title: Health-seeking behaviour and community perceptions of childhood undernutrition and a community management of acute malnutrition (CMAM) programme in rural Bihar, India: a qualitative study.
abstract: OBJECTIVE
  Since 2009, Médecins Sans Frontières has implemented a community management of acute malnutrition (CMAM) programme in rural Biraul block, Bihar State, India that has admitted over 10 000 severely malnourished children but has struggled with poor coverage and default rates. With the aim of improving programme outcomes we undertook a qualitative study to understand community perceptions of childhood undernutrition, the CMAM programme and how these affected health-seeking behaviour.
  
  
  METHODS
  Semi-structured and narrative interviews were undertaken with families of severely malnourished children, non-undernourished children and traditional and allopathic health-care workers. Analysis of transcripts was by qualitative content analysis.
  
  
  METHODS
  Biraul, Bihar State, India, 2010.
  
  
  METHODS
  One hundred and fifty people were interviewed in individual or group discussions during fifty-eight interviews.
  
  
  RESULTS
  Undernutrition was not viewed as a disease; instead, local disease concepts were identified that described the clinical spectrum of undernutrition. These concepts informed perception, so caregivers were unlikely to consult health workers if children were 'only skinny'. Hindu and Muslim priests and other traditional health practitioners were more regularly consulted and perceived as easier to access than allopathic health facilities. Senior family members and village elders had significant influence on the health-seeking behaviour of parents of severely malnourished children.
  
  
  CONCLUSIONS
  The results reaffirm how health education and CMAM programmes should encompass local disease concepts, beliefs and motivations to improve awareness that undernutrition is a disease and one that can be treated. CMAM is well accepted by the community; however, programmes must do better to engage communities, including traditional healers, to enable development of a holistic approach within existing social structures.
authors.affiliation: 1Médecins Sans Frontières (MSF),Vienna,Austria.
authors.forename: Doris
authors.initials: D
authors.lastname: Burtscher
authors.affiliation: 2Médecins Sans Frontières (MSF),C203 Defence Colony,New Delhi 110024,India.
authors.forename: Sakib
authors.initials: S
authors.lastname: Burza
mesh_terms: D002664:Child Nutritional Physiological Phenomena; D002675:Child, Preschool; D003150:Community Health Workers; D065246:Culturally Competent Care; D057210:Delayed Diagnosis; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006705:Homeopathy; D006801:Humans; D007194:India; D007223:Infant; D007390:International Agencies; D044342:Malnutrition / Q000175:diagnosis / Q000178:diet therapy / Q000209:etiology / Q000517:prevention & control*; D008519:Medicine, Traditional; D009752:Nutritional Status; D010342:Patient Acceptance of Health Care; D036301:Qualitative Research; D012423:Rural Health; D000067011:Severe Acute Malnutrition / Q000175:diagnosis / Q000178:diet therapy* / Q000209:etiology / Q000517:prevention & control; D014837:Voluntary Health Agencies; D000078329:Workforce
keywords: Community management of malnutrition; Health-seeking behaviour; India; Malnutrition; Traditional disease concepts