewer judgments are made by centre staff, parents are enabled to discover the capacities of their own children, and their own capacities to take care of them; and responsibilities during treatment are shared more.
• Default rates during treatment are reduced. In Kabul, defaulting decreased not only because of care practices but also because of an improvement in the whole approach and in the quality of services provided.

Conclusion and recommendations

Following the pilots in Juba and Kabul, the project has been extended to other countries and areas, including Darfur. The outputs of these pilots confirm the need to integrate care practices and mental health activities in all ACF’s therapeutic feeding centres, and this is beginning to happen. All nurses are trained in nutrition and care practices before they go on mission, and expatriates (psychologists and ergotherapists) support the field team in the implementation of these new activities in feeding centres.

Besides the direct benefits for ACF’s patients and programmes, the move to a more holistic approach and the addition of these new competencies has benefited the agency more broadly, in terms of:

• Facilitating context analysis, by taking into consideration the social and psychological consequences of crises for affected people and agency staff.
• Enabling a better understanding of the causes of malnutrition through the inclusion of care-practice factors in addition to food security, health and hygiene.
• Allowing the development and improvement of ACF programmes and interventions according to psychosocial and care-practice needs.

The sharing of experience in different contexts and with different organisations is needed to define the best and most efficient approaches (centre-based/community-based, individual/collective, counselling/play). Even after a general framework for integrating these care practices and supportive activities is established, a lot of work still has to be done. Transferring technical skills in care practices and mental health is a long and complex process, and needs to be adapted to fit the particular cultural context, beliefs and habits. Indicators for assessing needs and impact are not well-defined. There is a real need to develop these kinds of activities in emergency situations. This was one of the recommendations of the Standing Committee on Nutrition’s Working Group on Nutrition in Emergencies when it met in New York in March 2004.

Cécile Bizouerneis a clinical psychologist at ACF headquarters in Paris. She is responsible for care practices and mental health programmes. Her email address is cbizouerne@actioncontrelafaim.org. Psychologist Sandra Bernhardt worked with ACF in Darfur in 2004–2005, where she supported the implementation of care practices and mental health activities in nutrition centres. Her email address is sanber@wanadoo.es.

References and further reading

P. L. Engle, M. Bentley and G. Pelto, ‘The Role of Care in Nutrition Programmes: Current Research and a Research Agenda’, Proceedings of the Nutrition Society, vol. 59, no. 1, 2000, pp. 25–35.

Action Contre la Faim Géopolitique de la Faim (Paris: Presses Universitaires de France, 2004).

M. Geber, ‘Psychological Factors in the Aetiology of Kwashiorkor’, Bulletin OMS, XII, 1955, pp. 471–81.

S. Grantham-McGregor, ‘A Review of Studies of the Effect of Severe Malnutrition on Mental Development’ J Nutr, 125(8 Suppl), pp. 2,233S–2,238S.

S. Grantham-McGregor, C. Powell et al., ‘The Long-term Follow-up of Severely Malnourished Children Who Participated in an Intervention Program’, Child Dev, 65(2 Spec No), pp. 428–39.

C. Prudhon, La malnutrition en situation de crise – Manuel de prise en charge thérapeutique et de planification d’un programme nutritionnel, Action Contre la Faim and Karthala, 2001.

L. C. Terr, ‘Childhood Traumas: An Outline and Overview’, American Journal of Psychiatry, 148(1), 1991, pp. 10–20.
UNICEF, The Care Initiative: Assessment, Analysis and Action To Improve Care for Nutrition, 1997.