Formative Research to Understand Household Utilization of a Lipid-Based Nutrient Supplement in rural Malawi and Mozambique

Background: Malawi and Mozambique have seen improvements in their indicators of maternal and young child nutrition during the past decade, but rates of chronic undernutrition among young children remain high. To address the high rates of stunting, the World Food Programme is supporting the governments of Malawi and Mozambique to implement nutrition interventions as part of the Scaling Up Nutrition (SUN) movements in Ntchisi district and Cabo Delgado province, respectively. These interventions aim to improve overall maternal and child nutrition through an integrated package of intervention components, which include the provision of a small-quantity, lipid-based nutrient supplement (SQ-LNS) for children aged 6 - 23 months. SQ-LNSs are new to most targeted populations, as well as to implementing agencies. Previous research indicates that this product is highly acceptable to caregivers and young children but recent qualitative work suggests that at the household level it may not be utilized appropriately. To date there have been no comprehensive formative research studies conducted to examine the patterns and determinants of its household utilization. Methods: Two linked formative research studies were conducted in the communities of Ntchisi, Malawi and Cabo Delgado, Mozambique from Jan. – Aug. 2013. Data were conducted over three iterative phases using qualitative and ethnographic methods from community leaders, caregivers, health workers, and children aged 6 – 23 months. Data collection in phase 1 used in-depth interviews, household meal observations, and free lists of illnesses and foods to understand the food environment as well as attitudes toward and perceptions of food, health, and illness in these contexts. Phase 2 further examined food and illness domains with pile sorts, and additional direct observations were used to understand household utilization with the SQ-LNS. Phases 2 and 3 included home-feeding trials with the product. Phase 3 further used in-depth interviews, direct observations, and spot checks to understand caregivers’ experiences with the SQ-LNS, specifically identifying barriers and facilitating factors to its appropriate usage. Community workshops were also used to generate intervention strategies. Results: Use of the SQ-LNS generally did not follow the recommended usage (one sachet, one child 6 – 23 months, each day), with 50% of households in Malawi reportedly running out of stock too early and 87% of households in Mozambique either over- or under-using the product. Patterns of SQ-LNS utilization manifested in shared and distinct ways depending on country setting, with caregivers consuming it themselves, caregivers providing it to other household children, and product being stolen from households. Decisions about use of the product were generally made in line with core cultural values and as a coping mechanism in light of food insecurity, rather than intentional disregard of program guidelines. In both settings, differential risk perceptions toward chronic undernutrition, low value placed upon the small size of the SQ-LNS, and strong social pressures to share the product all contributed to its varied patterns of utilization. In Mozambique, three ethnic groups can be segmented into two audiences for behavior change communications based on their unique socio-cultural characteristics driven by geography. In Malawi one tailored approach that considers predictable household food allocation patterns and is tailored to local understandings of nutrition-related illness would be most appropriate. Such locally-tailored strategies are necessary to ensure appropriate SQ-LNS utilization. Discussion: Despite the potential for SQ-LNS to positively affect IYCF practices and improve the nutritional status of young children, in food insecure, interdependent cultural contexts, we found that the supplement is likely to be consumed by not only children 6 – 23 months but also other household and community members. Our findings contradict previous research which illustrated minimal household sharing of a SQ-LNS in the context of nutrition interventions. This may be due to our more rigorous methods for capturing such behaviors, including extensive direct observation within households, but may also be partially the result of a lack of communications promoting the appropriate use of the product. Conclusion: Strong formative research and culturally-appropriate behavior change strategies are keystones to any intervention using SQ-LNS in order to create enabling environments for caregivers to appropriately use such products. Otherwise, nutrition interventions using a SQ-LNS may not see their desired impacts