Perceptions of SAM treatment in infants under 6 months in Malawi
By Concetta Brugaletta
Concetta Brugaletta is a clinical research nurse working in neurology. Currently based in the UK, she is interested in infant malnutrition and holds a Masters in Clinical and Public Health Nutrition from University College London. She has four years of clinical experience in oncology and nearly two years of experience in child nutrition in Guinea Bissau and Malawi.
The author would like to thank her MSc supervisor, Dr Marko Kerac, for his guidance during the project described in this article. Marko Kerac gratefully acknowledges support from an Academy of Medical Sciences Clinical Lecturer Starter Grant supported by the Wellcome Trust, the British Heart Foundation, Arthritis Research UK, the Medical Research Council, Prostate Cancer UK and the Royal College of Physicians (http://www.acmedsci.ac.uk/careers/funding-schemes/starter-grants/) for supporting the fieldwork described in this project.
This article is a summary of an MSc thesis1.
Women's focus group
What we know: The global burden of SAM in infants under 6 months of age is significant. To date, treatment options have depended on inpatient care. Community based management is an option in the latest update of WHO guidance on SAM treatment. Context specific management options are lacking.
What this article adds: In Malawi, the perceptions of carers and health professionals regarding outpatient treatment of SAM in infants under 6 months were explored in a small qualitative study. Participants preferred inpatient management based on high expectations (rather than experience) of care. Early clinical signs of malnutrition were known but considered under-recognised in the community. Maternal mental health was not considered relevant. Priority actions included education of key community leaders. Expectations are compatible with community-based care. A strong informal community network was identified that could help shape future interventions.
As highlighted by the Management of Acute Malnutrition in Infants (MAMI) project2, malnutrition in infants below six months (infants <6m) has often been considered rare and has often been neglected. Yet, a recent study estimated that of 20 million children under five years with severe acute malnutrition (SAM) worldwide, 3.8 million are infants< 6m3. CMAM (Community-based Management of Acute Malnutrition) treatment is modelled on outpatient treatment, targeting children 6-59 months4. By contrast, international and national SAM guidance (including Malawi guidelines5) for infants <6m, recommend only inpatient-based care6. This may change with the just released WHO SAM guidelines7. For the first time, these describe outpatient-based treatment options for infants <6m.
The motivation for this research was to respond to the knowledge gap of how Malawian carers and healthcare professionals will perceive future changes from inpatient to outpatient treatment for infants <6m and what benefits and risks they expect. The study also aimed to identify key elements that might help to roll out future infants <6m SAM guidelines at the country level.
- To explore carer and health professional views and preferences regarding the existing management of SAM in infants less than 6 months.
- To analyse the risks and benefits of the community-based approach to infants <6m with SAM as perceived by these key stakeholders.
- To make recommendations, based on the previous two objectives, to improve eventual development and roll out of infants <6m SAM guidelines.
This was a qualitative study based on 12 interviews with health professionals (Nurses, Health Surveillance Assistants (HSAs)) and 20 focus group discussions (FGD) with carers (mothers, fathers and grandparents). The study was conducted in three urban and two rural health centres in the Blantyre district of Malawi. A pilot phase was conducted at the Queen Elizabeth Central Hospital, Blantyre. Further logistic support was given by the Malawi-Liverpool Wellcome Trust Science Communications team and by the Community of Sant’ Egidio.
A total of 143 people took part in the study. All participants signed informed consent. Sample size was determined by data saturation. Interviews and FGDs revolved around a topic guideline. Most of the FGDs were conducted in Chichewa language, while all the interviews (mainly with healthcare workers) where conducted in English. Focus groups had 5-7 participants each. A thematic analysis methodology was used.
The theme of infant malnutrition opened up different topics related to husband-wife relationships, the role of men and women in society, and the role of grandparents and traditional beliefs. The six major themes that emerged from the data (see Figure 1) were:
- Understanding of causes and symptoms of SAM in infants < 6m
- Perception of management of infants <6m with SAM at hospital level
- Perception of management of infants <6m with SAM at community level
- Caregiving resources (mother and household)
- Caregiving resources (community level)
- Perceived priorities for management of infant malnutrition
HSA: Health Surveillance Assistant;
CAG: Community Advisory Group;
CITE: Community Initiative for Tuberculosis Eradication
Both health professionals and carers were generally able to describe most of the multifactorial causes of malnutrition, including social and cultural, and the clinical symptoms of early and acute phases of SAM. However the early signs of acute malnutrition in infants <6m were considered under-recognised in the community. Most health workers relied on weight based anthropometric assessment; advantages of using MUAC assessment in this age group were recognised but some expressed doubts about its use in very young infants.
Among the causes of malnutrition, behavioural taboos were commonly mentioned in interviews and FGDs, e.g. unfaithfulness or another pregnancy. Most people considered causes related to the ability of the mother to produce enough milk, due to lack of food for example, rather than the causes related to the infant. The relationship between maternal mental health and child health was poorly understood and not considered to be a common factor.
Participants instinctively preferred the inpatient-based approach to treating infants <6m with SAM. This preference was based on relatively superficial risk-benefit judgments and (unrealistically) high expectations of care in this setting, not necessarily based on experience, e.g. hospitals viewed as educational centres of excellence, medicine and food availability with inpatient treatment.
Participants were asked who they seek help from in the community setting if infants <6m are malnourished. The majority identified the HSA, who is trained and close to the community, as well as the Community Advisory Group (CAG) volunteers, who are present in the rural centres, chosen from the community, and receive training on a health topic. Regarding outpatient treatment, respondents reported advantages (able to look after the home and older siblings) and disadvantages (challenge to follow prescribed care, sharing food with siblings, and weak community settings where mothers have little support). Family support included fathers, as provider and a key decision-maker on infant health, grandmothers and older siblings. “Well educated” women, in particular, influenced infant related decisions.
Participants identified that a priority for addressing infant malnutrition problems was more education at the family and community level, targeting key community figures such as HSAs, village chiefs, grandparents, religious leaders and traditional doctors. Interviewees preferred to receive training and education in groups in order to learn from each other and to access peer support, but favoured individual case management.
The approach to managing infants with SAM must be framed in the context of both the mother-infant dyad and wider social-family relationships (e.g. fathers and grandparents). To do this, close engagement with families and communities is crucial. Four out of six of the main themes emerging from the data were related to caregiving resources in the community. Expectations expressed for inpatient treatment are not incompatible with community-based care. A strong informal community network exists in this Malawian community that can support the mother-infant dyad and could help shape future interventions.
For more information, contact: Concetta Brugaletta, email: firstname.lastname@example.org
1Brugaletta C. An exploration of how Malawian carers and health professionals perceive the community-based management of acute malnutrition (CMAM) approach in infants aged <6 months. Unpublished MSc thesis, UCL 2013.
3Kerac M, Blencowe H, Grijalva-Eternod C, et al. Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards: a secondary data analysis. Arch Dis Child 2011; 96(11): 1008-13.
4For more information on CMAM, see http://www.cmamforum.org/
5MALAWI. Guidelines for community management of acute malnutrition. 2012.
6Kerac M, Trehan I, Weisz A, Agapova S, Manary M. Admisison and Discharge criteria for the management of severe acute malnutrition in infants < 6 months: an AGREE appraisal of national protocols and GRADE review of published literature. Presented to WHO NUGAG meeting, Feb 2012, Geneva 2012.
7Updates on the management of severe acute malnutrition in infants and children Guideline. WHO 2013. http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/index.html
More like this
FEX: Community management of uncomplicated malnourished infants under six months old: barriers to national policy change
By Sonja Read and Marie McGrath View this article as a pdf Sonja Read is a public health nutritionist and was lead researcher (ENN consultant) on the project. Marie McGrath...
FEX: Auditing the identification and inpatient management of acute malnutrition in infants under six months in Malawi
Summary of MSc thesis By Laura White Laura White is a Canadian-trained registered dietitian who recently completed an MSc in Nutrition for Global Health at the London School...
Summary of report1 Child malnutrition is a major global public health issue. The burden of acute malnutrition in children 6 months to 5 years is well recognised, and the...
Summary of research1 Location: Bangladesh What we know: The World Health Organization (WHO) recommends that infants under six months with uncomplicated severe acute...
Summary of research1 Location: Global What we know: The World Health Organization (WHO) recommends weight-for-length z score (WLZ) as an anthropometric indicator to identify...
On 27th January 2016, ENN, London School of Hygiene and Tropical Medicine (LSHTM) and Save the Children co-hosted a one day meeting of a Management of Acute Malnutrition in...
This article summarises key findings of an MSc thesis1 By Natasha Lelijveld Natasha Lelijveld has recently completed her MSc in International Child Health at UCL. She is...
FEX: Risk factors for severe acute malnutrition in infants <6 months old in semi-urban Bangladesh: A prospective cohort study to inform future assessment/treatment tools
Summary of conference abstract1 Presented at the ACF research conference, November 9th, 2016. By M Munirul Islam, Yasir Arafat, Nicki Connell, Golam Mothabbir, Marie...
By Anne Marie Kueter, Alice Burrell, Sarah Butler, Mostofa Sarwar and Habibur Rahaman View this article as a pdf Anne Marie is a nutritionist with over five years'...
By Caroline Wilkinson and Sheila Isanaka Caroline Wilkinson was Nutrition Advisor with Action Contre la Faim - France (ACF-F), until November 2008. She spent most of 2007 in...
FEX: Management of acute malnutrition in infants less than six months in a South Sudanese refugee population in Ethiopia
By Mary T Murphy, Kassahun Abebe, Sinead O'Mahony, Hatty Barthorp & Chris Andert View this article as a pdf Lisez cet article en français ici Sinead O'Mahony is a...
FEX: Risk factors associated with severe acute malnutrition in infants under six months in India: a cross sectional analysis
By Susan Thurstans Susan is a registered nurse and midwife with over 12 years' experience in maternal and child health and nutrition programmes in both development and...
FEX: Improving community management of uncomplicated acute malnutrition in infants under six months (C-MAMI): Developing a checklist version of the C-MAMI tool
Summary of MSc project report1 By Sonja Read Sonja Read is a public health nutritionist from the London School of Hygiene and Tropical Medicine. She has previously worked in...
NEX: Perceptions of severe acute malnutrition and its management in infants under six months of age: An exploratory study in Bangladesh
Yasir Arafat1is a medical doctor and public health practitioner, managing community-based nutrition programmes targeting acute malnutrition. He is currently working with Save...
Summary of published research1 Waiting for the ward round in the MOYO rehabilitation centre in Blantyre - Malawi's biggest feeding centre In a hospital-based HIV prevalence...
A one-day meeting of the Management of At risk Mothers and Infants (MAMI)1 Special Interest Group (SIG) took place in London on 17 January 2018. The meeting was hosted by ENN...
View this article as a pdf Summary of meeting report1 A two-day meeting of the MAMI Special Interest Group (SIG)2 was held on 12-13 December 2019, organised by Emergency...
FEX: Making connections: Joint meeting of WaSt Technical Interest Group and MAMI Special Interest Group
ENN coordinates two international technical groups, the Management of at-risk Mothers and Infants under six months Special Interest Group (MAMI SIG) and the Wasting and...
Resource: Perceptions of Acute Malnutrition and Its Management in Infants Under 6 Months of Age: A Qualitative Study in Rural Bangladesh
ABSTRACT Background: World Health Organization guidelines advise community-based care (CBC) for “uncomplicated” severe acute malnutrition (SAM) infants <6...
In January 2010, the report of ‘The Management of Acute Malnutrition in Infants aged <6 months’ (the MAMI project)1 was released. Key findings included: Large numbers of...
Reference this page
Concetta Brugaletta (). Perceptions of SAM treatment in infants under 6 months in Malawi. Field Exchange 47, April 2014. p14. www.ennonline.net/fex/47/perceptions