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Abstract

Background:

Providing additional nutriment represents one strategy for overcoming moderate–acute malnutrition (MAM) in children younger than 5 years. However, it is important to examine how well received such Supplemental Nutrition Assistance Programs (SNAP) are by caregivers in order to ensure optimal results.

Objective:

This study explores SNAP’s reception by caregivers of MAM children younger than 5 years.

Methods:

Qualitative research was conducted through semi-structured, in-depth interviews with 16 selected caregivers and 5 Nutritional Executives from October to November, 2016 at 4 health centers in Denpasar, Bali, Indonesia. The results are presented to highlight the underlying patterns of SNAP’s acceptance.

Results:

Overall, the informants responded negatively to SNAP, reporting that it was of limited usefulness. The results show 4 main themes relating to the receipt of SNAP. The first relates to the caregiver’s preferences in terms of the types of supplementary food on offer. Second, caregiver’s perceptions that the child was not, in fact, in a state of illness or disease due to a medical issue. Third, that the caregiver does not require supplementary food as they maintain that they are able to buy it independently. Fourth, factors related to the lack of support for health-care workers working with malnourished children.

Conclusion:

The study finds that strengthening the role of health workers in terms of enabling them to effectively communicate the benefits of supplementary food to caregivers as well as adjusting the range of foods available according to the recipient’s preferences is critical in overcoming malnutrition in children younger than 5 years.

Keywords

supplemental nutrition assistance programs children under 5 years moderate acute malnutrition improving nutritional status supplementary foods

Introduction

The provision of supplementary food to children suffering from moderate–acute malnutrition, also known as wasting, is a globally recognized health intervention.¹ This strategy has proven adept at improving the nutritional status of children younger than 5 years by fulfilling their dietary requirements in order to achieve globally accepted, age-specific health standards.^2
-4 In Indonesia, the provision of supplementary foods via Supplemental Nutrition Assistance Programs (SNAP) forms part of a nationally run nutrition program that is implemented in all districts.⁵ The form and type of such provision are adapted to local needs as well as local food availability, although formula milk and biscuits are the most commonly provided products.

Supplemental Nutrition Assistance Programs in Indonesia target all children younger than der 5 years who are recorded as having undernutrition according to body weight and age. The nutritional value of supplementary foods must meet the recommended daily intake for children to ensure nutritional adequacy set by the Ministry of Health.⁵ Studies conducted in South Africa reported that the provision of additional food for children with nutritional deficiencies was well received and considered as an effective treatment to help improve their nutritional intake.^6
-8 However, research carried out in Haiti reported that such food is often distributed to individuals other than children it was intended for.⁹

Further, in Burkina Faso, a study found that caregivers play an important role in the effective provision of supplemental food; this was mainly linked with their knowledge and confidence in the benefits of this approach to overcoming health issues caused by poor nutrition.¹⁰ Accurate monitoring of the uptake of supplemental food provided to caregivers of children under 5 years is essential in order to ensure that set targets are met.^10,11 Poor receptivity to such programs among this cohort can lead to caregivers using suboptimal supplemental foods, resulting in a failure to increase the nutritional status of children and, of course, wasting resources.¹⁰

Therefore, gaining a more in-depth understanding of the factors underlying this cohort’s attitudes to supplemental foods will enable such program to deploy more appropriate strategies, which in turn, it is hoped, will secure better child malnutrition and undernutrition outcomes. However, to date, no studies have been conducted to explore caregivers' attitudes, investigating how supplemental nutritional food acceptance shapes the recovery of malnourished children in Indonesia, although this strategy has been widely used.

In this article, we employ a qualitative methodology to explore the attitudes of caregivers of children under 5 years with wasting toward the acceptance of supplementary recovery food in Denpasar, Indonesia, as well as investigating the factors that lie behind such attitudes.

Research Setting

The research was conducted in Denpasar, the capital city of Bali Province, whose population in 2016 was 788 589 people. The average income per month for Denpasar is around Rp 3 000 000, with Rp 2 173 000 or US$15 553 as minimum wages per month in 2017. The city is divided into 4 subdistricts¹² with 11 public health centers (Puskesmas) providing primary health-care services including nutrition programs. Each Puskesmas covers a number of villages with populations ranging from 30 000 to 74 000.¹³

Similar to other big cities in Indonesia, Denpasar experiences double burden health problems ranging from infectious diseases to noncommunicable diseases. One of the persisting noncommunicable diseases experienced by Denpasar is undernutrition in children younger than 5 years, with the latest data indicating an increasing trend of under 5 years wasting from 0.1% in 2015 to 0.67% in 2016.¹³ Following national guidelines, to overcome the problem, the government of Denpasar has implemented SNAP targeting toddlers 6 to 59 months in the wasting category, defined by weight-for-length/height <−2 standard deviations.

While campaigning for local-based supplemental foods, in practice, this is not the case in Denpasar, mainly due to more practical consideration relating to data collection, foodstuff preparation, distribution, evaluation, and affordability. Therefore, formula milk and special toddlers’ rusks are provided for a period of 90 days or until recovery is medically certified. Weight monitoring is done monthly at toddler’s home or at public health centers. The present study was conducted in selected Puskesmas at the each subdistrict with the highest rates of wasting: Puskesmas I North Denpasar, Puskesmas II East Denpasar, Puskesmas II South Denpasar, and Puskesmas I North Denpasar.

Design and Research Procedure

This study employs a qualitative approach using data derived from semistructured, in-depth interviews carried out with the caregivers (n = 16) of children younger than 5 years with wasting, registered in SNAP, and have not increase in nutritional status within 6 months of administration of SNAP from July to December 2016. Participant selection proceeded by employing purposive sampling based on that criteria of caregivers at each of the 4 health centers. From this cohort, the proportion of infants both originated from Bali and those from the parents migrated from other parts of Indonesia was balanced to ensure a balanced sample selection. In addition, it was predetermined that chosen participants were able to communicate well and were indeed the caregivers of wasting under 5 years residing in the localities of Puskemas mentioned earlier.

Interviews were conducted using semistructured, in-depth interview questions divided into specific key themes according to the research objectives. The themes included in interviews were perceptions toward the health conditions of their children, SNAP, health-seeking behavior, health belief including foods’ preferences, family and community support, and health staff’s supports.

The first author conducted interviews at the house of selected caregivers, with written verbal consent provided before the interviews. Interviews were mainly conducted in Bahasa, Indonesia, and sometimes in Balinese for about 30 minutes to 1 hour. The recordings were transcribed in verbatim and analyzed using NVivo software version 11 for Windows. Thematic analysis using a combination of inductive and deductive approaches was used to ensure that the researcher’s preconceptions on the data did not affect the ability of authors to communicate participants’ real feelings and attitudes toward SNAP; this strengthens the study’s internal validity.¹⁴ In addition, internal validity was supported by data source triangulation which involved cross verification of the results from 4 participants and 5 Nutritional Executives at each Puskesmas involved in the study. In presenting research findings, we select quotes that are most representative of the findings. The setting and speakers are established in the text at the end of the quote. This study was approved by the Ethics Committee of the Faculty of Medicine, University of Udayana-Sanglah Hospital in Denpasar (266/UN.14.2/KEP/2017) issued on February 27, 2017.

Results and Discussions

The results of this research are presented according to the key themes identified by thematic analysis of participants’ attitudes toward SNAP. Specifically, 4 key themes emerged: (1) caregivers’ preferences in terms of the types of supplementary food on offer; (2) caregivers’ beliefs that the children were not, in fact, having wasting; (3) that the caregivers felt that SNAP assistance was unnecessary in meeting the nutritional needs of the infants; and (4) that SNAP health workers were able to provide limited support, at best.

Caregivers’ Preferences and Attitudes Toward SNAP

The success of SNAP in terms of patient recovery depends on the consistency of adherence to guidelines on the consumption of the supplemental food (WHO, 2012b).⁴ As the key factor in successful recovery depends on the consistency of consumption, infants' appetite is key; appetite is influenced by several factors such as infants' current nutritional status, living environment, and the impact of other diseases (including comorbidities that may be difficult for health workers to identify).² Thus, although such children may present with “normal” appetite, if the supplemental food is not to their taste or unfamiliar to them, they may be unwilling to consume it.¹⁵

Indeed, the results of this study suggest that one of the main reasons given by caregivers for nonadherence to SNAP feeding guidelines was that the food items were refused by their infants. Specifically, the caregivers stated that their toddlers indicated that they did not like the flavor of such foods and were not used to consuming supplemental food items. This is evidenced by the following quote from 2 participants, both housewives who were the primary caregivers for their wasting infants.

…yeah, my son doesn’t like it [formula milk], miss. So much is left over. I give him formula milk (normal white milk), but he only likes chocolate milk. So it's hard for us to make him drink it [formula milk] (DT14-Mother-25 years.)

…he doesn’t like anything [provided by SNAP]. He usually drinks chocolate milk, but they give us full cream milk. And, the biscuits–he’s never even eaten a biscuit like that before. (DS4-Mother-31 years.)

This highlights a major practical difficulty faced by SNAP in providing bulk-sourced food items; it is difficult to reconcile supplying a diverse range of well-accepted foods with the realities of complex mass distribution. However, in order to succeed in aiding the recovery of the target patient cohort, SNAP providers must overcome this issue and should make a special effort to develop and refine supplemental food procurement to suit the diverse preferences of the infants. However, currently, SNAP suffers from a lack of flexibility in this matter, as it provides a very limited selection of supplemental foodstuffs for all patients regardless of individual preferences.¹⁶ Aside from this shortcoming, it is important to bear in mind that infants’ food preferences and feeding behaviors are innate—they are shaped by learned process from birth—and in this respect, the role of parents/caregivers is very important in encouraging children to try a variety of food.^17,18 Therefore, it is essential that caregivers’ preferences and attitudes toward the foods they are willing to provide their children are taken into account.

In this respect, the coded data from the caregivers’ interviews highlight that there is a diverse range of preferences and attitudes toward the foods provided by SNAP. In particular, most respondents expressed a preference for a particular brand and considered it beneficial for the toddlers they care for. For example, a participant—a 32-year-old mother—attached great importance to the provision of the formula milk which is usually consumed by the offspring as demonstrated by the following excerpt:

…this is special, age-specific milk that I bought. This milk is well-known for being great [for infants]. But it’s expensive. If it’s possible, it would be good if you could change the milk you provide to Lactogrow because my child won’t drink anything else. (DU6-Housewife-32 years.)

However, it is important to note that such formula milk (for children of 2 years and older) is not advocated for provision as part of SNAP in the way that the regular milk provided by the program is, and in addition, it is not recommended for infants within the initiative’s target age range (under 5 years). In relation to this, it was determined that some toddlers younger than 2 were given another milk by their caregivers, when, in fact, it is indicated by the manufacturers that it is exclusively intended for consumption by children of 2 years and above.

In line with the present study’s finding that recipients of supplementary milk from SNAP indicated that their infants were unwilling to drink the formula milk provided, a qualitative study carried out in Gianyar, Bali, reported a similar finding. In this study, caregivers reported that their toddlers refused to drink the formula milk provided, as it was not their preferred brand.¹⁹ At this point, it seems pertinent to highlight that popular brands of formula milk employ considerable effort and expense in promoting their claims as to the nutritional values and quality of their products as well as targeting specific age groups with tailored products, and this may account for the perception among caregivers that these brands’ products are indeed more nutritionally beneficial for their children.²⁰

Related to caregivers’ perceptions of the potential benefits gained from providing their children with supplementary nutrition, the interviews suggest that the caregivers have specific, individualized beliefs related to the intrinsic value of such items which relate to nutritional value and greater resistance against illness. Specifically, it was found that the caregivers tend to evaluate whether such supplementary food is beneficial or not or will maintain a neutral attitude toward it.²¹ It seems that caregivers’ attitudes toward SNAP-provided food products are related to their perception of the benefits that such items can offer as well as their confidence in the suitability of such foods for their toddlers’ physical condition.²² Related to this, several ethnographic and anthropological studies have found that supplemental food-related beliefs (ie, the belief that a foodstuff is in fact beneficial or not as well as whether such foods are considered healthy or unhealthy for infants) will greatly affect their acceptance and use of these foods.^22,23 Further, such beliefs are generally associated with the texture/appearance of supplemental foods, the child’s appetite and acceptance, the perceived benefits provided, and other attributes inherent to foods such as their suitability for the child’s age group, brand associations (ie, high-quality, high in nutrients), as well the items’ retail price(s).

Following on from this point, the interview results found expression of disbelief and/or doubt that the items provided by SNAP are in fact suitable for their toddlers’ nutritional condition. As expressed by a caregiver, a housewife who had only attended primary school stated that the formula milk provided by SNAP is intended for consumption by adults and consequently was unwilling to give it to her toddler.

…. [I] do not want him to drink this formula milk. I don’t dare give it to him. It seems like this milk is for adults, so I don’t dare to give it to him…(DU6-Housewife-32 years.)

In addition, interviews also indicated that participants have doubt as to the benefits and effectiveness of supplementary nutritional items in terms of their contribution to improving their child’s nutritional condition. The following excerpts are from 2 participants who expressed similar opinions when questioned whether they were confident about the benefits of additional food given to increase nutrient intake to encourage weight gain in infants.

…. perhaps it works, yeah? [I] don’t know, it’s just biscuits milk and bread, can this really affect [children’s] weight? (DS1 -Mother Household-30 years.)

…. yeah, so we need to look at what condition the child is in, don’t we? If we give them [the supplemental items] and their weight chart goes up, that means that the help [additional food] is working. So far, his weight is pretty so-so. (KD17-Privately employed caregiver-34 years.)

From the 2 quotations above, it seems that the caregivers’ disbelief in the benefit of giving SNAP-provided food to their child is based on the child’s condition itself, in terms of a lack of weight gain in particular. This is instrumental in caregivers’ reluctance to accept the supplementary food items and use them as intended.

Caregivers’ Perceptions That the Children Are Not, in Fact, Wasting

In order to effectively treat children with wasting, understanding the role of their caregivers and specifically their attitudes toward and perceptions of the children’s health condition is of vital importance. The in-depth interviews found different perceptions related to the health conditions of the children. Some caregivers did not recognize that their toddler is, in fact, wasting. These caregivers claimed that their child appeared small not due to malnourishment but rather because of hereditary genetic traits. This was verbalized as words to the effect of “their mother or father was small, what do you expect?” Thus, they tended to reject that wasting is a serious health issue in the absence of marked physical symptoms caused by wasting such as weakness, paleness, fever, nausea, and other obvious physical symptoms. This is evident in the following excerpt from a caregiver in East Denpasar.

I think this [the infants small stature] is because of the [small] family genes. That’s why however much he eats and whatever he eats, he stays the same size. When he was young, his body was also small. When he’s a bit older, he’ll get bigger too. So, I think it’s normal. The kid’s normal. Not really skinny. He’s really active when he’s playing. Never really gets sick. (DT15 - stall keeper. 25 years.).

Thus, it seems that there is belief that wasting in toddlers should be marked by frequent sickness, weakness, extremely small size, retarded growth, and stunted development. Indeed, some participants stated that these symptoms were not present. This attitude is illustrated well by the excerpt below from a privately employed, 35-year old participant.

No, that’s not true. If he was malnourished, he would be pale too. If he’s underweight, it’s not from malnourishment. How about if the kid is just naturally small? If you look at him, he’s not that small, is he? The main thing is that he keeps on growing. He’s really rarely sick too, you see?” (KD19-Employee-35 years.)

In line with the present study’s finding, caregiver’s lack of understanding about their infants’ health relating to malnourishment and wasting is also supported by other studies in this area.^15,17 This research highlights that parents and caregivers who accept that their child is medically defined as being wasted are more likely to pay attention to the child’s nutrient intake compared to those who reject the diagnosis of malnutrition or wasting. Thus, caregivers' perceptions of the seriousness of the child’s medical condition could affect their provision of adequate daily nutrition; those who firmly believe that their children are not malnourished or wasted will tend to fail to see the need for supplemental food and so will often refuse to provide their children with it.

In addition to the differences between caregivers’ perceptions regarding the reality of infants’ health and sickness, the fact that SNAP involves home visits from health-care workers can cause mothers to become embarrassed about their living conditions and blamed at their lack of ability to care for their children. Having poorly fed children is regarded as shameful. For instance, 1 participant from outside of Bali living in a crowded boarding house in Denpasar expressed her feelings of discomfort in receiving SNAP assistance, especially as she was convinced that her child was healthy and not in need of supplemental nutrition.

…. if I’m honest, Miss, I’m not really that enthusiastic about getting the extra help. I don’t feel comfortable with it. I’m embarrassed. Do the health visitors have to come every month? It’s like my child is sick or something–a healthy active kid! (DS2-Housewife-27 years.)

When a perceived stigma is experienced by individuals or groups, a number of immediate, negative manifestations may result, including the fear of experiencing humiliating or degrading treatment;²⁴ perceived stigma—an individual’s experience of the negative meanings associated with internalized stigma²⁵ or self-stigma—negative self-sanction or judgments when people believe that stigmatizing public attitudes apply to themselves and shame.^26,27 Within the setting of this caregiver’s case, the feeling of shame came out after her family member (she lived in an extended family setting) asked why the health-care worker came to the house regularly to check the children's condition. The manifestations of stigma can lead to a number of stigma outcomes, such as delayed treatment seeking or poor medication adherence that ultimately lead to longer-term stigma impacts, including poorer quality of life and increased morbidity and mortality.²⁸ In addition to the differences in the perceptions of infants' health conditions by health-care workers compared to their caregivers in terms of nutritional health, caregivers also expressed that other causes unrelated to nutrition were to blame for their children’s poor health. For instance, caregivers described mystical causes for their children’s condition such as demons, magic, spells, or supernatural factors. And, as such, in treating malnutrition, medical treatment including supplementary feeding is considered useless or inappropriate and is considered a last resort.^29,30 This was mentioned by a caregiver, a 32-year old housewife from Karangasem (a district in rural Bali) now living in Denpasar, who agreed that a child was suffering from nutritional disorder, but caused by “a Bali disease” (ie, witchcraft).

…yes, he’s small because of Bali disease! If he wasn’t [suffering from this] I feel he would be normal [weight-wise]. I’ve taken him everywhere–to the doctors and there’s still no change. Then, my husband asked around in the family and in the end, we asked a witchdoctor for help. (DU6- Housewife-32 yrs.)

As illustrated earlier, the belief in nonmedical causes of poor growth and development (ie, witchcraft) is likely to be strengthened if various medical interventions are not effective in bringing about a positive change. As a consequence, the extent to which caregivers hold such beliefs may affect their level of acceptance of supplementary feeding programs.³¹ This finding has long been acknowledged in international literature, particularly from poor settings, where undernutrition is seen not as a health problem in itself but as a consequence of different disease conditions,^32,33 often spirits or witchcraft which are believed to be involved.^33
-35 Supplemental Nutrition Assistance Programs intervention could incorporate an educational aspect targeting health beliefs and caregivers’ misconceptions on undernutrition problems and its treatments. The aim should be to raise understanding and awareness of severe malnutrition as a health problem and assisting the caregivers to seek appropriate treatment.

Findings above indicates that a person’s perception of a health condition could affect how they will attempt to overcome it.³⁶ Specifically, in terms of the present study, the wasting infants' caregivers’ perceptions about the child’s condition will influence the actions they see necessary to overcome the disease, which in this case involved them providing supplemental food responses were received.³⁷

Caregivers’ Perceptions That They Do Not Require Supplemental Food Aid

Furthermore, the interviews revealed that caregivers were often reluctant to accept routine visits by health officers to bring supplemental food. They felt that they themselves were capable of providing their children with sufficient decent, healthy food, and this perception often drove them to ask for an alternative solution for treating their toddlers. The following excerpt from a 30-year-old housewife and 67-year-old family member of wasting children with high economic status illustrates this perception.

…So, every month they [health-care workers] come here, and again, bringing loads [of supplemental food]. But I’m like–‘give it to those in need.’ Many people need [the extra food].” (DS1–Housewife -30 years.)

…. We’re not hard up for food, yeah? Why are you giving us food? It would be better to try another solution, wouldn’t it? (KD20-Trader 67 years.)

The current supplementary feeding program targets every toddler who has wasting regardless of whether the recipients are well off or not.⁵ The negative perceptions and distrust of the program outlined in earlier sections, coupled with the caregivers’ belief that they have adequate financial resources, results in the overall negative reception of supplementary feeding program for children. A systematic review of supplementary feeding programs for malnourished and undernourished infants mentions that accepting additional nutrition is considered shameful or needy. The offer of nutritional support from such schemes tends to elicit a negative reaction among the caregivers considering that such programs are perceived and labeled as “outside help.”² Caregiver’s choices in terms of providing food for their children is often influenced by their wish to be positively assessed by others in terms of social prestige or social status. Hence, the provision of assistance, let alone in the form of food supplies, is likely to be viewed with disdain and a threat to their social position.³⁸ This finding supported conclusion found from other studies; an important criteria found to be supportive for SNAP’s acceptance is that the recipients have low economic status.^22,38,39 An individualized approach needs to be considered when delivering SNAP to family with different social economic conditions, for example, focusing on assistance in making supplemental food available locally.⁴⁰

Health Officer Support

Overall, the factors previously discussed in the context of wasting toddlers’ or infants’ caregivers will not be improved if the factors relating to the implementation of the program of support from health workers are not realized. As mentioned earlier, caregivers play an important role in ensuring toddlers are provided with additional food in accordance with the health workers’ instructions. However, it is crucial that health-care workers should also be able to motivate and stimulate caregivers’ participation, understand the barriers to effecting behavioral change, and support caregivers in providing supplementary feeding for infants. If these aspects cannot be realized, it is highly unlikely that supplementary feeding programs will be successful and sustainable.²

The acceptance and uptake of SNAP as illustrated in this study can also be attributed to the caregivers’ perception that the level of support provided by health-care workers is less than satisfactory. This is highlighted by an excerpt from a 34-year-old housewife who cares for her malnourished child in which she claims that despite being registered on the program, health workers had never visited her.

…They [the health-care workers] have not ever come [to my house]. Everything is done at the community clinic (posyandu)–weighing [the child] too. It seems like if they forget to visit me and bring the supplemental food, they ask me to collect it from the health center! (DT10-Housewife-31 years.)

In the excerpt above, it appears the caregiver feels burdened by (and objects to) having to visit the health center if the health workers forgot to leave additional food at the village clinic because the officers did not manage to bring the food to her house. Previous studies have suggested that regular visits from health-care workers are needed to ensure proper supply and adherence by checking the amount of food that has been consumed while also providing opportunity for health-care workers to assess the educational needs (as well as additional needs and other support) necessary for each family targeted by supplementary feeding programs.^39,41,42 Such visits, at the same time, will establish trust between the health-care workers and caregivers.

Meanwhile, for those who are not willing to accept home visits, they can be offered the option to attend local clinics or health centers to collect additional food, and thus can be educated on the feeding guidelines as well as carrying out weighing of the children visits. The forms of education provided should also vary depending on the needs of recipients which occur in the field. In cases where caregivers perceive that the supplemental food provided is incompatible with their children’s tastes or needs, it is necessary for health-care workers to be more dynamic in their assessments and to try to find the right solutions. Also, education on the causes of child malnutrition and dispelling caregivers’ misperceptions that malnutrition is not a condition which can be treated medically are essential. Related to this, explanations related to the various characteristics of malnutrition in young children, stressing that supplementary food aid is not only targeted at poor families, as well as encouraging local communities to participate in supporting caregivers in order to routinely provide supplementary feeding to toddlers, can be seen to lower the social stigma associated with SNAP.⁴¹

Conclusion

The present study has identified that a combination of factors such as varied preferences in terms of the types and brands of supplementary food items provided; perception that infants were not, in fact, wasted (or that they were suffering from illnesses or diseases caused by supernatural factors); the negative stigma surrounding SNAP; and factors relating the support of health workers need to be considered to improve acceptance to SNAP in Denpasar city. This research underscores the importance of establishing additional feeding strategies that are more appropriate for the sociocultural context of the target communities and the individual caregivers. Importance in individualized health-care support approach depending on caregivers’ preferences (especially regarding home visits) seems also to be an important factor for SNAP acceptance and adherence among participants.

Footnotes

Acknowledgments

The authors would like to convey their gratitude to all the participants and parties who supported the implementation and writing of this research. They extend their gratitude especially to Denpasar City Health Office, the Puskesmas, and caregivers’ who gave their kind permission to allow us to research this topic.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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