Varying ability to recognise (un/) healthy physical appearance

Mothers had mixed reactions to the sketched images of infants with varying MUAC Z-scores. Some displayed signs of hesitancy, while others confidently described their view of the child in the respective image. Most mothers, however, did not elaborate beyond ‘healthy’ and ‘unhealthy’. When they did, they mentioned ‘thin legs’, ‘a grown belly’ and ‘a head bigger than the body’ as visible indications of ill health. The more obvious images were correctly identified as presenting healthy (image N and image K) v. malnourished children (images P and B). However, image T was largely incorrectly identified as ‘healthy’ even though the MUAC Z-score (>–2 to ≤–1) indicates the child is at risk of malnutrition.

In addition to the physical attributes, mothers indicated changes in children’s behaviour and appearance as signs of malnourishment:

However, mothers acknowledged that they would find it difficult recognising the early signs of malnutrition with one mother saying:

The lack of profundity in the mothers’ discussions surrounding early sings of malnutrition warrants further research into identifying the point at which mothers/caregivers recognise the risk or presence of malnutrition in children, as well as the point that triggers concern and action on the part of caregivers. Descriptions of the symptoms of malnutrition resembled that of severe protein-energy malnutrition manifested as marasmus or kwashiorkor. This finding is consistent with previous literature in which children with comparable symptoms were recognised as being unhealthy, whereas short stature was considered the norm in communities with a high prevalence of linear growth faltering^{(Reference Mull5,Reference Kolsteren, Lefèvre and Lerude6,Reference Burtscher and Burza9,Reference Mwangome, Fegan and Prentice16,Reference Goudet, Faiz and Bogin21,Reference Roy, Rahman and Mitra22)} . This indicates a potential lack of awareness of other forms of malnutrition, specifically stunting. Further evidence providing a basis for context-relevant awareness-raising campaigns informing about all forms of malnutrition seem desirable, especially since the most common forms of malnutrition in Mozambique include stunting and Fe deficiency anaemia⁽²⁾.

Limited ability to identify prevention and treatment strategies

The meaning units gathered under this sub-theme displayed a limited malnutrition literacy. Attending the hospital for routine weighing was the only prevention measure mentioned. Monitoring the weight of the child and following instructions from hospital staff was also highlighted as a key treatment method. In general, the mothers’ responses exhibit low self-efficacy in preventing and treating malnutrition saying that they simply ‘don’t know’ how they would treat or prevent malnutrition and that they would have to seek advice from the hospital or ‘other people’. Their inputs into the discussion of prevention and treatment in this interview format were thus poor.

References to a biomedical understanding of malnutrition

Mothers’ descriptions of the causes of malnutrition were predominantly in line with biomedical concepts (lack of food, care and hygiene). Some demonstrated a basic awareness of the comorbidities of malnutrition (diarrhoea, tuberculosis, HIV/AIDs). However, the data also suggest that malnutrition is sometimes misdiagnosed within the community:

While most talk revolved around acute malnutrition, there were also a couple of references made to chronic malnutrition, for example, to pre- and postnatal factors:

The analysis shows an ability to reason and evaluate different biomedical explanatory models (causes and comorbidities) of malnutrition; however, the interviews did not give sufficient information for evaluating whether it was used as a base for nutritional strategies.

Fairly developed references to foods appropriate for age

Mothers displayed a higher level of awareness of the link between food and malnutrition. Inaccuracy in assessing a child’s need for food as well as an absence of ‘good food’ were identified as causes of malnutrition. However, perceptions often seemed to be based on texture rather than nutritional quality with ‘light’ foods considered suitable and ‘heavy’ foods unsuitable for U-5’s. When listing foods considered good for growth and development, xima (a thick porridge made from maize or corn flour), soups and curries enriched with peanuts were frequently mentioned. Cold foods were considered harmful to the child’s ‘organism’ resulting in an upset stomach.

Above all, mothers emphasised the importance of age-appropriate foods, for example, to not give juice and biscuits as ‘it is not the essentials that children need … at the age they have’ (FGD 7). A distinction was also made between foods appropriate for adults and children but mothers explained that because of a lack of ‘suitable’ food, adult food is sometimes given.

Meat and animal-source foods were noticeably absent in mothers’ responses, while ‘rich food’ described as vegetables and enriched porridges were recognised as foods that could be used to treat malnutrition. It is not clear from the data whether animal-source foods are purposively avoided due to food taboos or are considered inaccessible due to financial or structural constraints as identified in a previous study conducted in northern Mozambique^{(Reference Lusambili, Naanyu and Manda23)}. Considering the nutritional importance of animal-source foods for infants and children in providing high-quality protein and a range of key micronutrients conducive to the healthy growth and development of U-5’s^{(Reference Dror and Allen24,Reference Kaimila, Divala and Agapova25)} , further research into the root cause of this finding is needed.

The mothers’ conceptualisation of the link between malnutrition and food perceived to be appropriate for U-5’s was detailed with varied examples and strategic choices described in a more elaborate and confident manner compared to the other sub-themes.

Brief references to local allegories or beliefs

When mothers were asked how malnutrition is perceived in their community, the expression djambelada [the child ‘had been jumped’] was mentioned:

The literal meaning of this expression is that the mother, instead of letting the child sleep between the parents, had ‘jumped’ over the child and slept with her husband. This expression was also used with reference to breast-feeding and hygiene:

It is, from our material, not obvious to what extent the expression is an allegory for the mother not making the child’s needs a top priority or whether this is an explanatory model locally accepted as a cause of malnutrition. Regardless, the analysis indicates a general use and awareness of the expression. However, the way the mothers discussed this indicates that they perceived themselves as being aware of a variety of knowledge regimens related to behaviours and their link to the child’s well-being. Since previous research has acknowledged the great significance of incorporating local beliefs into health intervention programmes to increase their efficacy^{(Reference Burtscher and Burza9)}, gaining a better understanding of the significance of these local beliefs can allow a more comprehensive decision to be made about how they could be integrated into future interventions.

Firm requests for opportunities to learn about malnutrition

Mothers expressed a desire to learn more about malnutrition by directly requesting more information, for rexample, from hospital staff about general care practices, appropriate foods for children, causes of diarrhoea and causes of malnutrition:

The interviewees clearly expressed awareness of the need to increase their knowledge of malnutrition as well as an eagerness to improve their parental strategies to promote their children’s nutrition and health. Therefore, the results imply that future campaigns which aim to increase malnutrition literacy among caregivers would be welcomed in this setting.

Basic pursuit of healthcare to reduce health risks

This sub-theme is obvious throughout the dataset with mothers indicating that they would seek medical help at the hospital upon identifying physical or behavioural changes in their child such as weight loss, loss of appetite or a reluctance to be breastfed:

Mothers also reported recommending other mothers/caregivers to seek medical help to reduce health risks and emphasised the importance of following the instructions given at the hospital on how to rehabilitate the child. Importance was put on attending the hospital for an accurate diagnosis, since mothers alone may not be able to correctly identify what illness the child has:

While mothers made references to seeking care at the hospital upon noticing signs of ill health, the identification of signs differed as well as mothers’ timing of seeking medical help. One depicted determinant of this was the proximity of the hospital from the home, with further distance and the need for money for public transport resulting in a delay in seeking treatment.

The many references to the district hospital were most likely influenced by the study location being the hospital. Nevertheless, it is still noteworthy that there was a reliance and usage of the hospital in identifying and treating malnutrition, since similar studies conducted in community settings indicated a greater reliance on traditional doctors, religious leaders and community members to treat children with symptoms of malnutrition^{(Reference Mull5,Reference Kolsteren, Lefèvre and Lerude6,Reference Burtscher and Burza9)} .

While the findings show that mothers value the services of the MDH, a delay in seeking treatment may be the consequence of: (1) structural barriers such as proximity to the MDH; (2) economic barriers including the cost of transport to the MDH and (3) potential health literacy barriers as the interviewed mothers had difficulties in identifying the early stages of undernutrition. Therefore, even among service users of the MDH, the culmination of these barriers may result in malnutrition progressing to severe stages before the child reaches the hospital. Investigations into how different institutions can be strengthened to support mothers in preventing, detecting and treating malnutrition are therefore recommended, including investigations into what different roles general poverty reduction strategies, community members and local healthcare facilities can play for preventive strategies, early detection and treatment of late stages of malnutrition.

Assertive references to sociocultural conditions

Quality of parenting, parental educational level and attitudes towards feeding were, according to some mothers, related to malnutrition. In these general discussions, the term Djambelar was not used. Mothers emphasised the importance of paying attention to children, citing ‘lack of attendance to the child’ (FGD 1) as a cause of malnutrition and ill health. Mothers returning to work soon after giving birth and leaving the child in the care of someone else, particularly while the child is still of breast-feeding age, and the subsequent pre-mature weaning and increased risk of malnutrition that results from this^{(Reference Mata, Visser and Bindels26)}, was mentioned as a cause of malnutrition:

Due to work-related time constraints, mothers reported opting for convenience foods over home-cooked foods despite being aware that this is not ideal. This growing trend of preferences towards ready-to-eat convenience foods was identified as a factor associated with malnutrition.

Household food insecurity due to the presence of many family members was also identified as a cause of malnutrition. Some linked household food insecurity to the burden of feeding grandparents, yet others mentioned them as a source of knowledge and support, and indicated that the shift in parenting between generations, towards preferences for more convenient foods was a contributor to malnutrition.

Assertive references to economic conditions

There was a strong awareness of the link between poverty and malnutrition with mothers stating that they sometimes do not have the financial capacity to provide foods for their children never mind ‘good foods’.

A lack of financial support, possibly stemming from extreme poverty and resulting in chronic food insecurity, was a reoccurring theme.

Lack of income, with subsequent food insecurity, was similarly mentioned as a cause of malnutrition:

While mothers linked poverty directly with a lack of food, it was also linked with a lack of other resources that impact a child’s general health:

This sub-theme presents mothers’ awareness of not only the different links between the causes of poverty and malnutrition, but also the debilitating role that poverty plays in dictating caregivers’ ability to change their situation and respond appropriately to health challenges. These findings are consistent with similar studies which also found poverty to be a perceived cause of malnutrition^{(Reference Abubakar, Holding and Mwangome10,Reference Goudet, Faiz and Bogin21,Reference Maxwell, Armar-Klemesu and Brakohiapa27)} . While mothers linked malnutrition directly to poverty and a lack of resources, references to economic barriers in some findings were implicit, for example, mothers’ focus on providing enough calories as opposed to a variety of foods could be the consequence of systemic poverty, rather than simply a lack of knowledge at the individual level on what constitutes a sufficient diet for children⁽⁴⁾. This is consistent with the findings presented in the Government’s Multisectoral Action Plan for the Reduction of Chronic Undernutrition 2011–2015, which states that poorly diversified, low nutritional quality diets due to poverty and household food insecurity contribute to the high prevalence rates of stunting, anaemia and other micronutrient deficiencies in Mozambique⁽⁴⁾.