Mother’s experience in caring for children with severe malnutrition

It is a challenge for mothers to meet the need of children on nutrition. Failure in meeting this need causes malnutrition in children. This research is aimed to explore a mother’s experience in caring for children with severe malnutrition. A qualitative design was applied using a descriptive phenomenology approach. The total of participants involved were eight persons selected purposively. Data were collected through in interview. This research found that mothers did not realize that their children experience malnutrition, causing malnutrition condition is not their main priority. Aside from that, mothers got bad treatment from the health workers during the consultation. Mothers need to be supported and empowered, handling and preventing their children from malnutrition. Health workers need to change their attitude towards patients an their communication and counseling skills. This open access article is under the CC–BY-SA license.


A B S T R A C T
It is a challenge for mothers to meet the need of children on nutrition. Failure in meeting this need causes malnutrition in children. This research is aimed to explore a mother's experience in caring for children with severe malnutrition. A qualitative design was applied using a descriptive phenomenology approach. The total of participants involved were eight persons selected purposively. Data were collected through in interview. This research found that mothers did not realize that their children experience malnutrition, causing malnutrition condition is not their main priority. Aside from that, mothers got bad treatment from the health workers during the consultation. Mothers need to be supported and empowered, handling and preventing their children from malnutrition. Health workers need to change their attitude towards patients an their communication and counseling skills.
This open access article is under the CC-BY-SA license.
This open access article is under the CC-BY-SA license. It is a challenge for mothers to meet the need of children on nutrition. meeting this need causes malnutrition in children. This research is aimed to explore a mother's experience in caring for children with severe malnutrition. A qualitative design was applied using a descriptive ts involved were eight persons selected purposively. Data were collected through in-depth interview. This research found that mothers did not realize that their children experience malnutrition, causing malnutrition condition is not ide from that, mothers got bad treatment from the health workers during the consultation. Mothers need to be supported and empowered, handling and preventing their children from malnutrition. Health workers need to change their attitude towards patients and develop license.

Introduction
Malnutrition among children is a problem that often occurs in developing countries, including Indonesia. The prevalence of malnutrition among Indonesian under-five children in 2013 was increasing if compared to the previous years worth 5.4% in 2007 and 4.9% in 2010 (Kramer & Allen, 2015; Ministry Health of Indonesia, 2014a). Lampung Province is one of the provinces in Indonesia that has quite a high number of malnutrition. The malnutrition case in Lampung Province between 2003 -2012 was amount 200 -300 cases. The malnutrition prevalence in Lampung Province was not more than 5%, yet the number of malnutrition cases did not show a significant decrease (Dinas Kesehatan Provinsi Lampung, 2013).
Malnutrition causes growth and development disorders in children. The weakened body endurance of children causes them easily get any disease attacks, increases morbidity and mortality, extends treatment period, and increases treatment cost (Jones & Berkley, 2014;Prieto & Cid, 2011). Causes of malnutrition are inadequate food intake, socio-cultural differences, too much consumption of food that is not following body needs, diseases related to mastication, swallowing and absorption functions, poverty, bad health services, inadequate treatment, lousy sanitation, the lack of clean water supplies and low level of education, lifestyle as well as beliefs regarding health adopted in families (Bowden & Greenberg, 2010;Mizumoto et al., 2015;Scantlan & Previdelli, 2013).
Families, especially mothers, play an essential role in parenting children with malnutrition. Any risk of malnutrition may increase if mothers as the main sitters have depression and do not get any adequate support from the environment (Gulati, 2010;Marie, T A, 2012;Surkan et al., 2011). The health counseling provided for mothers of children with malnutrition showed a positive result accelerating recovery period, so the treatment cost decreased (Dido, Wakili, & Asekun-Olarinmove, 2011). Mothers needed some training and assistance, therefore they become confident in treating their children (Nahar et al., 2012).
Based on the above studies, mothers have an important role in the process of caring for children, especially children with malnutrition. Research on the experience of mothers caring for children with malnutrition, especially in Lampung province, has never been done before. Therefore, this study aimed to deeply depict the experience of mothers while giving treatment for children with malnutrition. This study depicted the way of a treatment process for children with malnutrition directly from mothers as the sitters in families. By understanding the experience of mothers while treating children with malnutrition, health workers will receive information to improve health services, so the health status of children with malnutrition can be increased.

Method
This study used the qualitative method with a descriptive phenomenology approach directly exploring any experience of participants, analyzing and describing determined phenomenon through the researcher's intuition (Creswell, 2013).
Eight participants were selected using a purposive sampling technique. This research was conducted in Lampung Province. The criteria of participants are mothers domiciled in Lampung Province having 1 -5 years old children suffering malnutrition, the children being or ever hospitalized in any health services agencies in Lampung Province. The children did not suffer serious diseases, such as congenital heart disease, malignancy, etc.
The data-collecting process was conducted by an indepth interview method using the Indonesian language. This study has used semi-structured interviews. Semi-structured interview employs a blend of closed-and open-ended questions. (Adams, 2015). Semi-structured interviews were executed in hospitals and houses of participants. The interviews were running for 40 -60 minutes involving the researcher and participants only.
The received data was analyzed using the Moustakas approach, 1999 (Creswell, 2013). Data saturation occurred in the eighth participant. The researcher listened to the interview records repeatedly, then made the interview transcript. Transcript was returned to participants to ensure the validity whether the content was already in accordance with what the participants meant to. The transcript was then read repeatedly to collect any significant questions into a theme. The theme was analyzed to depict what occurred based on the experience of mothers treating children with malnutrition (textural description) and depict the way mothers treat the children with malnutrition (structural description). The last step was combining the textural description and structural description then finding out the essence of children with malnutrition for mothers and mothers' experience treating children with malnutrition.
This study passed an ethics test from the Faculty of Nursing Research Ethics Committee, University of Indonesia, by Number. 0254/UN2.F12.D/HKP.02.04/2015. The researcher explained the aims of the study, and then the participants signed the informed consent voluntarily and without compulsion as an approval form to be participants. The place and time of interviews were completed in accordance with the appointment between the researcher and participants.

Demographic Characteristics of Participants
The age of the participants was various between 21 -44 years old. An explanation of the participants can be seen in the table 1.

Thematic Analysis Result
The theme obtained from the study was that malnutrition among children did not be mothers' priority for health consulting. Mothers accepted bad treatment from health workers, and mothers needed any social and financial supports while giving treatment for children.

Theme 1. Malnutrition as Non-Priority for Health Consulting
Mothers commonly did not realize that children suffered malnutrition, so they brought their children to health services agencies because the children suffered any affected diseases. The statements were depicted as follows: Malnutrition as mothers' non-priority for children's health consulting is caused by the lack of mothers' understanding of malnutrition status on children. Mothers do not realize that the children suffer malnutrition, so they only bring their children to health services agencies when their children suffer some affected diseases, such as fever, diarrhea and cough (de Onis & Branca, 2016).
During this time, procedure of treatment for children with malnutrition has been differentiated based on whether any affected diseases exist (Department Of Child And Adolescent Health And Development, 2009;Direktorat Jenderal Bina Gizi dan KIA, 2014;Ministry Health of Indonesia, 2014b). Children with malnutrition without any affected diseases are not hospitalized in health services agencies. This conditon commonly causes mothers not to become focus on malnutrition among children. The study result showed that mothers only brought their children to health services agencies when their children suffered some affected diseases, such as cough, diarrhea and fever, not because of malnutrition problem suffered by the children.
One of nutrition status screenings in communities was conducted through Integrated Management of Ill Under-Five Children (Manajemen Terpadu Balita Sakit/MTBS). MTBS has been executed in Indonesia since 1997 (Husni, Sidik A.D., Ansar, 2012). The study showed that MTBS execution was not yet maximum. Malnutrition-handling procedure during this time has emphasized treatment for affected diseases suffered by children, meanwhile, malnutrition problem that becomes the main problem has no proper and intensive interventions.
The monitoring of malnutrition in communities was not really felt by participants. This condition was caused by mothers passively bringing their children to Integrated Services Post (Posyandu) in every month. The reason why mothers did so was that they held the feeling of shame due to any unpleasant response from health workers. Mothers also became the party blamed when their children's body weights were decreasing, so this matter caused mothers not willing to bring their children to Posyandu. This study result is following the study conducted in 2012 stating that mothers having children with malnutrition were less active coming to Posyandu because they were not confident related to the condition of their children (Husni, Sidik A.D., Ansar, 2012).
Professional sitters have a central role in doing treatment for children with malnutrition. Besides being such nannies, sitters also take a role as counselors (Hockenberry, M.J. & Wilson, 2009;Hockenberry & Wilson, 2015;Potts & Mandleco, 2012). Mothers will not feel blamed if health workers can take a role as effective counselors. The role as effective counselors can be achieved if health workers are open, accepting the condition that the clients have their values influencing daily activities and able to show empathy that means understanding people from their perspectives (Ilmonen, Isolauri, & Laitinen, 2012;Lesmana, 2008).
Participants faced any feelings during taking a role as mothers who have children with malnutrition. Such feelings included feeling surprised, distrusted, sad, shamed, blamed, and finally accepting the condition of their children. The feeling of acceptance occurred when mothers were already able to create a way to solve problems (koping) of children's health. Parents commonly will suffer emotional distress then develop solutions and family supports to increase the health status of children (Hockenberry, M.J. & Wilson, 2009).
Proper koping may happen if social support is adequate. The social support can be obtained from families, such as husband, parents, children, and other relatives. Social support from health workers is needed, too. Such support can be in the form of direct counseling and assistance. Active listening skill is needed as an effective counselor (Heron, 2012;Hockenberry, M.J. & Wilson, 2009;Nahar et al., 2012). The effective counselor will be able to facilitate mothers for merely telling the problems they face in order to decrease emotional distress and develop their self-confidence in giving treatment for children.
Financial support can be executed through efforts to increase the accessibility of health services (Carlson, Kordas, & Murray-Kolb, 2015;Sapountzi-Krepia et al., 2006). Mothers domiciled in remote areas said that their families were difficult to access health services for improving the children's health status. So, the government needs to expand health services coverage (Kandala, Madungu, Emina, Nzita, & Cappuccio, 2011). Financial support executed by the government during this time is by providing additional food to children. However, this method, in the mothers' perspective, is less effective. Mothers said that children were not willing to consume the provided additional food.
Mothers said that during the time of treatment for children, training, and assistance where needed. This statement mainly told by mothers just having a child for the first time, so they were not yet experienced. Mothers just having a child for the first time needed supports to increase ability and knowledge in treating children, especially related to nutrition compliance. This is following the study stating that mothers needed supports in forms of training and assistance in order to be more confident in doing treatment for children with malnutrition (Alvarez Morán, Alé, Rogers, & Guerrero, 2018;Holmberg Fagerlund, Helseth, Owe, & Glavin, 2017;Nahar et al., 2012).
This study has several implications to health services, especially to children with malnutrition. Mothers as the leading sitters need any social support while treating the children with malnutrition in forms of direct counseling and assistance among mothers. This study result becomes such input for health workers, especially children sitters, to provide treatment not only focusing on children but also on mothers as the primary key of children parenting in the family (Harrison, 2010).
This study depicted how the treatment of children with malnutrition ever being hospitalized in hospitals directly from mothers as the sitters. Any following study may involve participants who have children with malnutrition that have not yet been hospitalized. Therefore the result of the study is expected to complement information to improve health services for children with malnutrition.
This study has several limitations that are only one participant coming from an upper-middle family and a higher level of education, so there is none of the comparator data for this variant of participants. Moreover, this study only involved participants who have children with malnutrition ever being hospitalized only.

Conclusions and Recommendations
The experience of mothers in treating children with malnutrition was depicted in the study results, namely malnutrition as non-priority for health consulting, accepting unpleasant treatment from health workers, and the healthy growth of children, obtaining any forms of social and financial supports are the needs of mothers. Mothers need adequate supports for treating children with malnutrition. Such supports can be delivered by health workers, especially sitters, by providing treatment not only focusing on children but also concerning on mothers as the main child-sitter.