Dear Lio, Thanks to raise the issue. Ideally, the term malnutrition should be translated into local language so that the community can understand easily. the translation exercise is usually done during the training exercise. When it is translated into local language, the meanings are always the signs of malnutrition like thin, weak, emaciated, sick, skinny, and so on. If these signs are appeared to a given child, then it is clear for the mother that something is wrong with her child. Once the mother acknowledge that weight of her child is significantly decreased, I think we should not worry whether the mother answers correctly saying "malnutrition" or not as it is not easy even for people who have better knowledge. The key issue that we need to give more attention is on the quality of interview. Unless there is proper probing, everything will end up “lack of knowledge”. moreover, the guiding questions should be adapted accordingly. The same is true about “lack of knowledge about the program”. I do agree on your point regarding the health seeking behaviour. High awareness rate malnutrition or awareness of CMAM program is not guarantee for high rate of service uptakes.

Dear Kiross, you are very correct about translating in local language; however we must admit that this exercise (find multiple local terms describing malnutrition) is mainly used for the active case finding exercise in order for the community/key actors to understand who we are looking for. When it comes to interview the carer of a not-covered child, the tendency is more to go for the "straightforward" terms (what we can call the more similar translation of "malnourished"). This comes indeed to the quality of the interview, "quality" in the sense that we should really try to understand if the mother perceive that the health of the child is not good in regard to growth/weight, this is not obvious in a context where stunting is very prevalent and the carer may thing that this is just how the child is. Basically my point is: since these two elements (awareness of malnutrition and awareness of the programme) are often the top list of barriers, we should pay more attention in the messages used in the sensitization activities and during coverage surveys.

Hi, I would like to jump in this interesting discussion about how community understands nutrition related terms and treatment services. I agree that most nutrition intervention messages tend to secure " screening " or services seeking " knowledge and attitudes. but there are other determinants of misunderstanding with mother/ community . in Niger, we have a " robust and well known local expression in hausa" for SAM in children that is "Tamoa ". whilst using this term could help identify community defined SAM, it does not refer to "growth failure", "weight loss" but the barely final state of being "emaciated" or having oedema. we find the same issue during a recent survey on percieved quality of household diet. while other survey results based on food quality measurement (and own knowledge of the reality of diet in Niger) shows that most diet are insufficient, our survey using percieved quality finds rather different percentages. the last thing we observe after years of food distributions,is the likely interest conflict in community answers on their child nutritional status, most community believe that surveys always preclude food distribution and you end up with biased results on knowledge of anything related to these kind of services to the community.

From Massimo Serventi: Mothers(parents) do not perceive that their child is malnourished, they know that HE IS SICK. Always sick, with diarrhea,fever sometimes, poor appetite. We know that these are the consequences of poor nutrition and not the cause of it, parents simply see half of the vicious circle. They have been to local healers before coming to our observation. We may try to convince them that the child has been poorly nourished, that he is slim....but in the deep of their heart there is the point: our child is sick and needs drugs, not food. The only way to make parents know the truth is to check regularly the body weight (monthly in the first 2 years) and to show the curve to them. Prof. David Morley spent his life to teach us all this simple fact: show to the mother where you put the dot, inform here,praise her, she will take action at home, with whatever food she has. Unfortunately growth monitoring (GM) has been abandoned in several countries(including Afghanistan where children are often malnourished). Why so? because 2 'scientific' articles have demonstrated that GM unaccompanied by a concrete action( distribution of food?) is not effective. I have the experience of 6 African countries and 2 of Asia: I read letters from Ministries of Health discouraging the practice of GW. Let's be serious: a person questioned about his size will reply that he is not obese, just a 'bit large', not much after all. Only when he will calculate by himself that his/her BMI is over 28 he will realize the truth of his condition. I do not agree with the distribution of plumpynut. Mothers perceive it as a 'drug/food', coming from rich and intelligent foreigners. They ignore that plumpynut contains mainly groundnuts that they cultivate: a food manufactured in Europe with ingredients available in Africa, to feed children poorly nourished who are believed by their parents to be sick Greetings from Dodoma Massimo Serventi Pediatrician massimoser20@gmail.com

Dear Massimo, I have posted your response to this discussion for you, as requested. However, just as a post-script, it is important to note that much Ready-to-Use Therapeutic Food (RUTF) is now produced in Africa, and this was, I believe, one of the reasons for the use of peanuts in its formulation - to enable local production. Best wishes, Tamsin

Caregivers will always have an opinion regarding the growth and health of their child. These opinions are guided by local norms and influence health care seeking decisions and consequently, the health of the infant. Mothers perception influences the outcome of interventions because it dictates whether or not mothers will follow instructions to achieve success (health belief model). The challenge that health workers face is brought about by the lack of understanding between the healthworkers and the community caregivers. Most African languages for example do not have a word that translates directly into the word nutrition and hence no word that translates to malnutrition. For example, the swahili words, "utapia mlo" which was cooked up in the early seventies to mean malnutrition is hardly used by local communities in Kenya and hence quite foreign. Most communities do not know this word exists!. Nevertheless, what communities are very much aware of is that there is a concept of growth and proportionality i.e the acceptable "healthy" and "unhealthy" looks for children in different ages within the community. Therefore, in my opinion, It would be most appropriate to ask caregivers for their opinion of what is normal by asking then to compare the growth and proportionality of their own child with that of others of the same age in the same community. Ofcourse the challenge is that, in a community with chronic food shortage, a normal child by the community's standards might be malnourished by anthropometric/clinical standards. The point being that by understanding the concept of growth within the community, one can design better messages for enhancing growth and the uptake of interventions within that community. Another way to assess maternal perception would be to develop, pilot and use a pictorial scale. This approach has been used very successfully in the well developed countries in assessing perception to over nutrition. See these references below Jeffery AN, Voss LD, Metcalf BS, Alba S, Wilkin TJ. (2005). Parents' awareness of overweight in themselves and their children: cross sectional study within a cohort (EarlyBird 21). BMJ;330(7481):23-4. Eckstein KC, Mikhail LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ. (2006). Parents' perceptions of their child's weight and health. Pediatrics;117(3):681-90. Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. (2000). Maternal perceptions of overweight preschool children. Pediatrics;106(6):1380-6. Maynard LM, Galuska DA, Blanck HM, Serdula MK. (2003). Maternal perceptions of weight status of children. Pediatrics;111(5 Part 2):1226-31. Genovesi S, Giussani M, Faini A, et al. (2005). Maternal perception of excess weight in children: a survey conducted by paediatricians in the province of Milan. Acta Paediatr;94(6):747-52. Hirschler V, Gonzalez C, Talgham S, Jadzinsky M. (2006). Do mothers of overweight Argentinean preschool children perceive them as such? Pediatr Diabetes;7(4):201-4. Hackie M, Bowles CL. (2007). Maternal perception of their overweight children. Public Health Nurs;24(6):538-46. He M, Evans A. (2007). Are parents aware that their children are overweight or obese? Do they care? Can Fam Physician;53(9):1493-9.

Just throwing in my tuppence from the perspective of coverage assessment and program reform. When interpreting the finding that "lack of knowledge of malnutrition" is a major barrier to coverage in CMAM programs we must consider the instrument used to collect the barriers data. This barrier data almost always comes from a filter question in a short questionnaire. The question flow is something like: 1. Do you think that this child is malnourished? __ |__| If YES ... 2. Do you know of a program that can treat malnourished children? __ |__| If YES ... 3. What is the name of this program? _____________________________________________ 4. Where is this program? _____________________________________________ 5. Why is this child not attending this program? Do not prompt. Probe ‘Any other reason?’ __ |__| Program site is too far away |__| Too busy to attend the program |__| Cannot travel with > 1 child |__| Ashamed to attend the program |__| Difficulty with childcare |__| Child previously rejected by program Record any other reasons ... __________________________________________ __________________________________________ __________________________________________ The first filter (Q1) is usually taken to give the barrier "lack of knowledge of malnutrition". The finding that "lack of knowledge of malnutrition" is a major barrier to coverage in CMAM programs comes from CSAS, SQUEAC, and SLEAC coverage assessments undertaken over the past ten year or so. In the context of these surveys we should seriously consider interpreting this barrier as a mismatch between program terms (as given in community mobilisation and sensitisation activities and mass-media messages ... and used in surveys) and local terms for malnutrition that refer to what "we" understand as "malnutrition". One example of this (seen in some Central and West African settings) is that "malnutrition" is associated with sexual libertinage. The term is not associated with wasting caused by infection, SAM is stigmatised and tends to remain hidden, and the overwhelming majority of people are unlikely to believe that sexual libertinage is something that can be addressed by RUTF (or F75 and F100) given to someone other than the libertine. All this leads to failures to seek treatment. In other settings I have found the term "malnutrition" to be associated with child-neglect, child-abuse, and psycho-social problems in parents. This has a similar effect. In such setting I have found that simple reforms such as altering program messages to emphasise (e.g.) "children who are sick or thin because they have not fully recovered from an illness such as diarrhoea and / or fever" (this is something like "tamoa" in Niger that Lio reports) rather "malnutrition" has had positive effects on coverage. In other settings (and in some UNO and NGO reports) there is a strong assumption that "malnutrition" is the result of poor food-security. This tends to exclude SAM as a sequelae to infection. The situation may be compounded by stigma associated with poverty. The point I am labouring to make is that mothers usually recognise what we call "malnutrition" but call it something else (usually with a well defined aetiology such as found in the terms "tamoa" or "kwashiorkor"). We must also use these terms or describe specific aetiologies, signs, and symptoms in program messages. We must try to avoid stigmatised terms and address stigma with sensitisation activities. We need to be careful positing a "population deficit" (i.e. stupid mothers) when we really have a "program deficit" (i.e. we used to the wrong messages and expected mothers to be able to discern our true meaning). One last thing ... RUTF is the enabling technology of CMAM. RUTF was formulated to enable local production and is frequently produced locally (in several African and Asian settings but in only one European county and on a small scale in North America). Groundnuts are only one ingredient in RUTF and one that can be replaced with another legume. Amongst the other ingredients in RUTF are sugar, vegetable fat, dried skimmed milk, and a mineral and vitamin mix to bring the product to the F-100 standard for a therapeutic feeding product. The current general policy push is away from "international Plump'Nut" towards locally produced RUTF. There has (e.g.) been no dumping of US agricultural surplus under the guise of RUTF even though all ingredients are produced and readily available in the United States. This is due to a policy of not wanting to undermine local production of RUTF. RUTF and CMAM (as CTC and then as CMAM) were developed and tested by people of many nationalities, many skin colours, different sexes, different ages, and different sexualities. CMAM is now most frequently delivered by local staff in local facilities in programs delivered and run by local ministries of health supported by local NGOs using locally (or regionally) produced RUTF.

Dear all, Due to offence taken, we have edited the comments made by Massimo (with his agreement) to reflect more concisely the argument he is making and remove any aspects that may be construed as sexist or racist, which were unintended. Mark has subsequently removed the specific responses to those from his posting. I would like to take this opportunity to remind all contributors to please consider the content and wording of their responses prior to posting. en-net is intended for peer to peer discussion and sharing of experience, however please remember that we now have close to 1000 subscribers around the world and it is important to avoid derogatory language or comments that are likely to cause offence to some readers. The en-net principles of participation can be found here: [url]http://www.en-net.org.uk/terms.aspx[/url] Best wishes & Happy New Year to all, Tamsin