integrating psychosocial support into nutrition programmes in west

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McGrath& Schafer

Integrating psychosocial support intonutrition programmes in West Africaduring the Sahel food crisis

MeganMcGrath & Alison Schafer

For optimal physical and cognitive development to

occur, a child requires adequate nutrition, but this

should occur in addition to physical and emotional

stimulation from a caregiver. Programmes, in which

interventions for nutrition, maternal mental health

and psychosocial stimulation are integrated, provide

much wider bene¢ts to a child’s psychical and cogni-

tive development than stand alone nutritional

responses. With this in mind, United Nations

Children’s Fund (UNICEF) prioritised the integ-

ration of psychosocial stimulation, within their

nutrition response, during theWestAfrica Sahelfood

crisis. Brief trainings were organised within ¢ve

West African countries in order to strengthen the

capacity of UNICEF and partner organisations to

initiate psychosocial activities within their nutri-

tional programmes.

Keywords: child protection, nutrition,psychosocial stimulation, Sahel, training,West Africa

Introduction: Sahel food crisisIn early to mid 2012, a serious food andnutrition crisis was threatening the Sahelregion of West Africa, with over 10 millionpeople experiencing food insecurity andover one million children su¡ering fromsevere and acute malnutrition, exacer-bating existing needs in already vulnerablepopulations. Unfortunately, as this articleis being written, the food crisis continues.Given the importance of adequate nutritionand stimulation on a child’s development,this crisis poses a signi¢cant risk to thephysical and cognitive growth of childrenin the region.

ht © War Trauma Foundation. Unautho

The impact of malnutrition,under-stimulation andmaternal mental health onchildren’s cognitivedevelopmentMalnourishment contributes to the deathsof ¢vemillionchildrenunder ¢ve, eachyear,in developing countries [United NationsChildren’s Fund (UNICEF, 2006)]. More-over, malnutrition is a major cause of poorbrain growth: children who have beenseverely malnourished as infants underperform at school, have less chance of doingproductive work later in life or forminghealthy relationships, and are more vul-nerable to physical and mental illness(UNICEF, 2012).The brain grows most rapidly in the ¢rstthree years of life and is also at its mostresponsive to stimuli presented (UNICEF,2012). A child is born with the basics of thebrain’s architecture already formed, how-ever, for the brain to develop to its fullpotential, connections must be ¢ne tunedand neural pathways strengthened to allowthe brain to process information e¡ectively.In order for this to happen, an infant mustbe exposed to positive stimulating experi-ences, ideally within the brains’ mostsensitive and responsive period of zero tothree years (The Center on the Develop-ing Child at Harvard University, 2009).However, according to WHO (2007) andUNICEF (2012), malnourished children,who commonly present with listlessness,apathy and unresponsiveness, often donot receive the stimulation and parental

rized reproduction of this article is prohibited.115

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Integrating psychosocial support into nutrition programmes in West Africa during the Sahel food crisis

Intervention 2014, Volume 12, Number 1, Page 115 - 126

responsiveness they require for the brain todevelop to its full capacity. Further, thecaregiver may consequently reduce theamount of stimulation they o¡er to thechild who is listless or unresponsive, andin a cyclic way, the child stops respondingto their caregiver (WHO, 2007). A similarcycle has been identi¢ed for motherswho experience symptoms of depression(UNICEF, 2012). Ultimately, the child-ren lacking psychosocial stimulation andparental responsiveness are at risk ofdelayed or stunted emotional, social,physical and cognitive development. Child-ren are, therefore, seriously impacted bythe combined crisis of malnutrition andunder-stimulation (Figure 1, WHO, 2007).This can also be the case for children withcaregivers who are experiencing mental


Figure 1: Malnutrition and reduced stimulation: implicatio

116

illness, including depression (UNICEF,2012).Given the known links between childnutrition, parent/child interaction and biopsychosocial child development, human-itarian organisations responding to foodcrises can no longer rely solely on physicalremedies to address the needs of malnu-trition. Psychosocial support initiatives, aspart of a child malnutrition emergencyresponse, must be incorporated to ensurethe quality and long-term bene¢ts ofinterventions for children. This was akey driving force in UNICEF’s responseto the Sahel food crisis. Some of theoperational activities are detailed below,following a brief review of some of theevidence on psychosocial stimulation inmalnourished children.

rized reproduction of this article is prohibited.

ns for children’s development. Source:WHO, 2007.

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Box 1: Psychosocial stimulation

‘Psychosocial stimulation refers to the

extent that the environment provides

physical stimulation through sensory

input (e.g. visual, auditory, tactile), as

well as emotional stimulation provided

through an affectionate caregiver-child

bond’ (WHO, 2007 pg. 3)

McGrath& Schafer

Evidence based programmingaddressing under-stimulationin malnourished childrenResearch into under-stimulation in mal-nourished children suggests that combiningnutritional programmes with support forpositive parenting and psychosocial stimu-lation are likely to have long-term bene¢tsfor children’s development and health. Ina rigorous study in Jamaica, Grantham-McGregor et al. (1991) demonstrated posi-tive and additive e¡ects on physical andpsychological development of children, agedup to seven years. This three-group com-parison study demonstrated that thecombination of nutritional feeding, plus psy-chosocial support, had the greatest impactonboththephysical andpsychological devel-opment of children. Taking a slightly di¡er-ent perspective, Morris et al. (2012) foundsigni¢cant links between infant psychosocialstimulation and positive maternal mood inUganda. Mothers involved in a playgroup,organised within a supplementary feedingcentre for severely malnourished children,showed signi¢cant increases in positivemood, and subsequently, increases inmaternal responsiveness and interactionwith their children.This was compared to acontrol group, where children received onlynutritional intervention, and the sameincreases in mothers’ moods or mother^child interactions were not recorded.These studies in Jamaica and Ugandademonstrate that the additive e¡ect of nutri-tion and psychosocial support interventionsare inseparable. Nutritional programmes


that contain both positive stimulation andsupport for caregivers are more e¡ective inpromoting growth and optimal child devel-opment than stand-alone nutrition pro-grammes (UNICEF, 2012). Undoubtedly,this is also why the inclusion of psychosocialsupport and stimulation, as part of foodand nutrition programmes, has beenincluded as a key action in the Inter-Agency

Standing Committee (IASC) Guidelines on Men-

tal Health and Psychosocial Support in Emergency

Settings (IASC, 2007; Action Sheet 9.1).

A training programmeAs part of their response plan to the Sahelfood and nutrition crisis, UNICEF West &Central Africa Regional O⁄ce (WCARO)wished to strengthen the capacity of partnerorganisations to initiate psychosocial acti-vities within their nutritional and con£ictresponses in ¢ve countries across the region:Burkina Faso, Niger, Mauritania, Chadand Senegal.The ¢rst author was seconded to UNICEF,fromWorldVision Australia’s HumanitarianEmergency A¡airs team, for a period ofsix weeks in order to visit the ¢ve countriesin the region. She spent six weeks provid-ing capacity building and programmedesign support to UNICEF sta¡ andpartner organisations, including communitybased organisations (CBOs), nongovern-ment organisations (NGOs), government,local psychologists and health care pro-fessionals. The majority of participantsinvolved in the training had in£uence overthe design of nutrition programmes, andsome worked within nutrition programmesdirectly. Many participants also worked inareas receiving refugees from Mali, inaddition to being responsible for local emer-gency response initiatives.Four training modules were developed andcontextualised for this consultancy period.The purpose of these modules was to builda solid knowledge base of infant mentalhealth and cognitive development, maternal


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Box 2: Quotes from participants

‘I feel regret that I did not use such tech-

niques on my own child, however, I pray

that I will be given a second chance if my

children bless me with grandchildren...’

(Participant, Burkina Faso)

‘After yesterday’s training, I went home

and looked into the eyes of my 3 week old

daughter. I then smiled at her and I could

see her respond. I am very grateful that

this training will allow me to be a better

parent, and encourage other parents in

Burkina Faso to show love and affection

to their children.’ (Doctor, Burkina

Faso)



mental health, and designing an integratedpsychosocial support and nutrition pro-gramme, in addition to mental health andpsychosocial support (MHPSS) program-ming, more generally. The four trainingmodules covered the following topics:Demystifying mental health and psychosocial sup-

port This session provided an introductionto the concept of MHPSS and explored thequestionof ‘what isMHPSS?’It covered topicssuch as the impact of emergencies on themental health of populations and an intro-duction to the IASC Guidelines on Mental

Health and Psychosocial Support in Emergency

Settings (IASC, 2007). Participants weretaskedwith designingan integratedMHPSSproject within a sector of their choice, basingtheir programmedesignonthe IASCMHPSS

Guidelines.Infant and child mental health and psychosocial

support in nutrition programmesThis central ses-sion explored the importance of nutrition,and emotional and physical stimulation ona child’s cognitive development. It focusedon the links between food shortage, malnu-trition and a lack of psychosocial stimu-lation. Various emotional and physicalstimulation techniques, relevant to a child’sstage of development, were also introduced.These were practised using the WHOMental Health in Food Shortages interven-tion table (Table 1, WHO, 2007), and theUNICEF & WHO Care for DevelopmentCounselling Cards (UNICEF & WHO,2012). Participants made dolls from localmaterials, whichwere then used in the train-ing to represent a malnourished infant.Using these dolls, participants practised psy-chosocial stimulation techniques, such asresponding to infant’s communication cues,looking into their infant’s eyes and smiling,talking or singing to the infant.Training alsoincluded sessions on how to make toys fromlocal materials, such as rattles, mobiles andpuzzles. Furthermore, the importance ofconsidering harmful traditional practiseswas explored through drama presentations.Examples included the father’s role in

ht © War Trauma Foundation. Unautho118

childcare, discipline within the family orattitudes towards playing with children.The dramatisations were then discussedas to whether such behaviours should beencouraged and built upon, or addressedwithin programmes to encourage change.Lastly, options for integrating psychosocialstimulation into the various nutrition pro-grammes were explored with participantstasked with designing their own integratednutrition and psychosocial stimulation pro-jects.

Maternal mental healthThis session providedan introduction to maternal mental health;exploring the risk factors for maternal men-tal illness and the impacts of maternaldepressionona child’s physical andcognitivedevelopment. Participants were introducedto various intervention ideas to prevent andsupport caregivers experiencing psycho-social concerns including; psychological ¢rstaid (PFA), woman and infant friendly spacesand stressmanagement techniques. Formoresevere cases, the need to refer to specialisedservices was emphasised, and participantsmapped referral pathways for mental healthconcerns that existed within their commu-nities.


Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.

Table 1. Psychosocial stimulation: principles and examples

Type of stimulation What to do Examples

Emotional stimulation:Interventions to improvechild/caregiver interactionsare important in order tofacilitate children’semotional, social, andlanguage development.This canbe accomplishedthrough educatingcaregivers on theimportance of emotionalcommunication.

Express warmth anda¡ection to the childin a manner consistentwith cultural norms.

Encourage caregiversto look into the child’seyes, smile at him orher, especially duringbreastfeeding. Expressphysical a¡ection towardsthe child (e.g., holdand cuddle the child).

Encourage verbal andnonverbalcommunication betweenthe child and caregiver.

Communicate with thechild as much aspossible. Ask the childsimple questions andrespond to his or herattempts to talk.Tryto get a conversationgoing with sounds andgestures (smiles, glances).Get the child to laughand vocalise.Teach thechild ‘action words’withactivities. For example,say ‘bye’whenwavinggoodbye.

Respond to the needs ofthe child.

Respond to the child’ssounds and interests.Be attentive to his orher needs as indicatedby his or her verbalor nonverbal cues(e.g., crying or smiling).

Show appreciation forwhat the childmanages to do.

Provide verbal praisefor the child’saccomplishments.Also, show nonverbalsigns of appreciationand approval (e.g.,clapping and smiling).

(continued )

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119


Type of stimulation What to do Examples

Physical stimulation:Children need a physicallystimulating environmentin order to develop theirpsychomotor and languageskills and to enhancecognitive development.

Ensure that theenvironment providesadequate sensoryexperiences for thechild.

Provide ways for childrento see, hear, and move.For example, placecolourful objectsaround the child andencourage the childto reach or crawl tothem. Sing local songsand play games involving¢ngers and toes.

Provide play materials. Inexpensive and funtoys such as a puzzleand a rattle can bemade out ofcardboard boxes andplastic bottles. Seereference section forexamples.

Provide meaning tothe child’s physicalworld.

Help the child to name,count, and compareobjects. For example,give the child plasticbottle caps and teachthem to stack them.Older children cansort tops by colourand learn conceptssuch as ‘high’and ‘low’.Describe to the childwhat is happeningaround them.

Provide opportunitiesto practice skills.

It is important to playwith each childindividually, forat least 15^30 minutesper day, as well asto provideopportunities forplay with otherchildren.

Source:WHO, 2007.



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Box 3:Training observation

The ‘referral system’for those experien-

cing severe mental illness inWest Africa

generally begins within the family, then

moves to the religious leaderor traditional

healer. If cases cannot be adequately

treated by these traditional approaches,

individuals were generally referred

to other specialised services, such as the

hospital.

McGrath& Schafer

Psychological ¢rst aid (PFA) training followedon from the maternal mental health session.PFA was highlighted as a skill set to assistthose working with caregivers and childrenshowing signs of distress. PFA is a humane,supportive response to those who may besu¡ering and in need of support (WorldHealth Organisation,War Trauma Founda-tion & World Vision International, 2011).Participants were trained on the actionprinciples of PFA; Look, Listen & Link(Table 2) using a number of crisis simu-lations. It was highlighted that all sta¡ andvolunteers working directly with womenand children should be trained in PFAto equip them to deal appropriately withthose in distress, allowing them to feel sup-ported, and to prevent further harm frominappropriate responses to that distress.

Box 4: Response to PFA training

‘The ‘Good and Bad Listening Exercise’

[in the PFA training] helped me to

feel how disrespected and unsupported

someone can feel if we do not provide

them with our full attention as we listen

to their needs and concerns.’ (Nutrition

actor, Chad)

Training outcomesAt the end of the training, participantsspent time designing an integrated project,


including psychosocial stimulation, mater-nal mental health considerations and PFA,within their existing or planned nutritionalactivities. Planned activities varied accord-ing to country and context, however, thevast majority of partner organisations inattendance indicated solid plans to integratethese approaches within their programmes.Planned activities included: undertaking atraining of PFA and psychosocial stimu-lation for all sta¡ working directly withcaregivers and children in nutritional pro-grammes (Chad); hiring local artists todesign posters and communicate messageson the importance of psychosocial inter-actions (Burkina Faso); establishing care-givers clubs within feeding centres topromote psychosocial stimulation (Niger,Burkina Faso, Chad, Mauritania); andensuring psychosocial stimulation is a corecomponent of all UNICEF funding agree-ments with nutrition partners going forward(Senegal) (Table 3). Initial project datacoming out of Senegal indicates substantial¢ndings in the average duration of treatmentof malnourished children, whichwas12 daysprior to the integration of psychosocial sup-port, with the average duration reduced to8 days after an integratedapproach hadbeenadopted (UNICEF, 2013).

Social norms and harmfultraditional practisesOne signi¢cant ¢nding during the train-ings was the vast child protection issuesdirectly impacting children’s nutritionalstatus and psychosocial wellbeing. Forexample in Niger, the ¢rstborn child istraditionally given to the grandmother atbirth and is commonly shownminimal a¡ec-tion or human interaction. Consequently,participants reported that ¢rstborn childrenare known to have behavioural problems.In another example, the Chief of UNICEFNutrition in Chad reported that childrenwho refused to eat due to illness and/ormalnutrition often have the uvula cut (the


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Table 2. Action principles of PFA: Look, Listen, Link

Principle Actions

LOOK -Check for safety.-Check for people with obvious urgent basic needs.-Check for people with serious distress reactions.

LISTEN -Approach people whomay need support.-Ask about people’s needs and concerns.-Listen to people, and help them to feel calm.

LINK -Help people address basic needs and access services.-Help people cope with problems.-Give information.-Connect people with loved ones and social support.

Source:World Health Organisation,WarTrauma Foundation &WorldVision International, 2011.



projection at the back of the throat), leadingto the child’s inability to swallow food, whichthen also contributes to severe malnutrition.Or, those with breathing di⁄culties havetheir chests cut deeply, as it is believed thiswill facilitate breathing. In another example,children with diarrhoea were reportedlytreated by having their anus burnt with hotirons in an e¡ort to stop the diarrhoea, lead-ing to infections that further impacted thechild’s health and nutritional status. Theseexamples show the importance of a holisticapproach in children’s health, protection,nutritional and psychosocial needs, whereeducation on the importance of combiningthese elements of child wellbeing is essential.

Challenges and opportunitiesOne of the greatest challenges of theMHPSSresponse in the Sahel food crisis was the lackof French speakers with combined expertisein psychosocial support and nutrition ^ notonly to facilitate the training, but to also sup-port the implementation of programmes.The consultant deployed for the trainingwas not a French speaker and thus requiredtranslation throughout the six-week period.While UNICEF advertised the positionwidely, there is a lackof expertise in this area


globally, and most prominently in Franco-phone countries. This is an area that theMHPSS sector needs to rapidly buildcapacity, especially in light of the projectedincreases of food crises in coming years.Another challenge was a lack of ‘buy in’ fromkey stakeholders in many of the a¡ectedcountries. For those who had worked in the¢eld of nutrition for some time, it wasdi⁄cult for them to understand the holisticnature of the approach and to see thebene¢t of adding a ‘soft’ activity (such asstimulation) alongside ‘hard’ nutritionalinputs. This was especially challenging asmeasurement of the bene¢ts of the ‘soft’activities, such as psychosocial support formothers and parent/infant stimulation, areoften di⁄cult to quantify.Additionally, the question of who ‘owns’anddrives this approach, both within UNICEFand partner organisations, is a questionthat needs to be systemically addressed inhumanitarian coordination sectors. Thepromotion of psychosocial support andstimulation within nutritional programmeshas links with nutrition, early childhooddevelopment and child protection. Thishas blurred the lines designating whichsector had ultimate responsibility for ensur-ing these initiatives were prioritised, and



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McGrath& Schafer

implemented, in the overall Sahel response.Ideally, collaboration should exist betweenthe various departments to ensure pro-gramme quality and holistic integration.A further challenge encountered was thepro¢le of participants. While the trainingwas targeted at programme implementerlevel (i.e., feeding centre sta¡),many partici-pants were, in fact, government delegates,UN agency country headquarters sta¡ ando⁄ce based NGO sta¡. Therefore, it raisedconcerns as to whether these participantswould take the training and their learningtowards operational implementation. Also,there was no capacity for the mentoringof participants and the monitoring of thequality of programmes they implementedas a result of the trainings. Ideally after anytraining, mentoring and follow-up shouldbe provided to ensure quality and thatmomentum is maintained.Finally, the evidence base for combiningpsychosocial support and stimulation acti-vities into nutritional programmes needsto be strengthened. Currently, the majorityof recommendations are based on a smallevidence base, plus theories on infantneurological development and the biopsychosocial needs of malnourished child-ren. Nonetheless, this evidence base createsan opportunity for the nutrition andMHPSS sectors. In the meantime, thereremains a great need for more targetedand longitudinal research into maternalmental health and infant stimulation pro-grammes operating within health andnutrition programmes, including speci¢cresearch from theWest and Central Africaregions, where food crises and child mal-nutrition is bound to be an ongoing chal-lenge. Therefore, an investment of rigorousresearch, randomised control trials, andimproved standards for monitoring andevaluation of programmes should be under-taken to ensure evidence of impact isfurther established.This would also supportfurther opportunities for funding of suchprogrammes in the future.


ConclusionWhile evidence is still lacking from lowerto middle income countries, the limitedevidence that does exist suggests thatan integrated nutrition, maternal mentalhealth and psychosocial stimulation pro-gramme provides much wider bene¢ts to achild’s psychic and cognitive developmentthan stand-alone nutrition responses. It isencouraging that UNICEF prioritised theestablishment of this approach withinthe Sahel food crisis response, and it ishoped that the capacity building conductedacross the region will feed into the existingevidence base and establish this approachas the ‘norm’ within nutritional program-ming. This will, therefore, enable the nextgeneration of children living in areasvulnerable to food crisis to reach their fullpotential.

ReferencesGrantham-McGregor, S. M., Powell, C. A.,Walker, S. P. & Himes, J. H. (1991). Nutritionalsupplementation, psychosocial stimulation, andmental development of stunted children: TheJamaican Study.The Lancet, 338,1-5.

Inter-Agency Standing Committee. (2007). IASCGuidelines on Mental Health and Psychosocial Support

in Emergency Settings. Geneva: IASC.

ICBF (Instituto Comombiano de BienestarFamiliar). (1997). Primera encuesta, Sistema de evalua-cion de impacto, Hogares communitarios de bienestar 0-6

anos (First systemic evaluation of impact of the Houses

ofWell-Being). Colombia: ICBF.

Morris, J., Jones, L., Berrino, A., Jordans, M.,Okema, L. & Crow, C. (2012). Does CombiningInfant Stimulation With Emergency FeedingImprove Psychosocial Outcomes for DisplacedMothers and Babies? A Controlled EvaluationfromNorthernUganda.AmericanJournalofOrthop-sychiatry, 82(3), 349-357.

The Center on the Developing Child at HarvardUniversity (2009). The Timing and Quality ofEarly Experiences Combine to Shape Brain


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Architecture: Working Paper No. 5. http://www.developingchild.harvard.edu.

UNICEF. (2012a). Integrating Early Childhood

Development (ECD) activities into Nutrition Pro-

grammes inEmergencies.Why,What andHow. Geneva:UNICEF.

UNICEF & WHO. (2012). Care for Development

Counselling Cards. Geneva: UNICEF.

UNICEF. (2012).Mission surDiourbel (20/12/2012)Visite du projet d’appui psychosocial des enfantsaccueil au Centre de Re¤ cupe¤ ration Nutritionnel(CREN).

UNICEF. (2006).Under ¢ve deaths by cause. Geneva:UNICEF.

WHO, Mental Health and Psychosocial Well-being among Children in Severe Food Shortage,


(2007). Evidence and Research Department ofMental Health and Substance Abuse,WHO.

WorldHealthOrganization,WarTraumaFounda-tion & WorldVision International. (2011). Psycho-logical ¢rst aid: guide for ¢eldworkers. Geneva:WHO.

Megan McGrath works for World Vision

Australia in the Humanitarian and Emergency

A¡airs department. She has post graduate

quali¢cations in both Psychology and Infant

Mental Health.

email: [email protected]

Alison Schafer is a clinical psychologist with

World Vision Australia’s Humanitarian and

Emergency A¡airsTeam. She is World Vision

International’s lead program advisor for mental

health and psychosocial support programmes.


http://www.developingchild.harvard.edu/

http://www.developingchild.harvard.edu/

mailto:[email protected]

integrating psychosocial support into nutrition programmes in west

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