A weapon against the cycle of malnutrition

Before the age of 5, children experience rapid growth and development both physically as well as cognitively. If proper nutrition is not prioritized or possible during these first years, the effects, including a potential reduction in their mental and emotional capacities, can be irreversible and a roadblock to reaching their full potential in the future. 

In Afghanistan, more than half of all children under the age of 5 are chronically malnourished; one-third are underweight and nearly one in five suffer from acute malnutrition.

Sadiqa, the mother of a malnourished 4-year-old girl was more concerned about the quantity than quality or diversity of calories she gave to her children.  “I didn’t know about different types of food,” she says.  “For me, it was not so important to give my children nutritious foods. I thought children [just] need food whenever they get hungry and we can make them full with just a piece of bread,” she explains, noting that this is the common knowledge that has been passed down to her and her sisters from their mothers and mothers-in-law.

The number of malnourished children coupled with erroneous cultural ideas about food and nutrition prompted World Vision Afghanistan to introduce the Positive Deviance Hearth (PDH) program, to fight malnutrition in children under 5 years old.

PDH is a community-based approach that helps identify local solutions to recuperate children with moderate malnutrition and to promote healthy behaviours. The programme lasts for 12 days, and is followed by a 2 week evaluation period, conducted by the volunteers through home visits. The purpose of these home visits is to encourage caregivers to continue the positive nutritional practices at home, and to help them overcome any barriers they face to providing adequate nutrition to their children.

Maryam is an experienced community health worker who has participated in many trainings on health-related issues from World Vision Afghanistan.  She has implemented the Positive Deviance Hearth model with mothers in her community to make sure children receive the care they need. She has also replicated the training others, allowing them to take the message back to their own communities.

“Three years ago, I was invited by World Vision organization to participate in a PDH training. The training was interesting,” says Maryam, noting how much she learned, even after nine years as serving as a community health worker. “The most interesting thing for me was how to cook nutritious foods with cheap and simple ingredients,” she says, her voice full of energy.  

“The training we received was very practical,” 

“The training we received was very practical,” she continues. “We learned to identify when a child wasn’t growing appropriately and what to do about it. We learned about vitamins, micronutrients [as well as other] various food categories.

Now, I counsel mothers on the feeding, caring, hygiene and health-seeking practices, as well as antenatal and postnatal care, family planning, and danger signs during pregnancy,” added Maryam.

Maryam had a hard time convincing mothers of malnourished children to participate in the programme initially. “They said [they didn’t want] to waste time and participate in sessions. It took one month to convince people to take part in sessions,” she remembers.  “After three or four [days], their opinions had totally changed and other families from other villages even came and requested to included in the sessions,” Maryam.

Rahima, a mother of 5, admitted, before she attended the PDH sessions, she used to prepare "instant meals" for her children, like tea, bread or water with sugar. She thought that since her children liked the instant meals, she didn’t need to cook other foods. But one of Rahima’s children, Marjan, who is 25 months old, is malnourished, weighing only 6 kilos.

“As I didn’t have enough time, money, information, or energy to cook, I always prepared the same kinds of meals and cooked them in the same way,”

“As I didn’t have enough time, money, information, or energy to cook, I always prepared the same kinds of meals and cooked them in the same way,” says Rahima. “When my child avoided eating, I didn’t coax or encourage them to eat. I thought that they aren’t hungry or would eat later. I was unaware that one day they would malnourished. It is shameful, but even I didn’t wash my children hands before eating food with soap, because I thought that washing face and hands with soap once in the morning was all they needed,” she added.

“Marjan was my youngest child and I didn’t pay attention to her feeding. It was my fifth baby and I had gotten weak during my pregnancy as I had a lot of vomiting. I couldn’t eat well. After she was born, I hadn’t enough milk to give Marjan, so my mother-in-law mixed oil and sugar to gave my baby. Sometimes she dipped her finger in her remaining food and then put it [her finger] into Marjan’s mouth. She said that Marjan would gain weight by this,” she remembers.

Malnourished children are more prone to disease. Without proper nutrition, their immune systems are not strong and they get sick easily. This is exactly what happened to Marjan. “Most of the winters, she suffers from pneumonia and in summer from diarrhoea,” says Rahiam. “Sometimes I too don’t feel well. I get tired and have headaches and dizziness. Maryam says that I have anaemia and should go to clinic to take medicine,” says Rahiam.

Malnourished mothers give birth to malnourished children, and thus create a vicious cycle that can continue for generations. Children who are malnourished today are at risk of giving birth to the next generation of malnourished children.

“My daughter, Marjan, and I both come here every morning. Some of our neighbours also participated in the sessions,” says Rahima.  “I learned about different health-related issues and nutrition. My daughter played with toys and other children. Her appetite has been increased since I am coming here,” admitted Rahima.

Three years ago, the remote village where Rahima lives was cut off from health services and information. “We didn’t even have a clinic in the village and because of the [lack of] security, most non-government organizations couldn’t dare go there,” she says, noting that several of her neighbours have had babies who die after two or three months, in large part due to false information and cultural beliefs, like not feeding their babies breast milk for fear that their milk was “dirty”. “I have learned a lot of information from the health sessions and understood that our neighbours [whose babies died] made a big mistake,” she says. 

On the last day of PDH sessions, Rahima and the other participants are happy to see that their children have gained weight. “Today the PDH supervisor weighted my child. She gained about 100 grams during the 12 days. I can’t believe with the cheap food material can help my child grow up healthy,” said Rahima, Marjan’s mother.

“I hope God forgives me because of my lack of information and low knowledge..."

“I hope God forgives me because of my lack of information and low knowledge [that allowed] one of my children to be malnourished. Now, thanks to the people who are implementing this worthy program in our community, in just 12 days, my child gained weight and now I am able to cook these foods in my home with simple [available] foods. All the foods we used in the PDH sessions are found in our homes, but before we didn’t have this initiative to cook with these foods to make healthy and different food,” added Rahima.

Through the Child Survival project, 54 community health workers were trained in PDH methodology. To date, more than 800 children have been rehabilitated through 55 sessions across 47 villages with an average weight gain of 0.8 kg per child.

Positive deviance is one of sustainable World Vision Afghanistan projects that enable communities to continue positive behaviours and lessons learned as well as replicate the information to others in their community.